Braddom's Physical Medicine and

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Braddom’s Physical Medicine
and Rehabilitation
SIXTH EDITION
Editor-in-Chief

David X. Cifu, MD
Associate Dean of Innovation and System Integration
Herman J. Flax, MD Professor and Chair, Department of Physical Medicine and Rehabilitation
Virginia Commonwealth University School of Medicine
Richmond, Virginia;
Senior TBI Specialist, U.S. Department of Veterans Affairs
Washington, DC;
Principal Investigator
Long-term Impact of Military-relevant Brain Injury Consortium - Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC)
Central Virginia VA Health Care System/Virginia Commonwealth University
Richmond, Virginia

Associate Editors

Blessen C. Eapen, MD Henry L. Lew, MD, PhD, ABPMR, CCC-A

Chief, Physical Medicine and Rehabilitation Professor and Chair
VA Greater Los Angeles Health Care System; Department of Communication Sciences and Disorders
Associate Clinical Professor John A. Burns School of Medicine
Department of Medicine University of Hawai’i at Mānoa
Division of Physical Medicine and Rehabilitation Honolulu, Hawaii;
David Geffen School of Medicine at UCLA Adjunct Professor
Los Angeles, California Department of Physical Medicine and Rehabilitation
Virginia Commonwealth University School of Medicine
Richmond, Virginia
Jeffery S. Johns, MD
Associate Professor Michelle A. Miller, MD
Physical Medicine and Rehabilitation
Vanderbilt University Medical Center; Assistant Clinical Professor
Medical Director Physical Medicine and Rehabilitation
Vanderbilt Stallworth Rehabilitation Hospital The Ohio State University;
Nashville, Tennessee Section Chief
Pediatric Physical Medicine
Nationwide Children’s Hospital
Karen Kowalske, MD Columbus, Ohio
Professor
Physical Medicine and Rehabilitation Gregory Worsowicz, MD, MBA
University of Texas Southwestern Medical Center
Dallas, Texas Professor of Clinical Physical Medicine and Rehabilitation
Department of Physical Medicine and Rehabilitation
University of Missouri
Columbia, Missouri
Elsevier
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BRADDOM’S PHYSICAL MEDICINE AND REHABILITATION,

SIXTH EDITION ISBN: 978-0-323-62539-5
Copyright © 2021 by Elsevier, Inc. All rights reserved.

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Last digit is the print number: 9 8 7 6 5 4 3 2 1

 This book is dedicated to my parents, John and Rosa,
who made me all that I am; my children, Brie and Belle,
who remind me to look to the horizon;
and to my love, Hilary, who makes it all worthwhile.

A special thank you to Randy Braddom for the legacy that

started this textbook and for his ongoing support.

Thank you to my amazingly supportive colleagues, staff,

and trainees all across Virginia Commonwealth University,
including in the School of Medicine and the Department of Physical
Medicine and Rehabilitation, for their mentorship,
their friendship, and the time to complete this project.

Thank you to the wonderful members of the Office of Rehabilitation

and Prosthetic Services in the U.S Department of Veterans Affairs
for all they do for America’s Veterans and Service Members
and for allowing me the time to complete this project.

Thank you to the thousands of patients and their family members

who allowed me to participate in their care over the years;
you have taught me so much.

Thank you to my family, friends, and other loved ones

for your ongoing support that allows me to pursue my work and career.

v
Contributors

Denise M. Ambrosi, MS, CCC-SLP W. David Arnold, MD

Director of Accreditation Associate Professor
Quality and Compliance Physical Medicine and Rehabilitation
Spaulding Rehabilitation Hospital; Neuromuscular Division
Assistant Professor Department of Neurology
Communication Sciences and Disorders Physiology and Cell Biology
MGH Institute of Health Professions Neuroscience
Charlestown, Massachusetts The Ohio State University
3 Rehabilitation of Swallowing Disorders Columbus, Ohio
40 Motor Neuron Diseases
Michael Andary, MD, MS
Professor Arash Asher, MD
Physical Medicine and Rehabilitation Director, Cancer Survivorship and Rehabilitation
Michigan State University College of Osteopathic Medicine; Samuel Oschin Comprehensive Cancer Institute
Residency Director, Physical Medicine and Rehabilitation Cedars-Sinai Medical Center
Sparrow Hospital Los Angeles, California
East Lansing, Michigan 29 Cancer Rehabilitation
8 Electrodiagnostic Medicine
James W. Atchison, DO
Karen L. Andrews, MD Chair
Physical Medicine and Rehabilitation Department of Physical Medicine and Rehabilitation
Mayo Clinic Mayo Clinic Florida
Rochester, Minnesota Jacksonville, Florida
24 Prevention and Management of Chronic Wounds 16 Manipulation, Traction, and Massage
25 Vascular Diseases
Rita Ayyangar, MBBS
Thiru M. Annaswamy, MD, MA Associate Professor
Professor Department of Physical Medicine and Rehabilitation
Department of Physical Medicine and Rehabilitation University of Michigan
University of Texas Southwestern Medical Center; Ann Arbor, Michigan
Section Chief, Spine and Electrodiagnostic Sections 48 Myelomeningocele and Other Spinal Dysraphisms
Physical Medicine and Rehabilitation Service
VA North Texas Health Care System Kim D.D. Barker, MD
Dallas, Texas Associate Professor
7 Quality and Outcome Measures for Medical Rehabilitation Physical Medicine and Rehabilitation
17 Physical Agent Modalities University of Texas Southwestern Medical Center
Dallas, Texas
Dixie Aragaki, MD 1 The Physiatric History and Physical Examination
Professor
Department of Medicine Touré Barksdale, MD
Division of Physical Medicine and Rehabilitation Mayo Clinic/Mayo Clinic Health System
David Geffen School of Medicine at UCLA; Physical Medicine and Rehabilitation
Program Director Mayo Clinic
Physical Medicine and Rehabilitation Residency Mankato, Minnesota
VA Greater Los Angeles Healthcare System 29 Cancer Rehabilitation
Los Angeles, California
6 Occupational Medicine and Vocational Rehabilitation

vi
 Contributors vii

Karen P. Barr, MD Mary Caldwell, DO

Associate Professor Assistant Professor
Chief, Division of Physical Medicine and Rehabilitation Sports Medicine/Physical Medicine and Rehabilitation
Department of Orthopaedics VCU Health
West Virginia University Richmond, Virginia
Morgantown, West Virginia 36 Lower Limb Pain and Dysfunction
33 Low Back Disorders
William Carne, PhD
Matthew N. Bartels, MD, MPH Associate Professor
Professor and Chairman of Rehabilitation Medicine Physical Medicine and Rehabilitation
Albert Einstein College of Medicine; Virginia Commonwealth University
Chairman, Department of Rehabilitation Medicine Richmond, Virginia
Montefiore Medical Center 45 Degenerative Movement Disorders of the Central Nervous System
The Bronx, New York
27 Acute Medical Conditions: Cardiopulmonary Disease, Priya Chandan, MD, MPH
Medical Frailty, and Renal Failure Assistant Professor
Division of Physical Medicine and Rehabilitation
Stacey A. Bennis, MD University of Louisville
Assistant Professor Louisville, Kentucky
Orthopaedics and Rehabilitation 45 Degenerative Movement Disorders of the Central Nervous System
Obstetrics and Gynecology
Loyola University Medical Center Shih-Ching Chen, MD, PhD
Maywood, Illinois Professor
38 Pelvic Floor Disorders Physical Medicine and Rehabilitation
Director
Theresa F. Berner, OTR/L, ATP Research Center of Rehabilitation Engineering and Assistive
Rehabilitation Clinical Manager Technology
Occupational Therapist Taipei Medical University
The Ohio State University Wexner Medical Center Taipei, Taiwan
Columbus, Ohio 19 Assistive Technology and Environmental Control Devices
14 Wheelchairs and Seating Systems
Wen-Shiang Chen, MD, PhD
Cathy Bodine, PhD, CCC-SLP Professor
Associate Professor Physical Medicine and Rehabilitation
Bioengineering College of Medicine
University of Colorado National Taiwan University;
Denver, Colorado Director
19 Assistive Technology and Environmental Control Devices Physical Medicine and Rehabilitation
National Taiwan University Hospital
Jaclyn Bonder, MD Taipei, Taiwan
Assistant Professor 17 Physical Agent Modalities
Rehabilitation Medicine
Weill Cornell Medical College Andrea Cheville, MD, MDCE
New York, New York Professor
38 Pelvic Floor Disorders Department of Physical Medicine and Rehabilitation
Director of Lymphedema and Cancer Rehabilitation Services
Angeline Bowman, MD Mayo Clinic
Assistant Professor Rochester, Minnesota
Department of Physical Medicine and Rehabilitation 29 Cancer Rehabilitation
University of Michigan
Ann Arbor, Michigan Li-Wei Chou, MD, PhD
48 Myelomeningocele and Other Spinal Dysraphisms Director and Professor
Physical Therapy and Graduate Institute of Rehabilitation Science
Thomas N. Bryce, MD China Medical University;
Professor Chairman
Rehabilitation and Human Performance Physical Medicine and Rehabilitation
Icahn School of Medicine at Mount Sinai Asia University Hospital;
New York, New York Attending Physician
49 Spinal Cord Injury Physical Medicine and Rehabilitation
China Medical University Hospital
Taichung, Taiwan
17 Physical Agent Modalities
viii Contributors

Jeffrey M. Cohen, MD Katherine Louise Dec, MD

Clinical Professor Professor
Rehabilitation Medicine Physical Medicine and Rehabilitation
NYU School of Medicine; Virginia Commonwealth University School of Medicine;
Medical Director, Medically Complex Rehabilitation Professor
Rusk Rehabilitation Orthopaedic Surgery
NYU Langone Health Virginia Commonwealth University School of Medicine;
New York, New York Past President
28 Chronic Medical Conditions: Pulmonary Disease, Organ American Medical Society for Sports Medicine;
Transplantation, and Diabetes Director, Sports Medicine and Performance
Physical Medicine and Rehabilitation
Rory A. Cooper, PhD Virginia Commonwealth University Health Systems
Director Richmond, Virginia
Human Engineering Research Laboratories 36 Lower Limb Pain and Dysfunction
VA Pittsburgh Healthcare System;
Associate Dean for Inclusion Andrew Cullen Dennison, Sr., MD
SHRS and FISA/Paralyzed Veterans of America Distinguished Adjunct Assistant Professor
Professor Rehabilitation Medicine
School of Health and Rehabilitation Sciences Emory University;
University of Pittsburgh Medical Director of Acquired Brain Injury Rehabilitation
Pittsburgh, Pennsylvania Shepherd Center
14 Wheelchairs and Seating Systems Atlanta, Georgia
44 Stroke Rehabilitation
Rosemarie Cooper, MPT/ATP
Assistant Professor Michael J. DePalma, MD
Department of Rehabilitation Science and Technology President and Medical Director
University of Pittsburgh; Virginia iSpine Physicians, PC;
Director, Center for Assistive Technology Director
University of Pittsburgh Medical Center Interventional Spine Care Fellowship Program
Pittsburgh, Pennsylvania Virginia iSpine Physicians, PC;
14 Wheelchairs and Seating Systems Director of Research
Virginia Spine Research Institute, Inc.
Anita Craig, DO Richmond, Virginia
Assistant Professor 32 Common Neck Problems
Physical Medicine and Rehabilitation
University of Michigan Kelly M. Derby, MS, APRN, CNS
Ann Arbor, Michigan Clinical Nurse Specialist
41 Neuropathies Department of Nursing
Mayo Clinic
Edan A. Critchfield, PsyD, ABPP Rochester, Minnesota
Clinical Neuropsychologist 24 Prevention and Management of Chronic Wounds
Psychology
South Texas Veterans Healthcare System Carmen P. DiGiovine, PhD, ATP/SMS, RET
San Antonio, Texas Clinical Associate Professor
4 Psychological Assessment and Intervention in Rehabilitation Director of Rehabilitation Science and Technology
Assistive Technology Center
Deepthi S. Cull, MD, CPE, FAAPM&R The Ohio State University
Encompass Health Deaconess Rehabilitation Hospital Columbus, Ohio
Newburgh, Indiana 14 Wheelchairs and Seating Systems
7 Quality and Outcome Measures for Medical Rehabilitation
Timothy Dillingham, MD, MS
Aaron Danison, DO Professor and Chairman
Physician Physical Medicine and Rehabilitation
Neurosurgery The University of Pennsylvania
Vidant Medical Center Philadelphia, Pennsylvania
Greenville, North Carolina 8 Electrodiagnostic Medicine
13 Spinal Orthoses
Carole Dodge, OTRL, CHT
Arthur J. De Luigi, DO, MHSA Allied Health Supervisor
Chair Occupational Therapy
Department of Physical Medicine and Rehabilitation Michigan Medicine
Mayo Clinic Arizona University of Michigan
Scottsdale, Arizona Ann Arbor, Michigan
39 Sports Medicine and Adaptive Sports 11 Upper Limb Orthotic Devices
 Contributors ix

David F. Drake, MD Jonathan Finnoff, DO, FACSM, FAMSSM

Associate Professor Professor
Department of Physical Medicine and Rehabilitation Department of Physical Medicine and Rehabilitation
Virginia Commonwealth University; Mayo Clinic
Director, Interventional and Integrative Pain Medicine Rochester, Minnesota;
Physical Medicine and Rehabilitation Service Chief Medical Officer
Central Virginia VA Healthcare System United States Olympic and Paralympic Committee
Richmond, Virginia Colorado Springs, Colorado
18 Integrative Medicine in Rehabilitation 35 Upper Limb Pain and Dysfunction

Daniel Dumitru, MD, PhD Gerard E. Francisco, MD

Professor Professor and Chair
Rehabilitation Medicine Department of Physical Medicine and Rehabilitation
University of Texas Health Science Center University of Texas Health Science (UTHealth) McGovern
San Antonio, Texas Medical School
8 Electrodiagnostic Medicine Houston, Texas
23 Spasticity
Jason Edinger, DO
Assistant Professor Kevin Franzese, DO
Physical Medicine and Rehabilitation Assistant Professor
University of Pittsburgh Medical Center Physical Medicine and Rehabilitation
Pittsburgh, Pennsylvania University of Pittsburgh
43 Traumatic Brain Injury University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Miguel X. Escalon, MD, MPH 43 Traumatic Brain Injury
Associate Professor
Department of Rehabilitation Medicine Vincent Gabriel, MSc, MD, FRCPC
Icahn School of Medicine Clinical Associate Professor
New York, New York Clinical Neurosciences, Pediatrics, and Surgery
49 Spinal Cord Injury University of Calgary
Calgary, Alberta, Canada
Reuben Escorpizo, PT, DPT, MSc 26 Burns
Clinical Associate Professor
Doctor of Physical Therapy Program Gary N. Galang, MD
Department of Rehabilitation and Movement Science Director of TBI Services
The University of Vermont Physical Medicine and Rehabilitation
Burlington, Vermont; University of Pittsburgh Medical Center
Adjunct Research Scientist Pittsburgh, Pennsylvania
Swiss Paraplegic Research 43 Traumatic Brain Injury
Nottwil, Switzerland
6 Occupational Medicine and Vocational Rehabilitation Justin J. Gasper, DO
St. Louis, Missouri
James E. Eubanks, MD, DC, MS 32 Common Neck Problems
Resident Physician
Physical Medicine and Rehabilitation Lance L. Goetz, MD
University of Pittsburgh Medical Center Associate Professor
Pittsburgh, Pennsylvania Physical Medicine and Rehabilitation
16 Manipulation, Traction, and Massage Virginia Commonwealth University;
Staff Physician
Gabriel Sunn Felsen, MD, FAAPMR Spinal Cord Injury and Disorders
Associate Professor of Rehabilitation Medicine Hunter Holmes McGuire VA Medical Center
University of Miami; Richmond, Virginia
Spinal Cord Injury and Wound Rehabilitation Physician 20 Neurogenic Lower Urinary Tract Dysfunction
Miami VA Healthcare System
Miami, Florida James W. Hall III, PhD
13 Spinal Orthoses Professor
Department of Communication Sciences and Disorders
University of Hawaii
Honolulu, Hawaii;
Professor
Osborne College of Audiology
Salus University
Elkins Park, Pennsylvania
50 Auditory, Vestibular, and Visual Impairments
x Contributors

R. Norman Harden, MD Lin-Fen Hsieh, Doctor of Medicine

Senior Associate Editor, Pain Medicine Adjunct Professor
Addison Chair in Pain Studies School of Medicine
Professor Fu Jen Catholic University
Department of Physical Medicine and Rehabilitation New Taipei City, Taiwan;
Department of Physical Therapy and Human Movements Attending Physician (Former Director)
­Sciences Department of Physical Medicine and Rehabilitation
Northwestern University Shin Kong Wo Ho-Su Memorial Hospital
Chicago, Illinois Taipei, Taiwan
37 Chronic Pain 31 Rheumatologic Rehabilitation

Mark A. Harrast, MD Wei-Li Hsu, PT, PhD

Clinical Professor Associate Professor
Departments of Rehabilitation Medicine, Orthopaedics, and School and Graduate Institute of Physical Therapy
Sports Medicine National Taiwan University;
University of Washington School of Medicine; Physical Therapist
Medical Director Physical Therapy Center
Sports Medicine Center at Husky Stadium; National Taiwan University Hospital
Program Director Taipei, Taiwan
Sports Medicine Fellowship 31 Rheumatologic Rehabilitation
University of Washington School of Medicine;
Medical Director Vincent Huang, MD
Seattle Marathon Assistant Professor
Seattle, Washington Department of Rehabilitation and Human Performance
39 Sports Medicine and Adaptive Sports Icahn School of Medicine at Mount Sinai
New York, New York
Julie A. Hastings, MD 49 Spinal Cord Injury
Assistant Professor
Physical Medicine and Rehabilitation Elizabeth Huntoon, MS, MD
Creighton University School of Medicine - Phoenix Campus; Associate Professor
Assistant Clinical Professor Program Director Pain Medicine Fellowship
Physical Medicine and Rehabilitation Physical Medicine and Rehabilitation
University of Arizona College of Medicine Virginia Commonwealth University
Phoenix, Arizona Richmond, Virginia
22 Sexual Dysfunction and Disability 36 Lower Limb Pain and Dysfunction

Radha Holavanahalli, PhD Sarah K. Hwang, MD

Professor Assistant Professor
Physical Medicine and Rehabilitation Physical Medicine and Rehabilitation
University of Texas Southwestern Medical Center Shirley Ryan AbilityLab;
Dallas, Texas Assistant Professor
26 Burns Obstetrics and Gynecology
Northwestern University
Amy Houtrow, MD, PhD, MPH Chicago, Illinois
Professor of Physical Medicine and Rehabilitation and Pediatrics 38 Pelvic Floor Disorders
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania Shoji Ishigami, MD, PhD
7 Quality and Outcome Measures for Medical Rehabilitation Assistant Professor
Interventional Spine Clinic
David Hryvniak, DO Department of Neurosurgery
Assistant Professor West Virginia University School of Medicine
Physical Medicine and Rehabilitation WVU Rockefeller Neuroscience Institute
University of Virginia; Martinsburg, West Virginia
Team Physician 32 Common Neck Problems
University of Virginia Athletics
Charlottesville, Virginia; Therese M. Jacobson, DNP, APRN, CNS, CWOCN
Team Physician Nursing Quality Specialist
James Madison University Athletics Nursing
Harrisonburg, Virginia Mayo Clinic
15 Therapeutic Exercise Rochester, Minnesota
24 Prevention and Management of Chronic Wounds
 Contributors xi

Carlos Anthony Jaramillo, MD, PhD Lester J. Kiemele, PA-C, MPAS

Staff Physician Physician Assistant
Polytrauma Rehabilitation Center Vascular Medicine
Clinical and Research Faculty Mayo Clinic
Geriatric Research, Education and Clinical Center (GRECC) Rochester, Minnesota
South Texas Veterans Health Care System; 24 Prevention and Management of Chronic Wounds
Assistant Professor
Department of Rehabilitation Medicine Daniel J. Kim, MD
University of Texas Health Science Center The Ohio State University Wexner Medical Center
San Antonio, Texas Columbus, Ohio
30 Geriatrics 14 Wheelchairs and Seating Systems

Jeffrey Jenkins, MD Adam P. Klausner, MD

Associate Professor Professor and Director of Neurourology and Voiding
Physical Medicine and Rehabilitation Dysfunction
University of Virginia Warren Koontz Professor of Urologic Research
Charlottesville, Virginia Surgery/Urology
15 Therapeutic Exercise Virginia Commonwealth University
Midlothian, Virginia;
Mariana M. Johnson, MD Staff Urologist
Assistant Professor Surgery/Urology
Physical Medicine and Rehabilitation Hunter Holmes McGuire VA Medical Center
University of Texas Southwestern Medical Center Richmond, Virginia
Dallas, Texas 20 Neurogenic Lower Urinary Tract Dysfunction
1 The Physiatric History and Physical Examination
Amy L. Kolarova, DO
Stephen C. Johnson, MD, MS ABI Physician
Clinical Assistant Professor Rehabilitation Medicine
Sports and Spine Division Shepherd Center
Department of Rehabilitation Medicine Atlanta, Georgia
University of Washington 44 Stroke Rehabilitation
Seattle, Washington
33 Low Back Disorders Alicia M. Koontz, PhD, RET, ATP
Professor
Wade Johnson, DO Department of Rehabilitation Science and Technology
Senior Associate Consultant University of Pittsburgh;
Physical Medicine and Rehabilitation Associate Director for Research
Mayo Clinic Health System Human Engineering Research Laboratories
Mankato, Minnesota VA Pittsburgh Healthcare System
35 Upper Limb Pain and Dysfunction Pittsburgh, Pennsylvania
14 Wheelchairs and Seating Systems
Shawn Jorgensen, MD
Clinical Professor Karen Kowalske, MD
Physical Medicine and Rehabilitation Professor
Albany Medical Center Physical Medicine and Rehabilitation
Albany, New York; University of Texas Southwestern Medical Center
Adjunct Professor Dallas, Texas
Family Medicine 26 Burns
Larner Medical College at the University of Vermont
Burlington, Vermont Christina Kwasnica, MD
40 Motor Neuron Diseases Medical Director, Neurorehabilitation
Physical Medicine and Rehabilitation
Brian M. Kelly, DO Barrow Neurological Institute
Professor and Medical Director Phoenix, Arizona
Division of Orthotics and Prosthetics 43 Traumatic Brain Injury
Physical Medicine and Rehabilitation
Michigan Medicine Dong Rak Kwon, MD, PhD
University of Michigan Professor
Ann Arbor, Michigan Rehabilitation Medicine
11 Upper Limb Orthotic Devices School of Medicine
Catholic University of Daegu
Daegu, Republic of Korea
17 Physical Agent Modalities
xii Contributors

Scott R. Laker, MD Chuan-Chin Lu, MD

Associate Professor Attending Physician
Department of Physical Medicine and Rehabilitation Department of Rheumatology
University of Colorado School of Medicine Department of Physical Medicine and Rehabilitation
Denver, Colorado Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation;
39 Sports Medicine and Adaptive Sports Assistant Professor
Department of Physical Therapy
Erek W. Latzka, MD, RMSK Hungkuang University
Clinical Assistant Professor Taichung, Taiwan
Department of Rehabilitation Medicine 31 Rheumatologic Rehabilitation
University of Washington School of Medicine
Seattle, Washington Hui-Fen Mao, MS, OT
39 Sports Medicine and Adaptive Sports Associate Professor
School of Occupational Therapy
Melissa Lau, MD College of Medicine
Resident National Taiwan University;
Physical Medicine and Rehabilitation Occupational Therapist
The Ohio State University Department of Physical Medicine and Rehabilitation
Columbus, Ohio National Taiwan University Hospital
40 Motor Neuron Diseases Taipei, Taiwan
31 Rheumatologic Rehabilitation
Yong-Tae Lee, MD
Assistant Professor of Physical Medicine and Rehabilitation Craig M. McDonald, MD
Harvard Medical School; Professor and Chair
Chief Medical Information Officer Department of Physical Medicine and Rehabilitation
Staff Physiatrist Professor
Spaulding Rehabilitation Hospital Department of Pediatrics
Charlestown, Massachusetts University of California Davis Health
3 Rehabilitation of Swallowing Disorders Sacramento, California
42 Myopathic Disorders
Henry L. Lew, MD, PhD, ABPMR, CCC-A
Professor and Chair Christopher W. McMullen, MD, CAQSM
Department of Communication Sciences and Disorders Clinical Assistant Professor
John A. Burns School of Medicine Department of Rehabilitation Medicine
University of Hawai’i at Mānoa University of Washington School of Medicine
Honolulu, Hawaii; Seattle, Washington
Adjunct Professor 39 Sports Medicine and Adaptive Sports
Department of Physical Medicine and Rehabilitation
Virginia Commonwealth University School of Medicine Sudeep K. Mehta, MD
Richmond, Virginia Chief Resident
19 Assistive Technology and Environmental Control Devices Department of Physical Medicine and Rehabilitation
50 Auditory, Vestibular, and Visual Impairments East Carolina University/Vidant Medical Center
Greenville, North Carolina
Sheng Li, MD, PhD 13 Spinal Orthoses
Professor
Physical Medicine and Rehabilitation Michelle A. Miller, MD
University of Texas Health Science Center Assistant Clinical Professor
Houston, Texas Physical Medicine and Rehabilitation
23 Spasticity The Ohio State University;
Section Chief
Mark Linsenmeyer, MD Pediatric Physical Medicine
Brain Injury Medicine and Rehabilitation Nationwide Children’s Hospital
Physical Medicine and Rehabilitation Columbus, Ohio
Sunnyview Rehabilitation Hospital 2 Examination of the Pediatric Patient
Schenectady, New York
43 Traumatic Brain Injury Douglas P. Murphy, MD
Associate Professor
William Lovegreen, MS, CPO Department of Physical Medicine and Rehabilitation
Prosthetist-Orthotist Regional Clinical Director School of Medicine at Virginia Commonwealth University;
Physical Medicine and Rehabilitation Staff Physician, Physical Medicine and Rehabilitation
Veterans Administration Central Virginia Veterans Healthcare System
Richmond, Virginia Richmond, Virginia
10 Lower Limb Amputation and Gait 10 Lower Limb Amputation and Gait
12 Lower Limb Orthoses 12 Lower Limb Orthoses
 Contributors xiii

Ram N. Narayan, MBBS, CRND Sofiya Prilik, MD

Assistant Professor Clinical Director of Cardiac and Pulmonary Rehabilitation
Department of Neurology Rusk Rehabilitation
Barrow Neurological Institute NYU Langone Medical Center
Phoenix, Arizona New York, New York
46 Multiple Sclerosis 28 Chronic Medical Conditions: Pulmonary Disease, Organ
Transplantation, and Diabetes
Christian M. Niedzwecki, DO, MS
Assistant Professor David Z. Prince, MD, FAAPMR
Physical Medicine and Rehabilitation Assistant Professor of Rehabilitation Medicine
Baylor College of Medicine Albert Einstein College of Medicine;
Houston, Texas Director, Cardiopulmonary Rehabilitation
47 Cerebral Palsy Department of Rehabilitation Medicine
Montefiore Medical Center
John W. Norbury, MD The Bronx, New York
Assistant Professor 27 Acute Medical Conditions: Cardiopulmonary Disease,
Department of Physical Medicine and Rehabilitation Medical Frailty, and Renal Failure
Brody School of Medicine at East Carolina
University Abu A. Qutubuddin, MD, MBBS
Greenville, North Carolina Assistant Professor
13 Spinal Orthoses Director of Rehabilitation
Associate Director of Rehabilitation
Justin J.F. O’Rourke, PhD, ABPP Parkinson’s Disease Research Education and Clinical Center
Neuropsychologist Physical Medicine and Rehabilitation and Neurology
Polytrauma Rehabilitation Center Virginia Commonwealth University;
Veterans Affairs; Hunter Holmes McGuire VA Medical Center
Neuropsychologist Richmond, Virginia
Clinical Neuropsychology of Texas; 45 Degenerative Movement Disorders of the Central Nervous
Site Primary Investigator System
TBI Model Systems
San Antonio, Texas Mohammed I. Ranavaya, MD, JD, MS, FRCPI, CIME
4 Psychological Assessment and Intervention in Professor and Chief
Rehabilitation Division of Occupational Medicine
Joan C. Edwards School of Medicine at Marshall University;
Ajit B. Pai, MD President
Assistant Professor American Board of Independent Medical Examiners;
Department of Physical Medicine and Rehabilitation Medical Director
Virginia Commonwealth University; Appalachian Institute of Occupational and Environmental
Solutions Expert Medicine
Office of Electronic Health Record Modernization Huntington, West Virginia
Veterans Health Administration 5 Practical Aspects of Impairment Rating and Disability
Richmond, Virginia Determination
18 Integrative Medicine in Rehabilitation
Zachary J. Resch, MS
Atul T. Patel, MD, MHSA Doctoral Candidate
Vice President Psychology
Physical Medicine and Rehabilitation Rosalind Franklin University
Kansas City Bone and Joint Clinic Chicago, Illinois
Overland Park, Kansas 4 Psychological Assessment and Intervention in Rehabilitation
11 Upper Limb Orthotic Devices
Gianna M. Rodriguez, MD
Terri K. Pogoda, PhD Associate Professor
Research Health Scientist Physical Medicine and Rehabilitation
Center for Healthcare Organization and Implementation University of Michigan
Research Ann Arbor, Michigan
VA Boston Healthcare System; 21 Neurogenic Bowel: Dysfunction and Rehabilitation
Research Assistant Professor
Health Law, Policy, and Management Robert D. Rondinelli, MD, PhD
Boston University School of Public Health Staff Physiatrist
Boston, Massachusetts UnityPoint Health Des Moines
50 Auditory, Vestibular, and Visual Impairments Des Moines, Iowa
5 Practical Aspects of Impairment Rating and Disability
Determination
xiv Contributors

Brendon Scott Ross, DO, MS Anjali Shah, MD

Assistant Professor Associate Professor
Primary Care Sports Medicine Physical Medicine and Rehabilitation
Department of Orthopedic Surgery and Rehabilitation University of Texas Southwestern Medical Center
Medicine Dallas, Texas
University of Chicago 46 Multiple Sclerosis
Chicago, Illinois
16 Manipulation, Traction, and Massage Terrence P. Sheehan, MD
Chief Medical Officer
Adam Saby, MD Adventist Healthcare, Rehabilitation
Assistant Medical Director Rockville, Maryland;
Division of Occupational Health Medical Director
Department of Emergency Medicine Amputee Coalition of America
University of California, Los Angeles Washington, DC
Los Angeles, California 9 Rehabilitation and Prosthetic Restoration in Upper Limb
6 Occupational Medicine and Vocational Rehabilitation Amputation

Neelwant S. Sandhu, MD Lori V. Shuart, MS, RKT

Clinical Assistant Professor Supervisory Kinesiotherapist
Department of Rehabilitation Medicine Physical Medicine and Rehabilitation Service
University of Washington Central Virginia VA Healthcare System
Seattle, Washington Richmond, Virginia
33 Low Back Disorders 18 Integrative Medicine in Rehabilitation

Mark Schmeler, PhD, OTR/L, ATP Beth A. Sievers, MS, APRN, CNS, CWCN
Vice Chair for Education and Training Nursing
Associate Professor Mayo Clinic
Department of Rehabilitation Science and Technology Rochester, Minnesota
University of Pittsburgh 24 Prevention and Management of Chronic Wounds
Pittsburgh, Pennsylvania
14 Wheelchairs and Seating Systems Andrew Simoncini, MD
Staff Physician
Evan T. Schulze, PhD Physical Medicine and Rehabilitation
Instructor Southeast Louisiana Veterans Health Care System
Neurology New Orleans, Louisiana
Saint Louis University 12 Lower Limb Orthoses
St. Louis, Missouri
4 Psychological Assessment and Intervention in Mehrsheed Sinaki, MD, MS
Rehabilitation Consultant
Department of Physical Medicine and Rehabilitation
Aloysia L. Schwabe, MD Mayo Clinic;
Associate Professor Professor of Physical Medicine and Rehabilitation
Physical Medicine and Rehabilitation Mayo Clinic College of Medicine and Science
Baylor College of Medicine Rochester, Minnesota
Houston, Texas 34 Osteoporosis
47 Cerebral Palsy
Curtis W. Slipman, MD
Kelly M. Scott, MD 32 Common Neck Problems
Professor
Physical Medicine and Rehabilitation Sean Smith, MD
University of Texas Southwestern Medical Center Assistant Professor
Dallas, Texas Department of Physical Medicine and Rehabilitation
22 Sexual Dysfunction and Disability University of Michigan
38 Pelvic Floor Disorders Ann Arbor, Michigan
29 Cancer Rehabilitation
Young Il Seo, MD
Fellow
Physical Medicine and Rehabilitation
Hunter Holmes McGuire VA Medical Center
Richmond, Virginia
10 Lower Limb Amputation and Gait
 Contributors xv

Fantley Clay Smither, MD Chiemi Tanaka, PhD

Mayo Scholar Adjunct Assistant Professor
Physical Medicine and Rehabilitation Department of Communication Sciences and
Mayo Clinic; Disorders
Amputee Fellow University of Hawai’i at Manoa
Physical Medicine and Rehabilitation Honolulu, Hawaii;
Hunter Homes McGuire VA Medical Center Director
Richmond, Virginia Advanced Audiology Center
25 Vascular Diseases Audmet K.K., Kawasak-shi
Kanagawa, Japan
Jason R. Soble, PhD, ABPP 50 Auditory, Vestibular, and Visual Impairments
Assistant Professor of Clinical Psychiatry and Neurology
Psychiatry Kate E. Temme, MD
University of Illinois College of Medicine Assistant Professor
Chicago, Illinois Department of Physical Medicine and
4 Psychological Assessment and Intervention in Rehabilitation Rehabilitation
Department of Orthopaedic Surgery
Christopher J. Standaert, MD University of Pennsylvania
Visiting Associate Professor Philadelphia, Pennsylvania
Department of Physical Medicine and Rehabilitation 22 Sexual Dysfunction and Disability
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania Sruthi P. Thomas, MD, PhD
33 Low Back Disorders Assistant Professor
Physical Medicine & Rehabilitation and Neurosurgery
Steven P. Stanos, DO Baylor College of Medicine
Medical Director, Pain Medicine and Services Houston, Texas
Swedish Pain Services 47 Cerebral Palsy
Swedish Health System
Seattle, Washington Ronald B. Tolchin, DO
37 Chronic Pain Medical Director
Miami Neuroscience Institute Spine Center
Siobhan M. Statuta, MD, CAQSM Baptist Health South Florida
Associate Professor Miami, Florida;
Family Medicine and Physical Medicine & Rehabilitation; Voluntary Clinical Associate Professor
Director, Primary Care Sports Medicine Fellowship Department of Neuroscience
Family Medicine FIU Herbert Wertheim School of Medicine
University of Virginia Miami, Florida;
Charlottesville, Virginia Voluntary Clinical Associate Professor
15 Therapeutic Exercise Department of Medicine
Kiran C. Patel College of Osteopathic
Phillip M. Stevens, Med, CPO Medicine
Director Nova Southeastern University
Department of Clinical and Scientific Affairs Fort Lauderdale, Florida
Hanger Clinic; 16 Manipulation, Traction, and Massage
Adjunct Professor
Physical Medicine and Rehabilitation Mark D. Tyburski, MD
University of Utah Chief, Comprehensive Pain Management Department
Salt Lake City, Utah Department of Physical Medicine and Rehabilitation
10 Lower Limb Amputation and Gait The Permanente Medical Group, Inc.
Sacramento/Roseville, California
Steven A. Stiens, MD, MS 37 Chronic Pain
Curator of Education
Adjunct Clinical Professor
Geisinger Commonwealth School of Medicine
Seattle, Washington
21 Neurogenic Bowel: Dysfunction and Rehabilitation

Olaf Stüve, MD, PhD

Professor
Department of Neurology
University of Texas Southwestern Medical Center
Dallas, Texas
46 Multiple Sclerosis
xvi Contributors

Amy K. Wagner, MD Robert P. Wilder, MD

Professor Professor and Chair
Physical Medicine and Rehabilitation, Neuroscience, and Medical Director, The Runner’s Clinic at UVA
Clinical and the Translational Science Institute Physical Medicine and Rehabilitation
University of Pittsburgh; The University of Virginia
Director, Translational Research Charlottesville, Virginia
Director, Brain Injury Medicine Fellowship 15 Therapeutic Exercise
Physical Medicine and Rehabilitation
University of Pittsburgh Medical Center; Lisa M. Williams, MD
Associate Director, Rehabilitation Research Assistant Clinical Professor
Safar Center for Resuscitation Research Department of Physical Medicine and Rehabilitation
Training Faculty University of California, Davis
Center for Neuroscience Sacramento, California
University of Pittsburgh 42 Myopathic Disorders
Pittsburgh, Pennsylvania
43 Traumatic Brain Injury Laurie L. Wolf, MD, FAAPM+R
Chair
Tyng-Guey Wang, MD Physical Medicine and Rehabilitation
Professor Acuity Neurology
Physical Medicine and Rehabilitation Wausau, Wisconsin
College of Medicine 25 Vascular Diseases
National Taiwan University;
Attending Physician Weibin Yang, MD, MBA
Physical Medicine and Rehabilitation Associate Professor
National Taiwan University Hospital Physical Medicine and Rehabilitation
Taipei, Taiwan UT Southwestern School of Medicine;
17 Physical Agent Modalities Chief
Physical Medicine and Rehabilitation Service
Joseph B. Webster, MD VA North Texas Health Care System
Associate Professor Dallas, Texas
Department of Physical Medicine and Rehabilitation 7 Quality and Outcome Measures for Medical Rehabilitation
School of Medicine at Virginia Commonwealth University; 17 Physical Agent Modalities
Staff Physician, Physical Medicine and Rehabilitation
Central Virginia Veterans Healthcare System Michael R. Yochelson, MD, MBA
Richmond, Virginia Chief Medical Officer
10 Lower Limb Amputation and Gait Medical Affairs
12 Lower Limb Orthoses Shepherd Center;
Adjunct Professor
Justin L. Weppner, DO Rehabilitation Medicine
Assistant Professor Emory University
Physical Medicine and Rehabilitation; Atlanta, Georgia
Director, Neurorehabilitation 44 Stroke Rehabilitation
University of Virginia
Charlottesville, Virginia Mauro Zappaterra, MD, PhD
43 Traumatic Brain Injury Director of Multidisciplinary Care and Clinical Research
Synovation Medical Group
Jonathan H. Whiteson, MBBS Pasadena, California;
Associate Professor VA Staff Physician Physical Medicine and Rehabilitation
Rehabilitation Medicine and Medicine ­Residency Program
NYU School of Medicine; Greater Los Angeles VA Healthcare System
Vice Chair, Clinical Operations; Los Angeles, California
Medical Director, Cardiac and Pulmonary Rehabilitation 6 Occupational Medicine and Vocational Rehabilitation
Rehabilitation Medicine
Rusk Rehabilitation, NYU Langone Health
New York, New York
28 Chronic Medical Conditions: Pulmonary Disease, Organ
Transplantation, and Diabetes
Preface
This 6th Edition of Braddom’s Physical Medicine and Rehabilitation
supports the field’s ongoing transition into the future of health-
care, while also securely tethering learners to the more than seven
decades of formal specialty recognition and centuries of rehabili-
tative practice. Stem cells, genetic engineering, brain-computer
interface, osseointegration, wearable diagnostics, and implantable
stimulators are no longer simply within the realm of researchers
and inventors but are now a part of the modern-day practice of
physiatrists and other physical rehabilitation practitioners. At
the same time, there is a blossoming of acceptance and applica-
tion of integrative medicine, or whole-health, approach to care,
which has always been an overarching tenet of the field of physi-
cal medicine and rehabilitation (PM&R) for decades, across all of
medicine, along with an increasing appreciation of the importance
and necessity of the interdisciplinary team. Similarly, a renewed
focus on physical activity, nutrition, emotional health, mind-
body interactions, and other vital elements of wellness across the
lifespan have burgeoned in popularity, acceptance, and key com-
ponents of physiatric care. Finally, the field and this 6th Edition
have a continuing and growing emphasis on unique populations
of individuals at risk for or with disability, including servicemem-
bers and veterans, women, children, elders, athletes, and workers.
People are living longer, demanding more from their bodies and
minds, seeking more from healthcare providers and having higher
expectations for their recovery and functioning than ever before.
While earlier research or clinical successes revolved around lifesav-
ing or life-lengthening discoveries, approaches, and interventions,
today’s individuals with disabilities and their caregivers are not
only expecting to survive their acute incident or injury but also
to thrive and return to an even higher level of living, working,
and playing. The physiatrist is being asked to balance the holistic
approach with cutting edge technology, to combine modern sci-
ence with old-world beliefs and practices, and to heal the mind,
body, and soul. This textbook has met all of these manifold chal-
lenges by bringing together an internationally renowned team of
authors and associate editors from the full range of physical and
rehabilitation medicine practices and systems who have created
informative and practical chapters covering the breadth of the
field of PM&R. The best of academic medicine, private practice,
veterans and military health, all aspects of rehabilitative services,
integrative practitioners, and a wide range of specialty areas have
been brought together to provide the most up-to-date and useful
resource for the field. This 6th Edition of Braddom’s Physical Medicine
and Rehabilitation is the foundational textbook of PM&R, serves
as a key reference across all of the rehabilitation disciplines, and
now offers both the traditional core written materials as well
as state-of-the art virtual teaching and training materials from
the internet. As with the field itself, it has been reinvented and
improved to meet the ever-demanding needs of the practitioner
caring for the individual with disability.
David X. Cifu, MD
Editor in Chief
Braddom’s Physical Medicine and Rehabilitation;
Associate Dean for Innovation and Systems Integration
Herman J. Flax, MD Professor and Chairman, Department of
PM&R
Virginia Commonwealth University School of Medicine;
Senior TBI Specialist
U.S. Department of Veterans Affairs;
Principal Investigator
Chronic Effects of NeuroTrauma Consortium (CENC-LIMBIC)
xvii
Acknowledgments
This 6th Edition of Braddom’s Physical Medicine and Rehabili-
tation has been made possible by the efforts of more than 200
authors—physiatrists and other rehabilitation professionals from
a wide range of practice settings, backgrounds, and specialty areas
who have given of their time, effort, and knowledge because of
their commitment and dedication to the field and to the individu-
als with disability that they continually strive to partner with to
enhance their lives. These colleagues and friends have my deepest
gratitude and respect for their contributions. The individuals who
have helped, guided, persuaded, cajoled, and at times “strongly
encouraged” all of these brilliant authors are the six associate
editors—Karen Kowalske, Michelle Miller, Blessen Eapen, Jeffery
Johns, Gregory Worsowicz, and Henry Lew—who truly have been
the force driving the process forward and getting the very best for
each of the chapters and topic areas. I am thankful for their dili-
gence, oversight, and persistence. The editorial team at Elsevier,
xviii
led tirelessly by our Content Specialist, Humayra R. Khan; Senior
Content Development Specialist, Ann Ruzycka Anderson; and
Health Content Management Specialist, Kristine Feeherty,
have been the consummate professionals and have again proven
themselves to be the best of the best. Finally, a special thanks
goes out to the mentors, professors, teachers, and practitioners
who have helped to educate, shape, and train all of the indi-
viduals who contributed to this foundational textbook, for it is
through their efforts over the past several decades that there exist
so many skilled and dedicated professionals who could bring this
book together. Just as with the best physical and rehabilitation
medicine practices across the globe, it takes a dedicated team of
professionals working in harmony to achieve the best outcomes.
This textbook is what happens when those people work together
for the advancement of the field—a great outcome. My warmest
thanks.
 SE C T I ON 1 Evaluation
1
The Physiatric History and
Physical Examination
KIM D.D. BARKER AND MARIANA M. JOHNSON
The physiatric history and physical examination (H&P) serves
several purposes. It serves as a written record that communi-
cates to other rehabilitation and nonrehabilitation health care
professionals. It is the data platform from which a treatment
plan is developed. Finally, the H&P provides the basis for physi-
cian billing17 and serves as a medicolegal document. Physician
documentation has become the critical component in inpatient
rehabilitation reimbursement under prospective payment (e.g.,
interdisciplinary plan of care, admission screening), as well as
documentation for coverage by private insurers.18 The scope of
the physiatric H&P varies enormously, depending on the set-
ting, from the focused assessment of an isolated knee injury
in an outpatient setting to the comprehensive evaluation of a
patient with traumatic brain or spinal cord injury admitted for
inpatient rehabilitation. An initial evaluation is almost always
more detailed and comprehensive than subsequent or follow-
up evaluations. An exception would be when a patient is seen
for a follow-up visit with substantial new signs or symptoms.
While initially physicians in training and new physiatrists tend
to over-assess, with time, the experienced physiatrist develops an
intuition for how much detail is needed for each patient, given a
particular presentation and setting.
The physiatric H&P resembles the traditional format taught
in medical school but with an additional emphasis on history,
signs, and symptoms that affect function or performance. The
physiatric H&P also identifies those systems not affected that
might be used for compensation.22 Familiarity with the 1997
World Health Organization classification is invaluable in grasp-
ing the philosophic framework for viewing the evaluation of
persons with physical and cognitive disabilities (Table 1.1).73
Identifying and treating the primary impairments to maximize
performance becomes the primary thrust of physiatric evaluation
and treatment.
Patients cared for in rehabilitation medicine can be extremely
complicated and this should be reflected in the H&P. Confirma-
tion of historical and functional items by other team members,
health care professionals, and family members can take several days
and is often reflected in addendums or subsequent notes. Many of
the functional items discussed in this chapter will be assessed and
explored more fully by other interdisciplinary team members dur-
ing the course of inpatient or outpatient treatment. It is impera-
tive that the physiatrist stays abreast of additional information and
findings as they become available and that lines of verbal or writ-
ten communication be directed through the medical leadership
of the team.
The exact structure of the physiatric assessment is deter-
mined in part by personal preference, training background, and
institutional requirements (e.g., physician billing compliance
expectations, proper linkage to resident documentation, forms
committees, and regulatory oversight). The use of templates can
be invaluable in maximizing the thoroughness of data collection
and minimizing documentation time. Pertinent radiologic and
laboratory findings should be clearly documented. The essen-
tial elements of the physiatric H&P are summarized in Box 1.1.
Assessment of some or all of these elements is required for a
complete understanding of the patient’s state of health and the
illness for which he or she is being seen. These elements also
form the basis for a treatment plan.
Electronic medical records (EMRs) have significantly altered
the landscape for documentation of the physiatric H&P in both
the inpatient and outpatients settings.23 The tracking of a variety
of quality measures to justify “meaningful use” of the EMR and
grade the physician encounter is commonplace.37 Among the
advantages of the EMRs are increased legibility, a certain degree
of efficiency afforded by the use of templates and “smart phrases”
that can be tailored to individual practitioners or clinical presen-
tations, automated warnings regarding medication interactions
or errors, and faster and more accurate billing. Disadvantages
include the unacceptable use of the “copy and paste” function,
leading to redundancy among consecutive notes and the per-
petuation of potentially inaccurate information, automated
importation of data not necessarily reviewed by the practitioner
at the time of service, and “alarm fatigue.” As regulation of hos-
pital and physician practice and billing increases, the EMR will
become more important in ensuring the proper, and sometimes
convoluted, documentation required for safety initiatives28 and
physician payment.17
The Physiatric History
History-taking skills are part of the art of medicine and are required
to fully assess a patient’s presentation. One of the unique aspects of
physiatry is the recognition of functional deficits caused by illness
or injury. Identification of these deficits allows for the design of a
1
2 SE C T I O N 1 Evaluation

treatment program to restore performance. In a person with stroke,
for example, the most important questions for the physiatrist are
not only the etiology or location of the lesion but also “What func-
tional deficits are present as a result of the stroke?” The answer could
include deficits in swallowing, communication, mobility, cognition,
activities of daily living (ADL), or a combination of these.
TABLE  World Health Organization Definitions
1.1
Term Definition
Impairment Any loss or abnormality of body structure or of a
physiologic or psychological function (essentially
unchanged from the 1980 definition)
Activity The nature and extent of functioning at the level of
the person
Participation The nature and extent of a person’s involvement in life
situations in relationship to impairments, activities,
health conditions, and contextual factors
From World Health Organization: International classification of impairments, activities, and
participation, Geneva, 1997, World Health Organization, with permission of the World Health
Organization.
The time spent in taking a history also allows the patient to
become familiar with the physician, establishing rapport and
trust. This initial rapport is critical for a constructive and pro-
ductive doctor–patient–family relationship and can also help the
physician learn about sensitive areas, such as sexual history and
substance abuse. It can also have an impact on outcome because
a trusting patient tends to be a more compliant patient.60 Assess-
ment of the tone of the patient or family (e.g., anger, frustration,
resolve, and determination), an understanding of the illness,
insight into disability, and coping skills are also gleaned during
history taking. In most cases, the patient leads the physician to a
diagnosis and conclusion. In other cases, such as when the patient
is rambling and disorganized, frequent redirection and gentle refo-
cus are required.
Patients are generally the primary source of information.
However, patients with cognitive, mood (denial or decreased
insight), or communication deficits, as well as small children,
might not be able to fully express themselves. In these cases,
the history taker might rely on other sources, such as family
members; friends; other physicians, nurses, and medical pro-
fessionals; or previous medical records. When these sources
are used, the documentation should reflect this. This can also
have an impact on physician billing. Caution must be exer-
cised in using previous medical records because inaccuracies
are sometimes repeated from provider to provider, sometimes

 Essential Elements of the Physiatric History and Physical Examination

• BOX 1.1 
History Review of Systems
Chief Complaint
History of Present Illness Physical Examination
Onset General Examination
Location General appearance
Duration Head, eyes, ears, nose, throat
Character/quality Cardiac
Aggravating and alleviating maneuvers or activities Pulmonary
Radiation Abdominal
Timing Psychiatric
Severity Other pertinent systems
Associated signs and symptoms Neurologic Physical Examination
Previous treatments tried Mental status
Functional History • Level of consciousness
Bed mobility, transfers, wheelchair mobility, ambulation, devices used • Attention
Activities of daily living: eating, bathing, toileting, dressing, hygiene, • Orientation
grooming • Memory
Instrumental activities of daily living: meal preparation, laundry, home • General fund of knowledge
maintenance, pet care • Abstract thinking
Driving Communication
Persons who provide assistance, if any Cranial nerve examination
Sensation
Medical and Surgical History Motor control
Medications • Strength
Allergies • Coordination
Social History • Apraxia
Substance abuse • Involuntary movements
Home environment • Tone
Social support system
Vocational activities Reflexes
Recreational activities Musculoskeletal Physical Examination
Sexual history Inspection: appearance, symmetry, deformities
Palpation: pain, stability, range of motion, strength testing
Family History Joint-specific provocative maneuvers
 CHAPTER 1 The Physiatric History and Physical Examination 3

referred to as “chart lore.” The use of an interpreter to interview physical examination and develop a treatment plan with reason-
patients who are not fluent in the language of the examining able short- and long-term goals.
physician is mandatory. Assessing the potential for functional gain or deterioration
requires an understanding of the natural history, cause, and time
Chief Complaint of onset of the functional problems. For example, most spontane-
ous motor recovery after ischemic stroke occurs within 3 months
The chief complaint is the symptom or concern that caused the of the event.65 For a patient with considerable motor impairments
patient to seek medical treatment. The most common chief com- who recently sustained a stroke, there is a greater expectation for
plaints seen in an outpatient physiatric practice are pain, weak- significant functional gain than in a patient with minor deficits
ness, or gait disturbance of various musculoskeletal or neurologic related to a stroke that occurred 2 years previously.
origins. On a physiatric consultation or an inpatient rehabilitation
service, the predominant chief complaints are typically related to Mobility
mobility, ADL, communication, or cognitive deficits. Unlike the Mobility is the ability to move about in one’s environment.
relatively objective physical examination, the chief complaint is Because it plays such a vital role in society, any impairment related
purely subjective and, when possible, the physician should use the to mobility can have major consequences for a patient’s quality
patient’s own words. A patient can have several related or unre- of life. A clear understanding of the patient’s functional mobility
lated complaints, in which case it is helpful to have the patient is needed to determine independence and safety, including the
rank problems from “most bothersome” to “least bothersome” use of, or need for, mobility assistive devices. There is a range of
while reinforcing that only one or two of those problems will be mobility assistive devices that patients can use, such as crutches,
addressed at the current appointment. canes, walkers, orthoses, and manual and electric wheelchairs
The specific circumstance of a patient offering a chief com- (Table 1.2).
plaint can also allude to a degree of disability or handicap. For Bed mobility includes turning from side to side, going from the
example, knowing that an obese mail carrier has the chief com- prone to supine positions, sitting up, and lying down. A lack of
plaint of difficulty in walking because of knee pain could suggest bed mobility places the patient at greater risk for pressure ulcers,
not only the impairment but also an impact on his vocation and deep vein thrombosis, and pneumonia. In severe cases, bed mobil-
role as a provider for his family. ity can be so poor as to require a caregiver. In other cases, bed
At some institutions, coders recommend listing the patient’s rails might be appropriate to facilitate movement. Transfer mobil-
diagnosis as the chief complaint. This is contrary to medical train- ity includes getting in and out of bed, standing from the sitting
ing and the definition of chief complaint, but an awareness of local position, whether from a chair or toilet, and moving between a
hospital guidelines is essential, especially for inpatient admission. wheelchair and another seat (car seat or shower seat). Once again,
the history taker should assess the level of independence, safety,
History of the Present Illness and any changes in functional ability.
The history of the present illness (HPI) details the chief
complaint(s) for which the patient is seeking medical attention, as
well as any related or unrelated functional deficits. It should also TABLE
 Commonly Used Mobility Assistive Devices
explore other information relating to the chief complaint, such 1.2
as recent and past medical or surgical procedures, complications Category Example
of treatment, and potential restrictions or precautions. The HPI
should include some or all of eight components related to the Crutches Axillary crutches
chief complaint: location, time of onset, quality, context, severity, Forearm crutches
duration, modifying factors, and associated signs and symptoms. Canes Straight cane
As a case example, a 70-year-old man referred by his neurolo- Wide- or narrow-based quad cane
gist for physical therapy because the patient cannot walk prop- Hemiwalker
erly (chief complaint). Over the past few months (duration), he
Walkers Standard walker
has noted slowly progressive weakness of his left leg (location).
Rolling walker
Subsequent workup by his neurologist suggested amyotrophic Platform walker
lateral sclerosis (context). The patient was active in his life and
working up until a few months previously, ambulating without Wheelchairs
an assistive device (context). Now he uses a straight cane for fear types Manual
of falling (modifying factor). Besides difficulty with walking, the Powered
Lightweight
patient also has some trouble swallowing foods (associated signs
and symptoms). Common modifications or Folding or solid frame
specifications Elevated or removable leg rests
Removable armrests
Functional Status Reclining
Detailing the patient’s current and previous functional sta- Off-the-shelf ankle/foot orthoses
tus is an essential aspect of the physiatric HPI. This generally Common custom orthoses Plastic ankle-foot orthosis
entails better understanding of the issues surrounding mobility, Metal ankle-foot orthosis
ADL, instrumental activities of daily living (I-ADL), commu- Knee orthosis
nication, cognition, work, and recreation, among others. The Knee-ankle-foot orthosis
data should be as accurate and detailed as possible to guide the
4 SE C T I O N 1 Evaluation
Wheelchair mobility can be assessed by asking whether patients
can propel their wheelchair independently, how far or how long
they can go without resting, and whether they need assistance with
managing the wheelchair parts. It is also important to assess the
extent to which they can move about at home, in the community,
and up and down ramps. Whether the home is potentially wheel-
chair-accessible is particularly important in cases of new onset of
severe disability.
Ambulation can be assessed by how far or for how long patients
can walk, whether they require assistive devices, and if they need
rest breaks. It is also important to know whether any symptoms
are associated with ambulation, such as chest pain, shortness
of breath, pain, or dizziness. Ask patients about any history of
falling or instability while walking and their ability to navigate
uneven surfaces. Stair mobility, along with the number of stairs
the patient must routinely climb and descend at home or in the
community, and the presence or absence of handrails should also
be determined.
Driving is a crucial activity for many people, not only as a
means of transportation but also as an indicator and facilitator of
independence. For example, older adults who stop driving have an
increase in depressive symptoms.3 It is important to identify fac-
tors that might prevent driving, such as decreased cognitive func-
tion and safety awareness, and decreased vision or reaction time.
Other factors affecting driving can include lower limb weakness,
decreased sensation, contracture, tone, or incoordination. Some
of these conditions might require use of adaptive hand controls
for driving. Cognitive impairment sufficient to affect the ability
to drive can be due to medications or organic disease (demen-
tia, brain injury, stroke, or severe mood disturbance). Ultimately,
the risks of driving are weighed against the consequences of not
being able to drive. If the patient is no longer able to drive, alter-
natives to driving should be explored, such as the use of public,
assisted transportation, or ridesharing. Laws differ widely from
state to state on the return to driving after a neurologic impair-
ment develops.
Activities of Daily Living and Instrumental
Activities of Daily Living
ADL encompass activities required for personal care, includ-
ing feeding, dressing, grooming, bathing, and toileting. I-ADL
encompass more complex tasks required for independent living in
the immediate environment, such as care of others in the house-
hold, telephone use, meal preparation, house cleaning, laundry,
and in some cases use of public transportation. In the Occupa-
tional Therapy Practice Framework, there are 11 activities for both
ADL and I-ADL (Box 1.2).51
The clinician should identify and document ADL that the
patient can and cannot perform and determine the causes of limi-
tation. For example, a woman with a stroke might state that she
cannot put on her pants. This could be due to a combination of
factors, such as a visual field cut, balance problems, weakness, pain,
contracture, hypertonia, or deficits in motor planning. Some of
these factors can be confirmed later in the physical examination. A
more detailed follow-up to a positive response to the question is fre-
quently needed. For example, a patient might say “yes” to the ques-
tion “Can you eat by yourself?” On further questioning, it might be
learned that she cannot prepare the food by herself or cut the food
independently. The most accurate assessment of ADL and mobility
deficits often comes from the hands-on assessment by therapists and
nurses on the rehabilitation team or from the patient’s family.
 Activities of Daily Living and
• BOX 1.2 
Instrumental Activities of Daily Living
Activities of Daily Living
•  athing and showering
B
• Bowel and bladder management
• Dressing
• Eating
• Feeding
• Functional mobility
• Personal device care
• Personal hygiene and grooming
• Sexual activity
• Sleep and rest
• Toilet hygiene
Instrumental Activities of Daily Living
•  are of others (including selecting and supervising caregivers)
C
• Care of pets
• Child rearing
• Communication device use
• Community mobility
• Financial management
• Health management and maintenance
• Home establishment and management
• Meal preparation and cleanup
• Safety procedures and emergency responses
• Shopping
Cognition
Cognition is the mental process of knowing (please also refer to
Chapters 4). Although objective assessment of cognition comes
under physical examination (memory, orientation, and the ability
to assimilate and manipulate information), impairments in cogni-
tion can also become apparent during the course of the history
taking. Because persons with cognitive deficits may not recog-
nize their own impairments (agnosia), it is important to gather
information from family members and others familiar with the
patient. Cognitive deficits and limited awareness of these deficits
are likely to interfere with the patient’s rehabilitation program
unless specifically addressed. These deficits can pose a safety risk
as well. For example, a man with a previous stroke who falls, sus-
taining a hip fracture requiring replacement, might not be able
to follow hip precautions, resulting in possible refracture or hip
dislocation. Executive functioning is another aspect of cognition,
which includes the mental functions required for planning, prob-
lem solving, and self-awareness. Executive functioning correlates
with functional outcome because it is required in many real-world
situations. Asking the basic questions of the mental status exami-
nation (MSE) will not give a complete picture of mental function,
particularly for issues such as impulsivity or judgment.43
Communication
Communication skills are used to convey information including
thoughts, needs, and emotions. Verbal expression deficits can be
subtle and might not be noticed in a first encounter. If there is a
reason to think that speech or communication has been affected
by a recent event, it is advisable to ask family members if they
have noticed recent changes. Patients who cannot communicate
through speech might or might not be able to communicate
through other means, known as augmentative communication,
depending on the type of communication dysfunction and other
 CHAPTER 1
physical and cognitive limitations. This can include writing and
physicality (such as sign language, gestures, and body language).
They can also use a variety of augmentative communication aids
ranging from simple picture, letter, and word boards to electronic
devices (please also refer to Chapter 19).
Past Medical and Surgical History
The physiatrist should understand the patient’s past medical and
surgical history. This knowledge allows the physiatrist to under-
stand how preexisting illnesses affect current status and how to
tailor the rehabilitation program for precautions and limitations.
The patient’s medical history can also have a major impact on
rehabilitation outcome.
Cardiopulmonary
Mobility, ADL, I-ADL, work, and leisure can be severely com-
promised by cardiopulmonary deficits. Ask the patient about any
history of congestive heart failure, recent and distant myocardial
infarction, arrhythmias, and coronary artery disease. Past surgical
procedures, such as bypass surgery, stent placement, valve replace-
ment or repair, heart transplantation, and recent diagnostic testing
(e.g., stress test or echocardiogram) should be ascertained. This
information is important to ensure that exercise prescriptions do
not exceed cardiovascular activity limitations. Patients with pul-
monary disease should also be asked about their activity tolerance,
surgery, such as lung volume reduction or lung transplant, and
their use of home oxygen. It is also important to identify modifi-
able risk factors for cardiopulmonary disease, such as smoking,
hypertension, and obesity. Often, medication adjustment to
maximize cardiac and pulmonary function accompanies mobiliza-
tion. Dyspnea from congestive heart failure or chronic obstructive
pulmonary disease can be a significant contributor to functional
limitations. A rehabilitation plan may include teaching energy
conservation and compensatory strategies to maximize indepen-
dence in the context of disease (please also refer to Chapters 27
and 28).
Musculoskeletal
There can be a wide range of musculoskeletal disorders from acute
traumatic injuries to gradual functional decline with chronic
osteoarthritis. Ask the patient about a history of trauma, rheu-
matological disease, amputation, joint contractures, musculoskel-
etal pain, congenital or acquired muscular problems, weakness, or
instability. It is important to understand the functional impact of
such impairments or disabilities. Patients with chronic physical
disability often develop overuse musculoskeletal syndromes, such
as the development of shoulder pain secondary to chronically pro-
pelling a wheelchair.34
Neurologic Disorders
Preexisting congenital or acquired neurologic disorders can
have a profound impact on the patient’s function and recovery
from both neurologic and nonneurologic illness. It is helpful to
know whether a neurologic disorder is congenital compared with
acquired, progressive compared with nonprogressive, central com-
pared with peripheral, demyelinating compared with axonal, or
sensory compared with motor. This information can be helpful in
understanding the pathophysiology, location, severity, prognosis,
and implications for management. The interviewer must assess the
premorbid need for assistive devices, orthoses, and the degree of
speech, swallowing, and cognitive impairments.
The Physiatric History and Physical Examination 5
Medications
All medications need to be documented, including prescription
and over-the-counter drugs, as well as nutraceuticals, supple-
ments, herbs, and vitamins. Medications should be documented
from the last institutional venues (acute care, nursing home) and
from home before institutionalization. Decreasing medication
errors by means of medication reconciliation is a major push of
the National Patient Safety Goals initiative.25 Physicians should
be aware that patients might not mention medications that they
do not think are relevant to their current problem, unless asked
about them in detail. It is especially important to gather the com-
plete list of medications being used by patients who are seeing
multiple physicians. Particular attention should be paid to nonste-
roidal antiinflammatory agents because these are commonly pre-
scribed by physiatrists for musculoskeletal disorders and caution
must be taken not to double dose the patient or prescribe them
for patients with kidney dysfunction, heart disease, or bleeding
disorder.28,33 The indications, precautions, and side effects of all
drugs prescribed should be explained to the patient. Drug and
food allergies should also be noted.
Social History
Home Environment and Living Situation
Understanding the patient’s home environment and living situa-
tion includes asking if the patient lives in a house or an apartment,
if there is ramp and/or elevator access, whether it is wheelchair
accessible, if there are stairs, whether the bathroom is accessible
from the bedroom, and whether the bathroom has grab bars or
handrails (and on which side). A home visit, if possible, provides
the best assessment. If there is no family or friend that can be a
caregiver at home, the patient could require a home health aide or
hired caregiver. These factors help determine many aspects of the
discharge plan.
Family and Friends Support
Patients who have lost function might require supervision, emo-
tional support, or actual physical assistance. Family, friends, and
neighbors who can provide such assistance should be identified.
The physiatrist should discuss the level of assistance the identified
caregivers are willing and able to provide. The assistance provided
by caregivers can be limited if they are elderly, have some type of
impairment, work, or are not willing to assist with bowel or blad-
der hygiene.
Substance Abuse
Patients should be asked about their history of smoking, alcohol
use or abuse, marijuana use in states where it is legal, and illicit
drug abuse. Because patients often deny substance abuse, this topic
should be discussed in a nonjudgmental manner. Patients frequently
feel embarrassment or guilt in admitting substance abuse and also
fear the legal consequences of such an admission. Substance abuse
can be a direct or indirect cause of disability and can influence neu-
rorecovery in traumatic brain injury.20 It can also have an impact
on community reintegration because patients with pain or depres-
sion are at risk for further abuse. Patients who are at risk should
be referred to social work to explore options for further assistance,
either during the acute rehabilitation or later in the community.
Sexual History
Patients and health care practitioners alike are often uncom-
fortable discussing the topic of sexuality, so developing a good
6 SE C T I O N 1 Evaluation
rapport during history taking can be helpful. Discussion of this
topic is easier if the health care practitioner has a basic knowl-
edge of how sexual function can be changed by illness or injury.
Sexuality is particularly important to patients in their reproduc-
tive years (such as with many spinal cord- and brain-injured
persons), but the physiatrist should inquire about sexuality in
adolescents and adults, including older adults. Sexual orienta-
tion, birth control, safe sex practices, and desire for pregnancy,
should be addressed when appropriate (please also refer to
Chapter 22).
Vocational Activities
Vocation is not only a source of financial security but also sig-
nificantly relates to self-confidence and even identity. The history
should include the patient’s educational level and recent work
history. Employment history must extend past a job title and
include physical, as well as cognitive requirements. One should
also ask about the ability to fulfill job requirements after the injury
or illness. If an individual cannot fully regain a previous level of
function, then explore available vocational options. It is possible
that the work environment can be modified to compensate for a
functional loss or minimize musculoskeletal pain complaints. An
example of this would be the installation of a wheelchair ramp for
an accountant with paraplegia. Vocational planners and referral
to state vocational agencies may facilitate work re-entry planning
(please also refer to Chapter 22).
Finances and Income Maintenance
Patients can have financial concerns that are attributable to or
exacerbated by their illness or injury. The rehabilitation team social
worker can also address these concerns. Whether a patient has the
financial resources or insurance to pay for adaptive devices, such
as a ramp or mobility equipment, can significantly affect discharge
planning. If patients cannot safely be discharged home, skilled
nursing facility or alternate placement may need to be explored, at
least on a temporary basis.
Recreation
The ability to engage in hobbies and recreational activities is
important to most people, and any loss or limitation of the ability
to perform these activities can be stressful. Recreation is a primary
outcome in sports medicine. The recreational activity affected
can involve physical exercise, such as a sporting activity, or can
be more sedentary, such as playing cards. The team recreational
therapist can be helpful in assisting to restore the patient’s favorite
recreations and offer new ones.
Psychosocial History
The history taker must recognize the psychosocial impact of
impairment. Beyond the loss of function, the patient can also feel
a loss of overall health, body image, mobility, or independence.
The loss of function, and possibly of income as well, can place
great stress on the family unit and caregivers. The treatment plan
should recognize the patient’s psychosocial context and provide
assistance in developing coping strategies, especially for depres-
sion and anxiety. This can help accelerate the patient’s process of
adjusting to a new disability.
Spirituality
Spirituality is an important part of the lives of many patients, and
some preliminary studies indicate that it can have positive effects
on rehabilitation, life satisfaction, and quality of life.13 Health care
providers should be sensitive to the patient’s spiritual needs, and
appropriate referral or counseling should be provided.19
Litigation
Patients should be asked in a nonjudgmental manner whether
they are involved in litigation related to their illness, injuries, or
functional impairment. The answer should not change the treat-
ment plan, but litigation can be a source of anxiety, depression, or
guilt. In some cases, the patient’s legal representative can play an
important role in obtaining needed services and equipment.
Family History
Ask patients about the health, or cause and age of death, of parents
and siblings. It is always important to know whether any family
members have a similar condition, either to assist with diagnosis
or to better understand anxieties experienced by the patient. They
should also be asked about any family history of heart disease,
diabetes, cancer, stroke, arthritis, hypertension, or neurologic ill-
ness. This will help identify genetic disorders within the family.
Knowledge of the general health of family members can also pro-
vide insight into their ability to provide functional assistance to
the patient.
Review of Systems
A detailed review of organ systems should be done to discover any
problems or diseases not previously identified during the course
of the history taking. More detailed questioning in certain organ
systems may be necessary, particularly as it relates to a patient’s
primary diagnosis.
The Physiatric Physical Examination
Neurologic Examination
Neurologic problems are common in the setting of inpatient and
outpatient rehabilitation, including functional deficits in persons
with conditions such as stroke, multiple sclerosis, peripheral neu-
ropathy, spinal cord injury, brain injury, neuro-oncological, and
spine disease. The neurologic examination should be conducted
in an organized manner to confirm or reconfirm the neurologic
disorder and subsequently to identify which components of the
nervous system are the most and the least affected.15,71 Identify
the precise location of the lesion, if possible, as well as the impact
of the neurologic deficits on the overall function and mobility of
the patient. If a cause of the patient’s condition has not been iden-
tified at presentation to the rehabilitation provider, a differential
diagnosis list should be developed, the neurologic examination
tailored appropriately, and consultations garnered, if indicated.
An accurate and efficient neurologic examination requires that the
examiner have a thorough knowledge of both central and periph-
eral neuroanatomy.
Weakness is a primary sign in neurologic disorders and is seen
in both upper motor neuron (UMN) and lower motor neuron
(LMN) disorders. UMN lesions involving the central nervous sys-
tem (CNS) are typically characterized by hypertonia, weakness,
and hyperreflexia without significant muscle atrophy, fascicula-
tion, or fibrillation (on electromyography). They tend to occur in
a hemiparetic, paraparetic, and tetraparetic pattern. UMN causes
include stroke, multiple sclerosis, traumatic and nontraumatic
brain and spinal cord injuries, and neurologic cancers, among
others. LMN defects are characterized by hypotonia, weakness,
 CHAPTER 1 The Physiatric History and Physical Examination 7

hyporeflexia, significant muscle atrophy, fasciculations, and elec- TABLE

tromyographic changes. They occur in the distribution of the 1.3
 Glasgow Coma Scale
affected nerve root, peripheral nerve, or muscle. UMN and LMN
lesions often coexist; however, the LMN system is the final com- Function Rating
mon pathway of the nervous system. An example of this is an Eye Opening E
upper trunk brachial plexus injury on the same side as spastic
hemiparesis in a person with traumatic brain injury.3 Spontaneous 4
Similar to physical examination in other organ systems, testing To speech 3
of one neurologic system is often predicated by the normal func-
tioning of other systems. For example, severe visual impairment To pain 2
can be confused with cerebellar dysfunction, as many cerebellar Nil 1
tests have a visual component. Consider the integrated functions
of all organ systems to provide an accurate clinical assessment Best Motor Response M
and potential limitations of the examination. The examiner must Obeys 6
keep in mind that the majority of the neurologic examination is
subjective so unusual findings, such as sensory changes that split Localizes 5
the midline or inconsistent muscle strength, may suggest a nonor- Withdraws 4
ganic etiology, such as functional neurologic disorder or malinger-
Abnormal flexion 3
ing. However, these diagnoses can only be made when underlying
disease is thoroughly excluded. Looking closely for sensory pat- Extensor response 2
terns, atrophy, reflexes, and cranial nerve findings may help clarify
Nil 1
if findings are organic. Functional assessment may also help with
sorting out inconsistent findings. Verbal Response V
Oriented 5
Mental Status Examination
Confused conversation 4
Perform the MSE in a comfortable setting where the patient is
Inappropriate words 3
not likely to be disturbed by external stimuli, such as televisions,
telephones, pagers, conversation, or medical alarms. Having a Incomprehensible sounds 2
familiar person, such as a spouse or relative, in the room may help Nil 1
reassure the patient. The bedside MSE might need to be supple-
mented by observations in therapy and in a far more detailed and Coma Score (E + M + V) 3–15
standardized evaluation performed by neuropsychologists, espe-
From Jennett B, Teasdale G: Assessment of impaired consciousness, Contemp Neurosurg
cially in cases of vocational and educational reintegration. General 20:78, 1981, with permission.
observation should include grooming (clean, disheveled), posture,
tracking (with severe disorders of consciousness), interactions
with present family or friends, and environmental clues (carry-
ing a book, ability to prepare for the examination independently). state is characterized by the presence of sleep-wake cycles but
Language is the gateway for assessment of cognition and is there- still no contingent relationship. Minimally conscious state indi-
fore limited in persons with significant aphasia. cates a patient who remains severely disabled but demonstrates
sleep-wake cycles and even inconsistent, nonreflexive, contingent
Level of Consciousness behaviors in response to a specific environmental stimulation. In
Consciousness is the state of awareness of one’s surroundings. A acute settings, the Glasgow Coma Scale is the most often used
functioning pontine reticular activating system is necessary for objective measure to document level of consciousness, assessing
normal conscious functioning. The conscious patient is awake and eye opening, motor response, and verbal response (Table 1.3).30
responds directly and appropriately to varying stimuli. Decreased
consciousness can significantly limit the MSE and the general Attention
physical examination. Attention is the ability to address a specific stimulus for a short
The examiner should understand the various levels of con- period without being distracted by internal or external stimuli.62
sciousness. Lethargy is the general slowing of motor processes (e.g., Vigilance is the ability to hold attention over longer periods. For
speech and movement) in which the patient can easily fall asleep example, with inadequate vigilance, a patient can begin a complex
if not stimulated but is easily aroused. Obtundation is a dulled or task but be unable to sustain performance to completion. Atten-
blunted sensitivity in which the patient is difficult to arouse and, tion is tested by digit recall, where the examiner reads a list of ran-
once aroused, is still confused. Stupor is a state of semiconscious- dom numbers and the patient is asked to repeat those numbers.
ness characterized by arousal only by intense stimuli, such as sharp The patient should repeat digits both forward and backward. A
pressure over a bony prominence (e.g., sternal rub), and the patient normal performance is repeating seven numbers in the forward
has few or even no voluntary motor responses.53 The Aspen Neu- direction, with fewer than five indicating significant attention
robehavioral Conference proposed, and several leading medical deficits.49,62
organizations have endorsed, three terms to describe severe altera-
tions in consciousness.30 In coma, the eyes are closed with absence Orientation
of sleep-wake cycles and no evidence of a contingent relationship Orientation is necessary for basic cognition. Orientation is com-
between the patient’s behavior and the environment.30 Vegetative posed of four parts: person, place, time, and situation. After asking
8 SE C T I O N 1 Evaluation
the patient’s name, place can be determined by asking the location
the patient is currently in or her or his home address. Time is
assessed by asking the patient the time of day, the date, the day of
the week, or the year. Situation refers to why the patient is in the
hospital or clinic. Time sense is usually the first component lost,
and the person is typically the last to be lost. Temporary stress can
account for a minor loss of orientation; however, major disorienta-
tion usually suggests an organic brain syndrome.66
Memory
The components of memory include learning, retention, and
recall. During the bedside examination, the patient is typically
asked to remember three or four objects or words. The patient is
then asked to repeat the items immediately to assess immediate
acquisition (encoding) of the information. Retention is assessed
by recall after a delayed interval, usually 5 to 10 minutes. If the
patient is unable to recall the words or objects, the examiner can
provide a prompt (e.g., “It is a type of flower” for the word “tulip”).
If the patient still cannot recall the words or objects, the examiner
can provide a list from which the patient can choose (e.g., “Was
it a rose, a tulip, or a daisy?”). Although abnormal scores must be
interpreted within the context of the remaining neurologic exami-
nation, normal individuals younger than 60 years should recall
three of four items.62
Recent memory can also be tested by asking questions about
the past 24 hours, such as “How did you travel here?” or “What
did you eat for breakfast this morning?” Assuming the informa-
tion can be confirmed, remote memory is tested by asking where
the patient was born or the school or college attended.44 Visual
memory can be tested by having the patient identify (after a few
minutes) four or five objects hidden in clear view.
General Fundamentals of Knowledge
Intelligence is a global function derived from the general tone and
content of the examination and encompasses both basic intel-
lect and remote memory. The examiner should note the patient’s
educational level and highest grade completed during the history.
Examples of questions that can be asked include names of impor-
tant elected officials, such as the current president of the United
States or recent past presidents. It can be difficult to identify when
a patient with a very high intelligence premorbidly drops to a
more average level after injury or illness. The history of memory or
intellectual decline from a family member or close friend should
prompt further evaluation of the patient.
Abstract Thinking
Abstraction is a higher cortical function and can be tested by the
interpretation of common proverbs such as “a stitch in time saves
nine” or “when the cat’s away the mice will play,” or by asking
similarities, such as “How are an apple and an orange alike?” A
concrete explanation for the first proverb would be “You should
sew a rip before it becomes bigger,” whereas an abstract explana-
tion would be “Quick attention to a given problem would prevent
bigger troubles later.” An abstract response to the similarity would
be “They are both kinds of fruit,” and a concrete response would
be “They are both round” or “You can eat them both.” Most nor-
mal individuals should be able to provide abstract responses. A
patient also demonstrates abstraction when he or she understands
a humorous phrase or situation. Persons with dementia, develop-
mental delay, or limited education may give concrete responses.
Abstract thinking should always be considered in the context of
intelligence and cultural differences.66
Insight and Judgment
Insight has been conceptualized into three components: awareness
of impairment, need for treatment, and attribution of symptoms.
Insight can be ascertained by asking what brought the patient into
the hospital or clinic.11 Recognizing that one has an impairment is
the initial step for recovery. A lack of insight can severely hamper
a patient’s progress in rehabilitation and is a major consideration
in developing a safe discharge plan. Insight can be difficult to dis-
tinguish from psychological denial.
Judgment is an estimate of a person’s ability to solve real-life
problems. The best indicator is usually simply observing the
patient’s behavior. Judgment can also be assessed by noting the
patient’s responses to hypothetical situations in relation to family,
employment, or personal life. Hypothetical examples of judgment
that reflect societal norms include “What should you do if you
find a stamped, addressed envelope?” or “How are you going to
get around the house if you have trouble walking?” However, these
are much less reliable than real world assessment of judgement.
Judgment is a complex function that is part of the maturational
process and is consequently unreliable in children and variable in
the adolescent years.67 Assessment of judgment is important to
assess the patient’s capacity for independent functioning.
Mood and Affect
Mood can be assessed by asking: “Do you often feel sad or depressed?”69
Establishing accurate information pertaining to the length of a partic-
ular mood is important. The examiner should document if the mood
has been reactive (e.g., sadness in response to a recent disabling event
or loss of independence) and whether the mood has been stable or
unstable. Mood can be described in terms of being, including happy,
sad, euphoric, blue, depressed, angry, or anxious.
Affect describes how a patient feels at a given moment, which
can be described by terms, such as blunted, flat, inappropriate,
labile, optimistic, or pessimistic. It can be difficult to accurately
assess mood in the setting of moderate to severe acquired brain
injury. A patient’s affect is determined by the observations made
by the examiner during the interview.12
General Mental Status Assessment
The Folstein Mini-Mental Status Examination is a brief and conve-
nient tool to test general cognitive function. It is useful for screen-
ing patients for dementia and brain injuries. Of a maximum 30
points, a score of 24 or above is considered within the normal
range.30 Also available is the easily administered Montreal Cog-
nitive Assessment.50 The clock-drawing test is another quick test
sensitive to cognitive impairment. The patient is instructed as fol-
lows: “Without looking at your watch, draw the face of a clock, and
mark the hands to show 10 minutes to 11 o’clock.” This task uses
memory, visual spatial skills, and executive functioning. The draw-
ing is scored on the basis of whether the clock numbers are generally
intact or not intact out of a maximum score of 10.63 The use of the
three-word recall test in addition to the clock-drawing test, which is
known collectively as the Mini-Cog Test, has recently gained popu-
larity in screening for dementia. The Mini-Cog Test can usually be
completed within 2 to 3 minutes.58 The reader is referred to other
excellent descriptions of the MSE for further reading.62
Communication
Aphasia
Aphasia involves the loss of production or comprehension of lan-
guage. The cortical center for language resides in the dominant
 CHAPTER 1
hemisphere. Naming, repetition, comprehension, and fluency are
the key components of the physician’s bedside language assess-
ment. The examiner should listen to the content and fluency of
speech. Testing of comprehension of spoken language should
begin with single words, progress to sentences that require only
yes/no responses, and then progress to complex commands. The
examiner should also assess visual naming, repetition of single
words and sentences, word-finding abilities, and reading and writ-
ing from dictation and then spontaneous reading and writing.
Circumlocutions are phrases or sentences substituted for a word
the person cannot express, such as responding “What you tell time
with on your wrist” when asked to name a watch. Alexia without
agraphia is seen in dominant occipital lobe injury. Here the patient
is able to write letters and words from a spoken command but is
unable to read the information after dictation.14 Some commonly
used standardized aphasia measures include the Boston Diagnos-
tic Aphasia Examination and the Western Aphasia Battery (please
also refer to Chapter 3).64
Dysarthria
Dysarthria refers to defective articulation but with the content of
speech unaffected. The examiner should listen to spontaneous
speech and then ask the patient to read aloud. Key sounds that can
be tested include “ta ta ta,” which is made by the tongue (lingual
consonants); “mm mm mm,” which is made by the lips (labial
consonants); and “ga ga ga,” which is made by the larynx, phar-
ynx, and palate (glottal consonants).44 There are several subtypes
of dysarthria, including spastic, ataxic, hypokinetic, hyperkinetic,
and flaccid.49
Dysphonia
Dysphonia is a deficit in sound production and can be secondary
to respiratory disease, fatigue, or vocal cord paralysis, which is seen
both with neurologic conditions and after intubation. The best
method to examine the vocal cords is by indirect laryngoscopy.
Asking the patient to say “ah” while viewing the vocal cords is
used to assess vocal cord abduction. When the patient says “e,” the
vocal cords will adduct. Patients with weakness of both vocal cords
will speak in whispers with the presence of inspiratory stridors.44
Verbal Apraxia
Apraxia of speech involves a deficit in motor planning (i.e.,
awkward and imprecise articulation in the absence of impaired
strength or coordination of the motor system). It is characterized
by inconsistent errors when speaking. A difficult word might be
spoken correctly, but trouble is experienced when repeating it.
People with verbal apraxia of speech often appear to be “groping”
for the right sound or word and might try to speak a word several
times before saying it correctly. Test verbal apraxia by asking the
patient to repeat words with an increasing number of syllables.
Oromotor apraxia is seen in patients with difficulty organizing
non-speech oral motor activity. This can adversely affect swallow-
ing. Tests for oromotor apraxia include asking patients to stick out
their tongue, show their teeth, blow out their cheeks, or pretend
to blow out a match (please also refer to Chapter 3, Speech and
Swallowing Disorders).57
Cognitive Linguistic Deficits
Cognitive linguistic deficits involve the pragmatics and context
of communication. Examples can include confabulation after a
ruptured aneurysm of the anterior communicating artery or dis-
inhibited or sexually inappropriate comments from a patient with
The Physiatric History and Physical Examination 9
frontal lobe damage after a traumatic brain injury. Cognitive lin-
guistic deficits are distinguished from fluent aphasias (Wernicke
aphasia) by the presence of relatively normal syntax and grammar.
Cranial Nerve Examination
Cranial Nerve I: Olfactory Nerve
The examiner should test both perception and identification of
smell with aromatic nonirritating materials that avoid stimulation
of the trigeminal nerve fibers in the nasal mucosa.57 The patient
is asked to close the eyes while the opposite nostril is compressed
separately. The patient should identify the smell in a test tube con-
taining a common substance with a characteristic odor, such as
coffee, peppermint, or soap. The olfactory nerve is the most com-
monly injured cranial nerve (CN) in head trauma, resulting from
shearing injuries with or without fractures of the cribriform plate,
making testing in this population an essential part of the physical
examination.5 This nerve is not actually routinely assessed dur-
ing a neurologic examination. However, because smell can alter a
person’s appetite, testing is warranted in patients with brain injury
who have an unusual loss of or gain in weight.57
Cranial Nerve II: Optic Nerve
The optic nerve is assessed by testing for visual acuity and visual
fields, and by performing an ophthalmologic examination.
Visual acuity refers to central vision, whereas visual field test-
ing assesses the integrity of the optic pathway as it travels from
the retina to the primary visual cortex. Assessing visual acuity is
often performed by using a Snellen chart or similar card and test-
ing one eye while the other is covered. Confrontation is the most
common way of testing visual fields. The patient faces the exam-
iner while covering one eye, so the other eye fixates on the oppo-
site eye of the examiner directly in front. The examiner wiggles
a finger at the outer boundaries of the four quadrants of vision
while the patient points to the quadrant where he or she senses
movement. More accurately, a red 5-mm pin can be used to map
out the visual field.5 For patients with visual field and extraocu-
lar movement deficits (see following discussion), further assess-
ment by a neuro-optometrist or a visually trained occupational
therapist can be helpful. Changes in vision can significantly alter
a person’s functioning and independence, for example, by caus-
ing blindness or altering depth perception. Testing both acuity
and visual fields in any person with a stroke or brain injury is
essential.
Cranial Nerves III, IV, and VI: Oculomotor, Trochlear, and
Abducens Nerves
These three CNs are best tested together because they are all
involved in ocular motility. The oculomotor nerve (III) provides
innervation to all the extraocular muscles except the superior
oblique and lateral rectus, which are innervated by the trochlear
(IV) and abducens nerves (VI), respectively. The oculomotor
nerve also innervates the levator palpebrae muscle, which elevates
the eyelid, the pupilloconstrictor muscle that constricts the pupil,
and the ciliary muscle that controls the thickness of the lens in
visual accommodation.
The primary action of the medial rectus is adduction (look-
ing in) and that of the lateral rectus is abduction (looking out).
The superior rectus and inferior oblique primarily elevate the eye,
whereas the inferior rectus and superior oblique depress the eye.
The superior oblique muscle controls gaze looking down, espe-
cially in adduction.44
10 SE C T I O N 1 Evaluation
Examination of the extraocular muscles involves assessing the
alignment of the patient’s eyes while the eyes are at rest and when
the eyes are following an object or finger held at an arm’s length.
The examiner should observe the full range of horizontal and
vertical eye movements in the six cardinal directions.5 The optic
(afferent) and oculomotor (efferent) nerves are involved with the
pupillary light reflex. A normal pupillary light reflex (CNs II and
III) should result in constriction of both pupils when a light stimu-
lus is presented to either eye separately. A characteristic head tilt
when looking down is sometimes seen in CN IV lesions.72
Cranial Nerve V: Trigeminal Nerve
The trigeminal nerve provides sensation to the face and mucous
membranes of the nose, mouth, and tongue. There are three sen-
sory divisions of the trigeminal nerve: the ophthalmic, maxillary,
and mandibular branches. These branches can be tested by pin-
prick sensation, light touch, or temperature along the forehead,
cheeks, and jaw on each side of the face. The motor branch of
the trigeminal nerve also innervates the muscles of mastication,
which include the masseters, the pterygoids, and the tempora-
lis. The patient is asked to clamp the jaws together, and then the
examiner will try to open the patient’s jaw by pulling down on the
lower mandible. Observe and palpate for contraction of both the
temporalis and the masseter muscles. The pterygoids are tested
by asking the patient to open the mouth. If one side is weak, the
intact pterygoid muscles will push the weak muscles, resulting in
a deviation toward the weak side. The corneal reflex tests the oph-
thalmic division of the trigeminal nerve (afferent) and the facial
nerve (efferent).
Cranial Nerve VII: Facial Nerve
The facial nerve provides motor innervation to all muscles of facial
expression; provides sensation to the anterior two-thirds of the
tongue and the external acoustic meatus; innervates the stapedius
muscle, which helps dampen loud sounds by decreasing excessive
movements of the ossicles in the inner ear; and provides secreto-
motor fibers to the lacrimal and salivary glands.
First, examine the facial nerve by watching the patient as she
or he talks and smiles, watching specifically for eye closure, flat-
tening of the nasolabial fold, and asymmetric elevation of one cor-
ner of the mouth. Then ask the patient to wrinkle the forehead
(frontalis), close the eyes while the examiner attempts to open
them (orbicularis oculi), puff out both cheeks while the examiner
presses on the cheeks (buccinator), and show the teeth (orbicularis
oris). A peripheral injury to the facial nerve, such as occurs in Bell
palsy, affects both the upper and the lower face, whereas a central
lesion typically affects mainly the lower face due to bilateral inner-
vation of the frontalis muscle.
Cranial Nerve VIII: Vestibulocochlear Nerve
The vestibulocochlear nerve, also known as the auditory nerve,
comprises two divisions. The cochlear nerve is the part of the audi-
tory nerve responsible for hearing, whereas the vestibular nerve is
related to balance. The cochlear division can be tested by checking
gross hearing. A rapid screen can be done if the examiner rubs the
thumb and index fingers near each ear of the patient. Patients with
normal hearing usually have no difficulty hearing this.
The vestibular division is seldom included in the routine neu-
rologic examination. Patients with dizziness or vertigo associated
with changes in head position or suspected of having benign
paroxysmal positional vertigo should be assessed with the Dix-
Hallpike maneuver (Fig. 1.1). The absence of nystagmus indicates
45
degrees
• Fig. 1.1The Dix-Hallpike maneuver is performed with the patient initially
seated upright. The patient is asked to fall backward so that the head is
below the plane of his or her trunk. The examiner then turns the patient’s
head to one side and asks the patient to look in the direction to which the
head is turned.
normal vestibular nerve function. With peripheral vestibular
nerve dysfunction, however, the patient complains of vertigo, and
rotary nystagmus appears after an approximately 2- to 5-second
latency toward the direction in which the eyes are deviated. With
repetition of maneuvers, the nystagmus and sensation of vertigo
fatigue and ultimately disappear. In central vestibular disease, such
as from a stroke, the nystagmus has latency and is nonfatigable.27
Rehabilitation therapists with training in vestibular rehabilitation
can also provide invaluable data for developing a differential diag-
nosis of and a treatment plan for balance deficits.
Cranial Nerves IX and X: Glossopharyngeal Nerve and
Vagus Nerve
The glossopharyngeal nerve supplies taste to the posterior one-
third of the tongue, along with sensation to the pharynx and the
middle ear. The glossopharyngeal nerve and vagus nerve are usu-
ally examined together. The patient’s voice quality should also be
noted because hoarseness is usually associated with a lesion of the
recurrent laryngeal nerve, a branch of the vagus nerve. The patient
is asked to open the mouth and say “ah.” The examiner should
inspect the soft palate, which should elevate symmetrically with
the uvula in midline. In an LMN vagus nerve lesion, the uvula
will deviate to the side that is contralateral to the lesion. A UMN
lesion presents with the uvula deviating toward the side of the
lesion.32
The gag reflex can be tested by depressing the patient’s tongue
with a tongue depressor and touching the pharyngeal wall with a
cotton tip applicator until the patient gags. The examiner should
compare the sensitivity of each side (afferent: glossopharyn-
geal nerve) and observe the symmetry of the palatal contraction
(efferent: vagus nerve). The absence of a gag reflex indicates loss
of sensation and/or loss of motor contraction. The presence of a
 CHAPTER 1
gag reflex does not imply the ability to swallow without risk of
aspiration.54
Cranial Nerve XI: Accessory Nerve
The accessory nerve innervates the trapezius and sternocleidomas-
toid muscles. While standing behind the patient, the examiner
should look for atrophy or spasm in the trapezius and compare the
symmetry of both sides. Atrophy of the trapezius can be observed
by a loss of the C-shaped contour with more of an L-shaped con-
tour. The scapula will also migrate laterally and have an “open
door” winging pattern. Traditionally, the strength of the trapezius
is tested by asking the patient to shrug the shoulders and hold
them in this position against resistance. Unfortunately, this may
be inaccurate because of substitution by other shoulder elevators
and assessing for atrophy may prove more reliable. For the strength
of the sternocleidomastoid muscle to be tested, the patient should
be asked to rotate the head against resistance. The ipsilateral ster-
nocleidomastoid muscle turns the head to the contralateral side.
The ipsilateral muscle brings the ear to the shoulder.
Cranial Nerve XII: Hypoglossal Nerve
The hypoglossal nerve is a pure motor nerve innervating the mus-
cles of the tongue. It is tested by asking the patient to protrude
the tongue, noting evidence of atrophy, fasciculation, or devia-
tion. The tongue should be evaluated at rest and with protrusion.
Fasciculations can be normal with protrusion but are pathologic at
rest and can be commonly seen in patients with amyotrophic lat-
eral sclerosis.31 The tongue typically points to the side of the lesion
in peripheral hypoglossal nerve lesions but toward the opposite
side of the lesion in UMN lesions such as stroke.
Sensory Examination
The examiner should be familiar with the normal dermatomal and
peripheral nerve sensory distribution (Fig. 1.2). Evaluation of the
sensory system requires testing of both superficial sensation (light
touch, pain, and temperature) and deep sensation (involves the
perception of position and vibration from deep structures, such as
muscle, ligaments, and bone).
Light touch can be assessed with a fine wisp of cotton or a
cotton tip applicator. The examiner should touch the skin lightly,
avoiding excessive pressure. Ask the patient to respond when a
touch is felt and to say whether there is a difference between the
two sides. Pain and temperature both travel via the spinothalamic
tracts and are assessed with a safety pin or other sharp sanitary
object, while occasionally interspersing the examination with
a blunt object. Patients with peripheral neuropathy might have
a delayed pain appreciation and often change their minds a few
seconds after the initial stimuli. Some examiners use the single
or double pinprick of brief duration to test for pain, whereas oth-
ers use a continuous sustained pinprick to better test for delayed
pain.48 Temperature testing is not often used and rarely provides
additional information, but it is sometimes easier for patients to
delineate insensate areas. Thermal sensation can be checked by
using two different cups—one filled with hot water (not hot
enough to burn) and one filled with cold water and ice chips.
Joint position sense or proprioception travel via the dorsal col-
umns along with vibration sense. Proprioception is tested by verti-
cal passive movement of the toes or fingers. The examiner holds
the sides of the patient’s fingers or toes and with the patient’s eyes
closed, asks the patient if the digits are in the upward or downward
direction. It is important to grasp the sides of the digits rather than
The Physiatric History and Physical Examination 11
the nailbed because the patient might be able to perceive pressure
in these areas, reducing the accuracy of the examination. Most
normal persons make no errors on these maneuvers. If a patient is
found to be abnormal on testing, evaluation of the next proximal
joint should be performed. For example, if proprioception at the
great toe is abnormal, test the ankle next.
Vibration is tested in the limbs with a 128-Hz tuning fork.
Place the tuning fork on a bony prominence, such as the dor-
sal aspect of the terminal phalange of the great toe or finger, the
malleoli, or the olecranon. The patient is asked to indicate when
the vibration ceases. The vibration stimulus can be controlled by
changing the force used to set the tuning fork in motion or by
noting the amount of time that a vibration is felt as the stimu-
lus dissipates. If the examiner has normal sensation, both patient
and examiner should feel the vibration cease at approximately the
same time.
Two-point discrimination is most commonly tested using cali-
pers with blunt ends. The patient is asked to close the eyes and
indicate whether one or two stimulation points are felt. The nor-
mal distance of separation that can be felt as two distinct points
depends on the area of body being tested. For example, the lips are
sensitive to a point separation of 2 to 3 mm, normally identified
as two points. Commonly tested normal two-point discrimination
areas include the fingertips (3 to 5 mm), the dorsum of the hand
(20 to 30 mm), and the palms (8 to 15 mm).44
Graphesthesia is the ability to recognize numbers, letters, or
symbols traced onto the palm. It is performed by writing recog-
nizable numbers on the patient’s palm with his or her eyes closed.
Stereognosis is the ability to recognize common objects placed in
the hand, such as keys or coins. This requires normal peripheral
sensation as well as cortical interpretation.
Motor Control
Strength
Manual muscle testing provides an important method of quanti-
fying strength and is outlined in the later section about musculo-
skeletal examination.
Coordination
The cerebellum controls movement by comparing the intended
activity with actual activity that is achieved. The cerebellum
enables smooth motor movements and is intimately involved with
coordination. Ataxia or motor coordination can be secondary to
deficits of sensory, motor, or cerebellar connections. Patients with
ataxia who have intact function of the sensory and motor path-
ways usually have cerebellar compromise.
The cerebellum is divided into three areas: the midline, the
anterior lobe, and the lateral hemisphere. Lesions affecting the
midline usually produce truncal ataxia in which the patient can-
not sit or stand unsupported. This can be tested by asking the
patient to sit at the edge of the bed with the arms folded so they
cannot be used for support. Lesions that affect the anterior lobe
usually result in gait ataxia. In this case, the patient is able to sit or
stand unsupported but has noticeable balance deficits on walking.
Lateral hemisphere lesions produce loss of ability to coordinate
movement, which can be described as limb ataxia. The affected
limb usually has diminished ability to correct and change direc-
tion rapidly. Tests that are typically used to test for limb coordina-
tion include the finger-to-nose test and the heel-to-shin test.3
Rapid alternating movements can be tested by observing the
amplitude, rhythm, and precision of movement. The patient is
12 SE C T I O N 1 Evaluation

Great auricular nerve

Anterior cut. nerve of neck

Supraclavicular nerves

Axillary nerve (circumflex) T2

3 Medial cut. nerve of arm
4 and intercostobrachial nerve
Lower lateral cut. nerve of arm 5
6 Medial cut. nerve of forearm
(from radial nerve)
7
8 Illiohypogastric nerve
Lateral cut. nerve of forearm 9
(from musculocut. nerve) 10
11 Radial nerve
12
Ilioinguinal nerve Median nerve

Femoral branch of genitofemoral nerve Ulnar nerve

(lumboinguinal nerve)
Genital branch of genitofemoral nerve
Lat. cut. nerve of thigh
Dorsal nerve of penis

Intermed. c med. cut nerves Scrotal branch of perineal nerve

of thigh (from femoral nerve)
Obturator nerve
Saphenous nerve
(from femoral nerve) Lateral cut. nerve of calf
(from common peroneal nerve)
Deep peroneal nerve Superficial peroneal nerve
(from common peroneal nerve) (from common peroneal nerve)

Medial & lateral plantar nerves Sural nerve

(from post. tibial nerve) (from tibial nerve)

Axillary nerve Greater occipital nerve

(circumflex) Lesser
Great auricular nerve
Posterior cut. nerve of arm
(from radial nerve)
Anterior cut. nerve of neck

Lower lateral cut. nerve of arm Supraclavicular nerves

(radial nerve) T2
3 Post.
4 cut. Medial cut. nerve of arm
Posterior cut. nerve of forearm 5 rami and intercostobrachial nerve
6 of
(from radial nerve) 7 thor.
89
nerves
Medial cut. nerve of forearm
10 11
Iliohypogastric nerve 12 Lateral cut. nerve of forearm
Post. rami (from musculocut. nerve)
Inferior medial clunical nerve of lumbar,
sacral, and Radial nerve
coccygeal
Lateral cut. nerve of thigh nerves Inferior lateral clunical nerves

Median nerve
Posterior cut. nerve of thigh
Ulnar nerve
Lateral cut. nerve of calf
(from common peroneal nerve) Obturator

Medial cut. nerve of thigh

Saphenous nerve
(from femoral nerve)
(from femoral nerve)

Superficial peroneal nerve Medial plantar

(from common peroneal nerve) nerve
Lateral plantar
Sural nerve (from tibial nerve) nerve

Calcanean branches of
sural and tibial nerves Calcanean branches of
Saphenous
sural and tibial nerves
nerve

• Fig. 1.2Distribution of peripheral nerves and dermatomes. (Redrawn from Haymaker W, Woodhall B:
Peripheral nerve injuries, Philadelphia, 1953, Saunders, with permission.)
 CHAPTER 1 The Physiatric History and Physical Examination 13

C2

C3
C2
C3
C4 C4 C4 T2 C4
T2 3
C5 3 C5 C5 C5
4
4
5
5
6
6 T2 7
T2 T2
T2 7 8
9
8 10
9 11
C6 T1 C6 C6
10 C6 12
T1 T1 T1
11 L1
L2
12
L1 Coc
S3 S3 S5
C8 C8 S4
S4 C8 L2 C8
L2
L2
C7 C7 C7 C7

S2 S2
L3 L3
L3

L5 L4 L4 L5 L5
L5 L5
L4 L4
L5
S1 L4 L4
S1
L5

S1 L5 S1
S1 S1

Fig. 1.2, cont’d

asked to place the hands on the thighs and then rapidly turn the
hands over and lift them off the thighs for 10 seconds. Normal
individuals can do this without difficulty. Dysdiadochokinesis is
the clinical term for an inability to perform rapidly alternating
movements.
The Romberg test can be used to differentiate a cerebellar
deficit from a proprioceptive one. The patient is asked to stand
with the heels together. The examiner notes any excessive postural
swaying or loss of balance. If loss of balance is present when the
eyes are open and closed, the examination is consistent with cer-
ebellar ataxia. If the loss of balance occurs only when the eyes are
closed, this is classically known as a positive Romberg sign indicat-
ing a proprioceptive (sensory) deficit.44
Apraxia
Apraxia is the loss of the ability to carry out programmed or
planned movements despite adequate understanding of the tasks.
This deficit is present even though the patient has no weakness or
sensory loss. For a complex act to be accomplished, there first must
be an idea or a formulation of a plan. The formulation of the plan
then must be transferred into the motor system where it is exe-
cuted. The examiner should watch the patient for motor-planning
problems during the physical examination. For example, a patient
might be unable to perform transfers and other mobility tasks but
has adequate strength on formal manual muscle testing.67
Ideomotor apraxia associated with a lesion of the dominant
parietal lobe occurs when a patient cannot carry out motor com-
mands but can perform the required movements under different
circumstances. These patients usually can perform many com-
plex acts automatically but cannot carry out the same acts on
command. Ideational apraxia refers to the inability to carry out
sequences of acts, although each component can be performed
separately. Other forms of apraxia are constructional, dressing,
oculomotor, oromotor, verbal, and gait apraxia. Dressing and con-
structional apraxia are often related to impairments of the non-
dominant parietal lobe, which typically are the result of neglect
rather than actual deficit in motor planning.44
Involuntary Movements
Documenting involuntary movements is important in the over-
all neurologic examination. A careful survey of the patient usu-
ally shows the presence or absence of voluntary motor control.
Tremor is the most common type of involuntary movement and is
a rhythmic movement of a body part. Myoclonus, a quick jerking
movement of a muscle or body part, can be seen with a variety
of cerebral and spinal cord lesions and as a side effect of medica-
tion. Lesions in the basal ganglia produce characteristic movement
disorders such as chorea, athetosis, dystonia, and hemiballismus.
Chorea describes movements that consist of brief, random, nonre-
petitive movements in a fidgety patient unable to sit still. Atheto-
sis consists of twisting and writhing movements and is commonly
seen in cerebral palsy. Dystonia is a sustained posturing that can
affect small or large muscle groups. An example is torticollis, in
which dystonic neck muscles pull the head to one side. Hemibal-
lismus occurs when there are repetitive violent flailing movements
that are usually caused by deficits in the subthalamic nucleus.49
14 SE C T I O N 1 Evaluation
Tone
Tone is the resistance of muscle to stretch or passive elongation
(see Chapter 23). Spasticity is a velocity-dependent increase in the
stretch reflex, whereas rigidity is the resistance of the limb to passive
movement in the relaxed state (non–velocity-dependent). Variabil-
ity in tone is common because patients with spasticity can vary in
their presentation throughout the day and with positional changes
or mood. Some patients will demonstrate little tone at rest (static
tone) but experience a surge of tone when they attempt to move
the muscle during a functional activity (dynamic tone). Accurate
assessment of tone might require repeated examinations.53
Initial observation of the patient usually shows abnormal pos-
turing of the limbs or trunk. Palpation of the muscle also pro-
vides clues, because hypotonic muscles feel soft and flaccid on
palpation, whereas hypertonic muscles feel firm and tight. Passive
range of motion (ROM) provides information about the muscle
in response to stretch. The examiner provides firm and constant
contact while moving the limbs in all directions. The limb should
move easily and without resistance when altering the direction
and speed of movement. Hypertonic limbs feel stiff and resist
movement, whereas flaccid limbs are unresponsive. The patient
should be told to relax because these responses should be exam-
ined without any voluntary control. Clonus is a cyclic alternation
of muscular contraction in response to a sustained stretch, and
is assessed with a quick stretch stimulus that is then maintained.
Myoclonus refers to sudden, involuntary jerking of a muscle or
group of muscles. Myoclonic jerks may not be pathologic because
they are typically part of the normal sleep cycle. However, myoclo-
nus that impacts functioning can result from hypoxia, drug toxic-
ity, and metabolic disturbances. Other causes include degenerative
disorders affecting the basal ganglia and certain dementias.59
The Modified Ashworth Scale, a six-point ordinal scale, can
quantify tone. A pendulum test can also be used to quantify spas-
ticity. While in the supine position, the patient is asked to fully
extend the knee and then allow the leg to drop and swing like a
pendulum. A normal limb swings freely for several cycles, whereas
a hypertonic limb quickly returns to the initial dependent starting
position.64
The Tardieu Scale has been suggested to be a more appropriate
clinical measure of spasticity than the Modified Ashworth Scale. It
involves assessment of resistance to passive movement at both slow
and fast speeds. Measurements are usually taken at three velocities
TABLE
1.4
 Notable Superficial Reflexes
Reflex Elicited By
Corneal Touching cornea with hair
Cremasteric Stroking medial surface of upper
thigh
Bulbocavernosus (male) Pinching dorsum of glans
Clitorocavernosus (female) Pinching clitoris
Superficial anal Pricking perineum
Modified from Mancall EL: Examination of the nervous system. In Mancall EL, editor: Alpers and Mancall’s essentials of the neurologic examination, ed 2, Philadelphia, 1981, FA Davis, with permission
of FA Davis.
(V1, V2, and V3). V1 is taken as slow as possible, slower than the
natural drop of the limb segment under gravity. V2 is taken at
the speed of the limb falling under gravity. V3 is taken with the
limb moving as fast as possible, faster than the natural drop of the
limb under gravity. Responses are recorded at each velocity and
the degrees of angle at which the muscle reaction occurs.35
Reflexes
Superficial Reflexes
Superficial reflexes are motor responses to scraping of the skin. The
plantar reflex is the most common superficial reflex examined. A
stimulus (usually by the handle end of a reflex hammer) is applied
on the sole of the foot from the lateral border up and across the
ball of the foot. A normal reaction consists of flexion of the great
toe or no response. An abnormal response in adults consists of
dorsiflexion of the great toe with an associated fanning of the other
toes. This response is the Babinski sign and indicates dysfunction
of the corticospinal tract but no further localization. Stroking
from the lateral ankle to the lateral dorsal foot can also produce
dorsiflexion of the great toe (Chaddock sign). Flipping the little
toe outward can also produce the upgoing great toe and is called
the Stransky sign. Other superficial reflexes include the cremas-
teric, bulbocavernosus, and superficial anal reflexes (Table 1.4).49
Primitive Reflexes
Primitive reflexes are abnormal or pathological adult reflexes that
represent a regression to a more infantile level of reflex activity.
Redevelopment of an infantile reflex in an adult suggests signifi-
cant neurologic abnormalities. Examples of primitive reflexes can
be seen in Table 1.5 and include the previously discussed plantar
reflex in which the great toe dorsiflexes (Babinski sign). Another
example is the sucking reflex, in which the patient makes sucking
movements when the lips are lightly touched. The rooting reflex
is elicited by stroking the cheek, resulting in the patient turning
toward that side and making sucking motions with the mouth.
The grasp reflex occurs when the examiner places a finger on the
patient’s open palm. Attempting to remove the finger causes the
grip to tighten. Many times families mistake this response as a
volitional action. The snout reflex occurs when a lip-pursing move-
ment happens when there is a tap just above or below the mouth.
The palmomental response is elicited by quickly scratching the
Response Segmental Level
Contraction of orbicularis oculi Pons
Ipsilateral elevation of testicle L1, L2
Insert gloved finger to palpate anal S3, S4
contraction
Insert gloved finger to palpate anal S3, S4
contraction
Contraction of rectal sphincters S5, coccygeal
 CHAPTER 1 The Physiatric History and Physical Examination 15

TABLE
1.5
 Primitive and Pathological Reflexes

Reflex Elicited by Response

Plantar Stimulus applied to the sole of foot from lateral border Normal before the age of 2: great toe dorsiflexion.
up and across the ball of the foot. Normal after the age of 2: great toe flexion or no movement.
Abnormal (positive) after the age of 2: great toe dorsiflexion. This is also
called a Babinski reflex.
Hoffman Loosely holding the 3rd digit (middle finger) and Abnormal (positive): flexion and adduction of the 1st digit (thumb). However, a
flicking the fingernail downward allowing the finger bilateral positive response may be a normal variant.
to move automatically upwards.
Rooting Stroking the cheek. Abnormal (positive) after the age of 4 months: turning to the side that is being
stroked and making sucking motions with the mouth.
Grasp Placing a finger in the open palm, then attempting to Abnormal (positive) after the age of 9 months: grip tightens on the examiner’s
remove the finger. finger.
Snout Tapping just above or below the mouth. Abnormal (positive) after 6 months: lip-pursing movements.
Palmomental Quickly scratching the palm of the hand. Abnormal (positive) after 6 months: sudden contraction of the mentalis
muscle.

palm of the hand. A positive reflex is indicated by sudden contrac- TABLE

tion of the mentalis (chin) muscle. It arises from unilateral damage 1.6
 Muscle Stretch Reflexes
of the prefrontal area of the brain.1
Muscle Peripheral Nerve Root Level
Muscle Stretch Reflexes Biceps Musculocutaneous nerve C5, C6
Muscle stretch reflexes (which are sometimes referred to as deep
tendon reflexes) are assessed by tapping over the muscle tendon Brachioradialis Radial nerve C5, C6
with a reflex hammer (Table 1.6). The muscle stretch reflex is a Triceps Radial nerve C7, C8
simple reflex, with the receptor neuron having direct connections
Pronator teres Median nerve C6, C7
to the muscle spindle and with the alpha motor neurons in the
central nervous system that send axons back to that muscle. Nor- Patella (quadriceps) Femoral nerve L2–L4
mal muscle stretch reflexes result in contraction only of the muscle
Medial hamstrings Sciatic (tibial portion) nerve L5–S1
whose tendon is stretched and any muscle with the same action
(agonist muscles). There is also inhibition of antagonist muscles. Achilles Tibial nerve S1, S2
To best elicit the response, the patient is positioned into the mid-
range of the arc of joint motion and instructed to relax. Tapping of
the tendon results in visible movement of the joint. The response
is assessed as 0, no response; 1+, diminished but present and The examination starts by asking the patient to walk across the
might require facilitation; 2+, usual response; 3+, more brisk than room in a straight line. This can also be assessed by observing the
usual; and 4+, hyperactive with clonus. If muscle stretch reflexes patient walking from the waiting area into the examination room.
are difficult to elicit, the response can be enhanced by reinforce- The patient is then asked to stand from a chair, walk across the
ment maneuvers, such as hooking together the fingers of both room, and come back toward the examiner. The examiner should
hands while attempting to pull them apart (Jendrassik maneuver). pay particular attention to the following:
While pressure is still maintained, the lower limb reflexes can be 1. Ease of arising from a seated position. Can the patient easily arise
tested. Squeezing the knees together and clenching the teeth can from a sitting position? Difficulty with a sit-to-stand task may
reinforce responses to the upper limbs.44 indicate proximal muscle weakness, movement disorders with
difficulty initiating movements, or a balance problem.
Gait 2. Balance. Does the patient lean or veer off to one side, which is
an indication of cerebellar dysfunction? Patients with medul-
Gait evaluation is an important and often neglected part of the lary lesions and cerebellar lesions tend to push to the side of the
neurologic evaluation. Gait is described as a series of rhythmic, lesion. Diffuse disease affecting both cerebellar hemispheres
alternating movements of the limbs and trunks that result in the can cause a generalized loss of balance. Patients with cerebellar
forward progression of the center of gravity.10 Gait is dependent disorders usually have balance issues with or without their eyes
on input from several systems, including the visual, vestibular, cer- open. Patients with proprioceptive dysfunction can use their
ebellar, motor, and sensory systems. The cause of dysfunction can visual input to compensate for their sensory deficit.
be determined by understanding the aspects of gait involved. One 3. Walking speed. Does the patient start off slow and then acceler-
example is a shuffling gait, which is consistent with parkinsonism, ate uncontrollably? Patients with Parkinson disease will have
or a lack of balance and wide-based gait, which can be suggestive problems initiating movements but then lose their balance
of cerebellar dysfunction. once they are in motion. Patients with pain, such as knee or hip
16 SE C T I O N 1 Evaluation
arthritis, often have limitations of ROM affecting gait speed. It
has been shown that a self-selected gait speed of less than 0.8
m/sec is a risk factor for falls in the stroke population.56 The
speed of walking remains stable until about age 70 years when
there is a 15% decline per decade. Gait speed is lower because
elderly people take shorter steps.7
4. Stride and step length. Does the patient take a small step or shuf-
fle while walking? Patients with normal pressure hydrocepha-
lus and Parkinson disease usually take small steps or shuffle
(decreasing their step and stride length). Stride length is the
linear distance between successive corresponding points of heel
contact of the same foot; whereas step length is the distance
between corresponding, successive contact points of opposite
feet.9 An antalgic gait is characterized with the patient spend-
ing more time in stance phase on one leg and is usually due to
pain in the other leg. An average step length is approximately 2
feet for women and 2.5 feet for men.70
5. Attitude of arms and legs. How does the patient hold his or her
arms and legs? Loss of movement as in a spastic or contracted
patient should be assessed. Patients with knee extension weak-
ness might swing their knees into terminal extension, thereby
locking their knee (genu recurvatum).
6. Special tests. Gait disorders have stereotypical patterns that reflect
injury to various aspects of the neurologic system (Table 1.7).
Higher-level balance can be tested by observing the tandem
gait of a patient. Ask the patient to walk in a straight line by
putting one heel of one foot directly in front of the toe of the
other. Tandem gait can be difficult for older patients and in
some other medical conditions (even without neurologic dis-
ease). Other tests to assess gait function and strength include
observing patients walk on their toes and heels. Patients with a
Trendelenburg gait tend to sway toward the leg in stance phase
because of abductor weakness. Balance and strength can also be
assessed by asking patients to hop in place and to do a shallow
knee bend.
Musculoskeletal Examination
Caveats
The musculoskeletal (MSK) examination confirms the diagnostic
impression and lays the foundation for the physiatric treatment
plan. It incorporates inspection, palpation, passive and active
ROM, assessment of joint stability, manual muscle testing, joint-
specific provocative maneuvers, and special tests (Table 1.8).29,36,46
The functional unit of the musculoskeletal system is the joint,
and its comprehensive examination includes related structures,
such as muscles, ligaments, and the synovial capsule.47 The MSK
examination also indirectly tests coordination, sensation, and
endurance.29,50 There is overlap between the examination (and
clinical presentation) of the neurologic and musculoskeletal sys-
tems. Neurologic disease may lead to secondary musculoskeletal
complications of immobility and suboptimal movement. The
MSK examination should be performed in a routine sequence for
efficiency and consistency and must be approached with a solid
knowledge of anatomy. Of importance is that the MSK exami-
nation is largely subjective. Close attention should be paid to
objective findings such as atrophy, instability, or joint effusion or
deformity. The reader is referred to several references that provide
in-depth reviews of the MSK examination.a
aReferences 4, 19a, 29, 38, 38a, 43, 54.
Inspection
Inspection of the musculoskeletal system begins during the history.
Attention to subtle cues and behaviors can guide the approach to
the examination. Inspection includes observing mood, signs of
pain or discomfort, functional impairments, or evidence of malin-
gering (Waddell signs). Inspect the spine for scoliosis, kyphosis,
and lordosis, whereas limbs should be examined for symmetry,
circumference, and contour. In persons with amputation, the
level, length, and shape of the residual limb should be appreci-
ated. Depending on the clinical situation, it can be important to
assess for muscle atrophy, masses, edema, scars, skin breakdown,
and fasciculations.61 Inspect joints for deformity, visible swelling,
and erythema.
Recognition of the kinetic chain is fundamental to a compre-
hensive MSK examination. Kinetic chain refers to the summation
of individual joint movements linked in a series leading to the
production of a larger functional goal.39 A change in movement of
a single joint may affect the motion of adjacent as well as distant
joints in the chain. This may result in asymmetric patterns, caus-
ing disease at seemingly unrelated sites.
Palpation
Palpation is used to further evaluate initial impressions made
through inspection. This may help to identify tender areas over
soft tissue or bone. In addition, palpation may facilitate localiza-
tion of trigger points, muscle guarding, or spasticity.61 Joints and
soft tissues should be assessed for effusion, warmth, masses, tight
muscle bands, tone, and crepitus.38 It is important to palpate
the limbs and cranium for evidence of fracture in patients with a
change in mental status after a fall or trauma.49
Assessment of Joint Stability
The assessment of joint stability judges the capacity of structural
elements to resist forces in nonfunctional directions.49,61 Stabil-
ity is determined by several factors, including bony congruity,
capsular and cartilaginous integrity, and the strength of ligaments
and muscles.49 Bilateral examination is critical because assessment
of the “normal” side establishes a patient’s unique biomechanics.
The examiner should identify areas of pain and resistance in the
affected joint, followed by an evaluation of ROM, to determine
hypomobility or hypermobility.
Joint play or capsular patterns assess the integrity of the cap-
sule in positions of minimal bony contact, sometimes referred to
as open-packed position.54 Active ROM (AROM) or voluntary
movement of a joint is insufficient to exploit the full ROM for
that joint. More extreme end ROM that is not under voluntary
control must be assessed by the examiner through passive ROM
(PROM) testing. There are several types of end feels when the ter-
minal feel of a joint is evaluated through the extremes of its ROM.
Soft end feel is commonly associated with tissue compression and
is normal in extreme elbow or knee flexion with PROM testing.
If the sensation, however, is felt prematurely (before the expected
full PROM), the cause may be pathologic, such as from inflamma-
tion or edema. If tissue (muscle, capsule, or ligament) is stretched
at the end of ROM, the resultant end feel is one that is firm yet
slightly forgiving, such as with terminal passive metacarpophalan-
geal extension and hip flexion. Palpation of a premature firm end
feel can be a sign of increased tone or capsular tightening. A hard
end feel is experienced as a result of bony contact and is felt nor-
mally with elbow extension or knee extension. If a hard end feel is
 CHAPTER 1 The Physiatric History and Physical Examination 17

TABLE
1.7
 Common Gait Disturbances

Gait Type Disease or Anatomic Location Gait Characteristics

Hemiplegic Unilateral upper motor neuron
lesions with spastic hemiplegia
Scissoring Bilateral corticospinal tract lesions
often seen in patients with
cerebral palsy, incomplete
spinal cord injury, and multiple
sclerosis
Ataxic Cerebellar dysfunction or severe
sensory loss (such as tabes
dorsalis)
The affected lower limb is difficult to move, and the knee is held in extension. With ambulation, the
leg swings away from the center of the body, and the hip hikes upward to prevent the toes and
foot from striking the floor. This is known as “circumduction.” If the upper limb is involved, there
may be decreased arm swing with ambulation.29 The upper limb has a flexor synergy pattern
resulting in shoulder adduction, elbow and wrist flexion, and a clinched fist.
Hypertonia in the legs and hips results in flexion and the appearance of a crouched stance. The
hip adductors are overactive causing the knees and thighs to touch or cross in a “scissor-like”
movement. In cerebral palsy, there can be associated ankle plantar flexion forcing the patient
to tiptoe walk. The step length is shortened by the severe adduction or scissoring of the hip
muscles.29
Ataxic gait is characterized by a broad-based stance and irregular step and stride length. In ataxic
gait from proprioceptive dysfunction (tabes dorsalis), gait will markedly worsen with the eyes
closed. There is a tendency to sway, whereas watching the floor usually helps guide the uncertain
steps. Ataxic gait from cerebellar dysfunction will not worsen with eyes closed. Movement of
the advancing limb starts slowly, and then there is an erratic movement forward or laterally.
The patient will try to correct the error but usually overcompensates. Tandem gait exacerbates
cerebellar ataxia.58

Myopathic Myopathies cause weakness of Myopathies result in a broad-based gait and a “waddling-type” appearance as the patient tries to
the proximal leg muscles. compensate for pelvic instability. Patients will have problems with climbing stairs or rising from a
chair without using their arms. When going from floor to standing, the patient will use their arms
and hands to climb up their legs—known as Gowers sign.13

Trendelenburg Caused by weakness of the
abductor muscles (gluteus
medius and gluteus minimus)
as in superior gluteal nerve
injury, poliomyelitis, or
myopathy
Parkinsonian Seen in Parkinson disease and
other disorders of the basal
ganglia
Steppage Diseases of the peripheral
nervous system including
L5 radiculopathy, lumbar
plexopathies, and peroneal
nerve palsy
During the stance phase, the abductor muscle allows the pelvis to tilt down on the opposite side. To
compensate, the trunk lurches to the weakened side to maintain the pelvis level during the gait
cycle. This results in a waddling-type gait with an exaggerated compensatory sway of the trunk
toward the weight-bearing side. It is important to understand that the pelvis sags on the opposite
side of the weakened abductor muscle.13
Patients have a stooped posture, narrow base of support, and a shuffling gait with small steps. As
the patient starts to walk, the movements of the legs are usually slow with the appearance of
the feet sticking to the floor. They might lean forward while walking so the steps become hurried,
resulting in shuffling of the feet (festination). Starting, stopping, or changing directions quickly
is difficult, and there is a tendency for retropulsion (falling backward when standing). The whole
body moves rigidly, requiring many short steps, and there is loss of normal arm swing. There can
be a “pill-rolling” tremor while the patient walks.58
The patient with foot drop has difficulty dorsiflexing the ankle. The patient compensates for the
foot drop by lifting the affected extremity higher than normal to avoid dragging the foot. Weak
dorsiflexion leads to poor heel strike with the foot slapping on the floor.25 An ankle-foot orthosis
can be helpful.

noted prematurely or inappropriately, it may indicate an arthritic
joint or heterotopic ossification. An “empty” feel does not suggest
a mechanical restriction but is rather a limitation in ROM due to
muscle contraction generated by the patient to guard against pain.
It is important to identify both hypomobile and hypermobile
joints. The former increase the risk for muscle strains, tendon-
itis, and nerve entrapments, whereas the latter increase the risk
for joint sprains and degenerative joint disease.52 An inflam-
matory synovitis, for example, can increase joint mobility and
weaken the capsule (it tightens the capsule acutely and weakens
it chronically). In the setting of decreased muscle strength, the
risk of trauma and joint instability is increased.3 If joint insta-
bility is suspected, confirmatory diagnostic testing can be done
(e.g., radiography)—for example, flexion-extension spine films
to assess vertebral column instability or magnetic resonance
imaging (MRI) to visualize the degree of anterior cruciate liga-
ment rupture.21,40,42,45
Assessment of Range of Motion General Principles
ROM testing is used to assess the integrity of a joint, to monitor
the efficacy of treatment regimens, and to determine the mechanical
cause of an impairment.40 Limitations not only affect ambulation
and mobility but also ADL. Normal ROM varies according to age,
gender, conditioning, body habitus, and genetics.54 Males typically
have a more limited range when compared with females, depending
on age and specific joint action.8 Vocational and avocational patterns
of activity can also alter ROM. For example, gymnasts generally
have increased ROM at the hips and lower trunk.54 PROM should
18 SE C T I O N 1 Evaluation

TABLE
1.8
 Musculoskeletal Provocative Maneuvers

Test Description
Cervical Spine Tests
Spurling/neck A positive test is reproduction of radicular symptoms distant from the neck with passive
compression lateral flexion and compression of the head.
test

Shoulder A positive test is relief or reduction of ipsilateral cervical radicular symptoms with active
abduction abduction of the ipsilateral arm with the hand on the head.
(relief) sign

Neck distraction A positive test is relief or reduction of cervical radicular symptoms with an axial traction
test force applied by the examiner under the occiput and the chin while the patient is supine.

Lhermitte sign A positive test is the presence of electric-like sensations down the extremities with passive
cervical forward flexion.

Rotator Cuff/Supraspinatus Tests

Empty can/ A positive test is pain or weakness in the ipsilateral shoulder with resisted abduction of the
supraspinatus shoulder, which is in internal rotation, with the thumb pointing toward the floor and a
test forward angulation of 30 degrees.

Drop arm test A positive test is noted if the patient is unable to return the arm to the side slowly or has
severe pain after the examiner abducts the patient’s shoulder to 90 degrees and then
asks the patient to slowly lower the arm to the side.

Rotator Cuff/Infraspinatus and Teres Minor Tests

Patte test A positive test is pain or inability to support the arm or rotate the arm laterally with the
elbow at 90 degrees and the arm at 90 degrees of forward elevation in the plane of the
scapula. This indicates tears of the infraspinatus and/or teres minor muscles.
 CHAPTER 1 The Physiatric History and Physical Examination 19

TABLE
1.8 Musculoskeletal Provocative Maneuvers—cont’d

Test Description
Lift-off test A positive test is the inability to lift the dorsum of the hand off the back with the arm
internally rotated behind the back as starting position. This indicates a disorder of the
subscapularis.

Scapular Tests
Lateral scapular This test allows for identification of scapulothoracic motion deficiencies with the contralateral
slide test side as an internal control. The reference point used is the nearest spinous process. A
scapulothoracic motion abnormality is noted if there is at least a 1-cm difference. The first
position of the test is with the arm relaxed at the side. The second is with the hands on the
hips with the fingers anterior and the thumb posterior with about 10 degrees of shoulder
extension. The third position is with the arms at or below 90 degrees of arm elevation
with maximal internal rotation at the glenohumeral joint. These positions offer a graded
challenge to the functioning of the shoulder muscles to stabilize the scapula.
Isometric pinch This test is used to evaluate scapular muscle strength. The patient is asked to retract the
test scapula into an “isometric pinch.” Scapular muscle weakness can be noted as a burning
pain in less than 15 s. Normally, the scapula can be held in this position for 15–20 s with
no discomfort.

Biceps Tendon Tests

Yergason test The test is done with the elbow flexed to 90 degrees and the forearm in pronation. The
examiner holds the patient’s wrist to resist supination and then directs active supination
be made against his or her resistance. Pain that localizes in the bicipital groove indicates
a disorder of the long head of the biceps. It can also be positive in fractures of the lesser
tuberosity of the humerus.

Speed test A positive test is pain in the bicipital groove with resisted anterior flexion of the shoulder
with extension of the elbow and forearm supination.

Shoulder Impingement Tests

Neer’s sign test The test is positive if pain is reproduced with forward flexion of the arm in internal rotation
or in the anatomic position of external rotation. The pain is thought to be caused by
impingement of the rotator cuff by the undersurface of the anterior margin of the
acromion or coracoacromial ligament.

Hawkin test This test is positive if there is pain with forward flexion of the humerus to 90 degrees with
forcible internal rotation of the shoulder. This drives the greater tuberosity under the
coracoacromial ligament, resulting in rotator cuff impingement.

Continued
TABLE
1.8  Musculoskeletal Provocative Maneuvers—cont’d

Test Description
Yocum test This test is positive if there is pain with raising the elbow while the ipsilateral hand is on the
contralateral shoulder.

Shoulder Stability Tests

Apprehension The test is positive if there is pain or apprehension while the shoulder is moved passively
test into maximal external rotation while in abduction followed by forward pressure applied to
the posterior aspect of the humeral head. This test can be done either in the standing or
supine position.

Fowler’s sign The examiner performs the apprehension test, and at the point where the patient feels pain
or apprehension, the examiner applies a posteriorly directed force to the humeral head. If
the pain persists despite the posteriorly applied force, it is primary impingement. If there
is full pain-free external range, it is a result of instability.

Load and shift The scapula is stabilized by securing the coracoid and the spine of the scapula with one
test hand with the patient in a sitting or supine position. The humeral head is then grasped
with the other hand to glide it anteriorly and posteriorly. The degree of glide is graded
mild, moderate, or severe.

Labral Disorder Tests

Active The patient is asked to forward flex the affected arm 90 degrees with the elbow in full
compression extension. The patient then adducts the arm 10–15 degrees medial to the sagittal plane
test (O’Brien) of the body with the arm internally rotated so the thumb is pointed downward. The
examiner then applies downward force to the arm. With the arm in the same position,
the palm is then supinated and the maneuver is repeated. The test is considered positive
if pain is elicited with the first maneuver and is reduced or eliminated with the second
maneuver.
Crank test With the patient in an upright position, the arm is elevated to 160 degrees in the scapular
plane. Joint load is applied along the axis of the humerus with one hand while the other
performs humeral rotation. A positive test is when there is pain during the maneuver
during external rotation with or without a click or reproduction of the symptoms. The test
should be repeated in the supine position when the muscles are more relaxed.

Acromioclavicular Joint Tests

Apley scarf test A positive test is pain at the acromioclavicular joint with passive adduction of the arm
across the sagittal midline, attempting to approximate the elbow to the contralateral
shoulder.

Lateral and Medial Epicondylitis Tests

Resisted wrist For lateral elbow pain, the test is positive if pain is worsened with extension of the wrist
extension against resistance.
 CHAPTER 1 The Physiatric History and Physical Examination 21

TABLE
1.8  Musculoskeletal Provocative Maneuvers—cont’d

Test Description
Resisted wrist This test is positive if medial epicondylar pain is reproduced with forced wrist extension as
flexion and the patient maintains the elbow in 90 degrees of flexion with the forearm supinated and
pronation the wrist flexed. A positive test indicates involvement of the flexor carpi radialis tendon.
Medial elbow pain is most exacerbated with the elbow flexed.

Elbow Stability Tests

Varus stress This test is positive if there is excessive gapping on the lateral aspect of the elbow joint.
The arm is placed in 20 degrees of flexion with slight supination beyond neutral. The
examiner gently stresses the lateral side of the elbow joint.

Valgus stress This test is positive if there is excessive gapping on the medial aspect of the elbow joint.
(Jobe test) The elbow is placed in 25 degrees of flexion to unlock the olecranon from its fossa. The
examiner gently stresses the medial side of the elbow joint.

Carpal Ligament and Joint Tests

Finkelstein test This test is positive if there is pain at the styloid process of the radius as the patient
places the thumb within the hand, which is held tightly by the fingers, followed by ulnar
deviation of the hand.

Thumb basilar The basal joint grind test is performed by stabilizing the triquetrum with the thumb and
joint grind test index finger and then dorsally subluxing the thumb metacarpal on the trapezium while
providing compressive force with the other hand.

Median Nerve Tests at the Wrist

Carpal This test consists of gentle, sustained, firm pressure to the median nerve of each
compression hand simultaneously. Within a short time (15 s to 2 min) the patient will complain of
test reproduction of pain, paresthesia, and/or numbness in the symptomatic wrist(s).

Phalen test (wrist This test is positive if there is numbness and paresthesia in the fingers. The patient is asked
flexion) to hold the forearms vertically and to allow both hands to drop into flexion at the wrist for
approximately 1 min.

Continued
TABLE
1.8  Musculoskeletal Provocative Maneuvers—cont’d

Test Description
Reverse Phalen The patient is asked to keep both wrists in complete dorsal extension for 1 min. If
test (Wrist numbness and tingling were produced or exaggerated in the median nerve distribution of
extension test) the hand within 60 s, the test is judged to be positive.

Lumbar Spine Motion Tests

Schober test The first sacral spinous process is marked, and a mark is made about 10 cm above this
mark. The patient then flexes forward, and the increased distance is measured.

Lumbar Disk Herniation Tests

Straight-leg raise The supine patient’s leg is raised with the knee extended until the patient begins to feel
pain, and the type and distribution of the pain as well as the angle of elevation are
recorded. The test is positive when the angle is between 30 and 70 degrees and pain is
reproduced down the posterior thigh below the knee.

Crossed straight- The supine patient’s contralateral leg is raised with the knee extended until the patient
leg raise begins to feel pain in the ipsilateral leg, and the type and distribution of the pain as well
as the angle of elevation are recorded. The test is positive when the angle is between
30 and 70 degrees and pain is reproduced down the ipsilateral posterior thigh below the
knee.

Bowstring sign After a positive straight-leg raise, the knee is slightly flexed while pressure is applied to the
tibial nerve in the popliteal fossa. Compression of the sciatic nerve reproduces leg pain.

Slump test The patient is seated with legs together and knees against the examining table. The patient
slumps forward as far as possible, and the examiner applies firm pressure to bow the
patient’s back while keeping sacrum vertical. The patient is then asked to flex the head,
and pressure is added to the neck flexion. Lastly, the examiner asks the patient to extend
the knee, and dorsiflexion at the ankle is added.

Ankle dorsiflexion After a positive straight-leg raise or slump test, the leg is dropped to a nonpainful range,
test (Bragard and the ipsilateral ankle is dorsiflexed, reproducing the leg pain.
sign)

Femoral nerve With the patient prone, the knee is dorsiflexed. Pain is produced in the anterior aspect of the
stretch test thigh and/or back.
 CHAPTER 1 The Physiatric History and Physical Examination 23

TABLE
1.8  Musculoskeletal Provocative Maneuvers—cont’d

Test Description
Sacroiliac Joint Disorder Tests
Gillet test (One- This test is performed with the patient standing, facing away from the examiner with the
leg Stork test) feet approximately 12 inches apart. The examiner’s thumbs are placed on each posterior
superior iliac spine (PSIS). The patient is then asked to stand on one leg while flexing the
contralateral hip and knee to the chest.

Compression test The examiner places both hands on the patient’s anterior superior iliac spine (ASIS) and
exerts a medial force bilaterally to implement the test. The compression test is more
frequently performed with the patient in a side-lying position. The examiner stands
behind the patient and exerts a downward force at the upper part of the iliac crest.

Patrick (FABERE) With the patient supine on a level surface, the thigh is flexed and the ankle is placed
test above the patella of the opposite extended leg. As the knee is depressed with the ankle
maintaining its position above the opposite knee, the opposite ASIS is pressed, and
the patient will complain of pain before the knee reaches the level obtained in normal
persons. This creates a combined flexion, abduction, external rotation, and extension
(FABERE) movement.

Gaenslen test The patient lies supine and flexes the ipsilateral knee and hip against the chest with the
aid of both hands clasped about the flexed knee. This brings the lumbar spine firmly in
contact with the table and fixes both the pelvis and lumbar spine. The patient is then
brought to the very side of the table, and the opposite thigh is slowly hyperextended with
gradually increasing force by pressure of the examiner’s hand on the top of the knee.
With the opposite hand, the examiner assists the patient in fixing the lumbar spine and
pelvis by pressure over the patient’s clasped hands. The hyperextension of the hip exerts
a rotating force on the corresponding half of the pelvis in the sagittal plane through
the transverse axis of the sacroiliac joint. The rotating force causes abnormal mobility
accompanied by pain, either local or referred, on the side of the lesion.
Shear test This test consists of the patient lying in the prone position, and the examiner applies
pressure to the sacrum near the coccygeal end, directly cranially. The ilium is held
immobile through the hip joint as the examiner applies counter pressure against legs
in the form of traction force directed caudad. The test is considered positive if the
maneuver aggravates the patient’s typical pain.

Fortin finger test The patient is asked to point to the region of pain with one finger. It is positive if the patient
can localize the pain with one finger to an area inferomedial to the PSIS within 1 cm and
if the patient consistently pointed to the same area over at least two trials.

Continued
24 SE C T I O N 1 Evaluation

TABLE
1.8  Musculoskeletal Provocative Maneuvers—cont’d

Test Description
Hip Tests
Thomas test The patient lies supine while the examiner checks for excessive lordosis. The examiner
flexes one of the patient’s hips, bringing the knee to the chest and flattening out the
lumbar spine while the patient holds the flexed hip against the chest. If there is no flexion
contracture, the hip being tested (the straight leg) remains on the examining table. If a
contracture is present, the patient’s leg rises off the table. The angle of the contracture
can be measured.

Ely test The patient lies prone while the examiner passively flexes the patient’s knee. Upon flexion
of the knee, the patient’s hip on the same side spontaneously flexes, indicating that the
rectus femoris muscle is tight on that side and that the test is positive. The two sides
should be tested and compared.

Ober test The patient lies on one side with the thigh next to the table flexed to obliterate any lumbar
lordosis. The upper leg is flexed at a right angle at the knee. The examiner grasps the
ankle lightly with one hand and steadies the patient’s hip with the other. The upper leg
is abducted widely and extended so that the thigh is in line with the body. If there is an
abduction contracture, the leg will remain more or less passively abducted.

FAIR The patient is supine on a flat surface while the examiner flexes the hip and adducts the leg
across midline while also internally rotating. This creates a combined flexion, adduction,
and internal rotation (FAIR) movement.

Trendelenburg The patient is observed standing on one limb. The test is felt to be positive if the pelvis on
test the opposite side drops. A positive Trendelenburg test is suggestive of a weak gluteus
muscle or an unstable hip on the affected side.

Patrick (FABERE) See earlier (Sacroiliac Joint Disorder Tests).

test
 CHAPTER 1 The Physiatric History and Physical Examination 25

TABLE
1.8  Musculoskeletal Provocative Maneuvers—cont’d

Test Description
Anterior Cruciate Ligament Tests
Anterior drawer The patient is supine with hip flexed to 45 degrees and the knee flexed to 90 degrees. The
test examiner sits on the patient’s foot with hands behind the proximal tibia and thumbs on
the tibial plateau. Anterior force is applied to the proximal tibia. Hamstring tendons are
palpated with index fingers to ensure relaxation. Increased tibial displacement compared
with the opposite side is indicative of an anterior cruciate ligament tear.

Lachman test The patient lies supine. The knee is held between full extension and 15 degrees of flexion.
The femur is stabilized with one hand while firm pressure is applied to the posterior
aspect of the proximal tibia in an attempt to translate it anteriorly.

Pivot shift test The leg is picked up at the ankle. The knee is flexed by placing the heel of the hand behind
the fibula. As the knee is extended, the tibia is supported on the lateral side with a
slight valgus strain. A strong valgus force is placed on the knee by the upper hand. At
approximately 30 degrees of flexion, the displaced tibia will suddenly reduce, indicating a
positive pivot shift test.

Posterior Cruciate Ligament Tests

Posterior sag sign The patient lies supine with the hip flexed to 45 degrees and the knee flexed to 90 degrees.
In this position, the tibia “rocks back,” or sags back, on the femur if the posterior cruciate
ligament is torn. Normally, the medial tibial plateau extends 1 cm anteriorly beyond the
femoral condyle when the knee is flexed 90 degrees.

Posterior drawer The patient is supine with the test hip flexed to 45 degrees, knee flexed to 90 degrees,
test and foot in neutral position. The examiner sits on the patient’s foot with both hands
behind the patient’s proximal tibia and thumbs on the tibial plateau. Posterior force is
applied to the proximal tibia. Increased posterior tibial displacement as compared with
the uninvolved side is indicative of a partial or complete tear of the posterior cruciate
ligament.

Patellofemoral Tests
Patellar grind test The patient is supine with the knees extended. The examiner stands next to the involved
(compression side and places the web space of the thumb on the superior border of the patella. The
test) patient is asked to contract the quadriceps muscle while the examiner applies downward
and inferior pressure on the patella. Pain with movement of the patella or an inability to
complete the test is indicative of patellofemoral dysfunction.
Knee Meniscal Injury Tests
Joint line The medial joint line is easier to palpate with internal rotation of the tibia, allowing for
tenderness easier palpation. Alternatively, external rotation allows improved palpation of the lateral
meniscus.

Continued
26 SE C T I O N 1 Evaluation

TABLE
1.8  Musculoskeletal Provocative Maneuvers—cont’d

Test Description
McMurray test With the patient lying flat, the knee is first fully flexed; the foot is held by grasping the heel.
The leg is rotated on the thigh with the knee still in full flexion. By altering the position of
flexion, the whole of the posterior segment of the cartilages can be examined from the
middle to the posterior attachment. The leg is brought from its position of acute flexion
to a right angle while the foot is retained first in full internal rotation and then in full
external rotation. When the click occurs (in association with a torn meniscus), the patient
is able to state that the sensation is the same as experienced when the knee gave way
previously.
Apley grind test With the patient prone, the examiner grasps one foot in each hand and externally rotates as
far as possible, then flexes both knees together to their limit. The feet are then rotated
inward and knees extended. The examiner’s left knee is then applied to the back of
the patient’s thigh. The foot is grasped in both hands, the knee is bent to a right angle,
and powerful external rotation is applied. Next, the patient’s leg is strongly pulled up,
with the femur being prevented from rising off the couch. In this position of distraction,
external rotation is repeated. The examiner leans over the patient and compresses the
tibia downward. Again, the examiner rotates powerfully, and if addition of compression
produces an increase of pain, this grinding test is positive and meniscal damage is
diagnosed.
Ankle Stability Tests
Anterior drawer With the patient relaxed, the knee is flexed and the ankle at right angles, the ankle
test is grasped on the tibial side by one hand, and the index finger is placed on the
posteromedial part of the talus and the middle finger lies on the posterior tibial malleolus.
The heel of this hand braces the anterior distal leg. On pulling the heel forward with the
other hand, relative anteroposterior motion between the two fingers (and thus between
talus and tibia) is easily palpated and is also visible to both the patient and examiner.

Talar tilt The talar tilt angle is the angle formed by the opposing articular surfaces of the tibia and
talus when these surfaces are separated laterally by a supination force applied to the
hind part of the foot.

Syndesmosis Tests
Syndesmosis The squeeze test is performed by manually compressing the fibula to the tibia above the
squeeze test midpoint of the calf. A positive test produces pain over the area of the syndesmotic
ligaments.

Achilles Tendon Rupture Tests

Thompson test The patient lies in a prone position with the foot extending over the end of the table. The
calf muscles are squeezed in the middle one-third below the place of the widest girth.
Passive plantar movement of the foot is seen in a normal reaction. A positive reaction is
seen when there is no plantar movement of the foot and indicates rupture of the Achilles
tendon.
Modified from Malanga GA, Nadler SF, editors: Musculoskeletal physical examination: an evidence-based approach, Philadelphia, 2006, Mosby.
 CHAPTER 1
• Fig. 1.3 Universal goniometer. (Redrawn from Kottke FJ, Lehman JF:
Krusen’s handbook of physical medicine, ed 4, Philadelphia, 1990, Saun-
ders, with permission.)
be performed through all planes of motion (sagittal, coronal, and
transverse) by the examiner in a relaxed patient to thoroughly assess
end feel.54 AROM is performed by the patient through all planes of
motion without assistance from the examiner and evaluates muscle
strength, coordination of movement, and functional ability.
Contractures are often visualized during inspection because
they affect the true full ROM of a joint via either soft tissue or
bony changes. A soft tissue or muscle contracture decreases with
a prolonged stretch, whereas a bony limitation does not. It can be
difficult or impossible to differentiate a contracture from severe
hypertonia in certain CNS diseases. A diagnostic peripheral nerve
block can eliminate the hypertonia for a few hours to determine
the etiology of the contracture and guide the correct treatment for
impaired mobility or ADL.
Assessment Techniques
As previously mentioned, ROM is a function of joint morphology,
capsule and ligament integrity, and muscle and tendon strength.54,61
Range is measured with a universal goniometer, a device that has a
pivoting arm attached to a stationary arm divided into 1-degree
intervals (Fig. 1.3). Regardless of the type of goniometer used, reli-
ability is increased by knowing and using consistent surface land-
marks and test positions.29 Joints are measured in their plane of
movement with the stationary arm parallel to the long axis of the
proximal body segment or bony landmark.54 The moving arm of
the goniometer should also be aligned with a bony landmark or par-
allel to the moving body segment. The impaired joint should always
be compared with the contralateral unimpaired joint, if possible.
Sagittal, coronal, and transverse planes divide the body into
three cardinal planes of motion (Fig. 1.4). The sagittal plane
divides the body into left and right halves, the coronal (frontal)
plane into anterior and posterior halves, and the transverse plane
into superior and inferior parts.29 For sagittal plane measure-
ments, the goniometer is placed on the lateral side of the joint,
except for a few joint motions, such as forearm supination and
pronation. Coronal planes are measured anteriorly or posteriorly,
with the axis coinciding with the axis of the joint.
The Physiatric History and Physical Examination 27
tal Front
Sagit al
Tran
s vers
e
• Fig. 1.4 Cardinal planes of motion.
The 360-degree system was first proposed by Knapp and
West41,50 and denotes 0 degrees directly overhead and 180 degrees
at the feet. In the 360-degree system, shoulder forward flexion
and extension ranges from 0 to 240 degrees (Fig. 1.5A). The
American Academy of Orthopedic Surgeons uses a 180-degree
system.50 The standard anatomic position16 is described as an
upright position with the feet facing forward, the arms at the
side with the palms facing anterior.29 A joint at 0 degrees is in the
anatomic position, with movement occurring up to 180 degrees
away from 0 degrees in either direction.29 With the use of shoul-
der forward flexion as an example, the normal range for flexion in
the 180-degree system is 0 to 180 degrees, and for extension is 0
to 60 degrees (see Fig. 1.5B). These standardized techniques have
been well described.b
Figs. 1.6–1.21 outline the correct patient positioning and plane
of motion for the joint and goniometer placement. To increase accu-
racy, many practitioners recommend taking several measurements
and recording a mean value.54 Measurement inaccuracy can be as
high as 10% to 30% in the limbs and can be difficult to quantify
in the spine if based on visual assessment alone.4,68 Spinal ROM is
more difficult to measure, and its reliability has been debated.29,38
The most accurate method of measuring spinal motion is with radio-
graphs; however, this is not practical in most clinical scenarios. In the
absence of radiographs, the next best system is based on inclinom-
eters, fluid-filled instruments with a 180- or 360-degree scale.4,38
Although rarely used now due to subjectivity and variability, the
American Medical Association’s Guides to the Evaluation of Perma-
nent Impairment4 outlines the specific inclinometer techniques for
measuring spinal ROM.
Assessment of Muscle Strength
General Principles
Manual muscle testing is used to establish baseline strength,
to determine functional ability or the need for adaptive equip-
ment, to confirm a diagnosis, and to suggest a prognosis.55
Whereas strength is a rather generic term and can refer to a wide
variety of assessments and testing situations,6 manual muscle
bReferences 4, 19a, 29, 38, 38a, 43, 54.
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selves, and that the Absolute is therefore a society of selves? Our
answer to this question must depend, I think, upon two
considerations,—(a) the amount of continuity we regard as essential
to a self, and (b) the kind of unity we attribute to a society.
(a) If we regard any and every degree of felt teleological continuity
as sufficient to constitute a self, it is clear that we shall be compelled
to say that selves, and selves only, are the material of which reality is
composed. For we have already agreed that Reality is exclusively
composed of psychical fact, and that all psychical facts are
satisfactions of some form of subjective interest or craving, and
consequently that every psychical fact comprised in the whole
system of existence must form part of the experience of a finite
individual subject. Hence, if every such subject, whatever its degree
of individuality, is to be called a self, there will be no facts which are
not included somewhere in the life of one or more selves. On the
other hand, if we prefer, as I have done myself, to regard some
degree of intellectual development, sufficient for the recognition of
certain permanent interests as those of the self, as essential to
selfhood, we shall probably conclude that the self is an individual of
a relatively high type, and that there are consequently experiences of
so imperfect a degree of teleological continuity as not to merit the
title of selves.
And this conclusion seems borne out by all the empirically
ascertained facts of, e.g., the life of the lower animals, of human
infants, and again of adults of abnormally defective intellectual and
moral development. Few persons, unless committed to the defence
of a theory through thick and thin, would be prepared to call a worm
a self, and most of us would probably feel some hesitation about a
new-born baby or a congenital idiot. Again, finite societies are clearly
components of Reality, yet, as we have seen, it is probably an error
to speak of a society as a self, though every true society is clearly an
individual with a community and continuity of purpose which enable
us rightly to regard it as a unity capable of development, and to
appreciate its ethical worth. Hence it is, perhaps, less likely to lead to
misunderstandings if we say simply that the constituents of reality
are finite individual experiences, than if we say that they are selves.
The self, as we have seen, is a psychological category which only
imperfectly represents the facts of experience it is employed to
correlate.
(b) Again, if we speak of the Absolute as a society of finite
individuals, we ought at least to be careful in guarding ourselves
against misunderstanding. Such an expression has certainly some
manifest advantages. It brings out both the spiritual character of the
system of existence and the fact that, though it contains a plurality of
finite selves and contains them without discord, it is not properly
thought of as a self, but as a community of many selves.
At the same time, such language is open to misconstructions,
some of which it may be well to enumerate. We must not, for
instance, assume that all the individuals in the Absolute are
necessarily in direct social interrelation. For social relation, properly
speaking, is only possible between beings who are ἴσοι καὶ ὅμοιοι at
least in the sense of having interests of a sufficiently identical kind to
permit of intercommunication and concerted cooperation for the
realisation of a common interest. And our own experience teaches
us that the range of existence with which we ourselves stand in this
kind of relation is limited. Even within the bounds of the human race
the social relations of each of us with the majority of our fellows are
of an indirect kind, and though with the advance of civilisation the
range of those relations is constantly being enlarged, it still remains
to be seen whether a “cosmopolitan” society is a realisable ideal or
not. With the non-human animal world our social relations, in
consequence of the greater divergence of subjective interest, are
only of a rudimentary kind, and with what appears to us as inanimate
nature, as we have already seen, direct social relation seems to be
all but absolutely precluded.
Among the non-human animals, again, we certainly find traces of
relations of a rudimentarily social kind, but once more only within
relatively narrow limits; the different species and groups seem in the
main to be indifferent to one another. And we have no means of
disproving the possibility that there may be in the universe an
indefinite plurality of social groups, of an organisation equal or
superior to that of our human communities, but of a type so alien to
our own that no direct communication, not even of the elementary
kind which would suffice to establish their existence, is possible. We
must be prepared to entertain the possibility, then, that the
individuals composing the Absolute fall into a number of groups,
each consisting of members which have direct social relations of
some kind with each other, but not with the members of other
groups.
And also, of course, we must remember that there may very well
be varieties of degree of structural complexity in the social groups
themselves. In some the amount of intelligent recognition on the part
of the individuals of their own and their fellows’ common scheme of
interests and purposes is probably less articulate, in others, again, it
may be more articulate than is the case in those groups of co-
operating human beings which form the only societies of which we
know anything by direct experience.
On the other hand, we must, if we speak of the Absolute as a
society, be careful to avoid the implication, which may readily arise
from a false conception of human societies, that the unity of the
Absolute is a mere conceptual fiction or “point of view” of our own,
from which to regard what is really a mere plurality of separate units.
In spite of the now fairly complete abandonment in words of the old
atomistic theories, which treated society as if it were a mere
collective name for a multitude of really independent “individuals,” it
may be doubted whether we always realise what the rejection of this
view implies. We still tend too much to treat the selves which
compose a society, at least in our Metaphysics, as if they were given
to us in direct experience as merely exclusive of one another, rather
than as complementary to one another. In other words, of the two
typical forms of experience from which the concept of self appears to
be derived, the experience of conflict between our subjective
interests and our environment, and that of the removal of the
discord, we too often pay attention in our Metaphysics to the former
to the neglect of the latter. But in actual life it is oftener the latter that
is prominent in our relations with our fellow-men. We—the category
of co-operation—is at least as fundamental in all human thought and
language as I and thou, the categories of mutual exclusion. That you
and I are mutually complementary factors in a wider whole of
common interests, is at least as early a discovery of mankind as that
our private interests and standpoints collide.
 If we speak of existence as a society, then we must be careful to
remember that the individual unity of a society is just as real a fact of
experience as the individual unity of the members which compose it,
and that, when we call the Absolute a society rather than a self, we
do not do so with any intention of casting doubt upon its complete
spiritual unity as an individual experience. With these restrictions, it
would, I think, be fair to say that if the Absolute cannot be called a
society without qualification, at any rate human society affords the
best analogy by which we can attempt to represent its systematic
unity in a concrete conceptual form. To put it otherwise, a genuine
human society is an individual of a higher type of structure than any
one of the selves which compose it, and therefore more adequately
represents the structure of the one ultimately complete system of the
Absolute.
We see this more particularly in the superior independence of
Society as compared with one of its own members. It is true, of
course, that no human society could exist apart from an external
environment, but it does not appear to be as necessary to the
existence of society as to that of a single self, that it should be
sensible of the contrast between itself and its rivals. As we have
already sufficiently seen, it is in the main from the experience of
contrast with other human selves that I come by the sense of my
own selfhood. Though the contents of my concept of self are not
purely social, it does at least seem clear that I could neither acquire
it, nor retain it long, except for the presence of other like selves
which form the complement to it. But though history teaches how
closely similar is the part played by war and other relations between
different societies in developing the sense of a common national
heritage and purpose, yet a society, once started on its course of
development, does appear to be able to a large extent to flourish
without the constant stimulus afforded by rivalry or co-operation with
other societies. One man on a desert land, if left long enough to
himself, would probably become insane or brutish; there seems no
sufficient reason to hold that a single civilised community, devoid of
relations with others, could not, if its internal organisation were
sufficiently rich, flourish in a purely “natural” environment. On the
strength of this higher self-sufficiency, itself a consequence of
superior internal wealth and harmony, a true society may reasonably
be held to be a finite individual of a higher type than a single human
self.
The general result of this discussion, then, seems to be, that
neither in the self nor in society—at any rate in the only forms of it
we know to exist—do we find the complete harmony of structure and
independence of external conditions which are characteristic of
ultimate reality. Both the self and society must therefore be
pronounced to be finite appearance, but of the two, society exhibits
the fuller and higher individuality, and is therefore the more truly real.
We found it quite impossible to regard the universe as a single self;
but, with certain important qualifications, we said that it might be
thought of as a society without very serious error.[194] It will, of
course, follow from what has been said, that we cannot frame any
finally adequate conception of the way in which all the finite
individual experiences form the unity of the infinite experiences. That
they must form such a perfect unity we have seen in our Second
Book; that the unity of a society is, perhaps, the nearest analogy by
which we can represent it, has been shown in the present
paragraph. That we have no higher categories which can adequately
indicate the precise way in which all existence ultimately forms an
even more perfect unity, is an inevitable consequence of the fact of
our own finitude. We cannot frame the categories, because we, as
finite beings, have not the corresponding experience. To this extent,
at least, it seems to me that any sound philosophy must end with a
modest confession of ignorance.
 “There is in God, men say,
A deep but dazzling darkness,”

is a truth which the metaphysician’s natural desire to know as much

as possible of the final truth, should not lead him to forget.
§ 5. This is probably the place to make some reference to the
question whether the self is a permanent or only a temporary form in
which Reality appears. In popular thought this question commonly
appears as that of the immortality (sometimes, too, of the pre-
existence) of the soul. The real issue is, however, a wider one, and
the problem of immortality only one of its subsidiary aspects. I
propose to say something briefly on the general question, and also
on the special one, though in this latter case rather with a view to
indicating the line along which discussion ought to proceed, than
with the aim of suggesting a result.
It would not, I think, be possible to deny the temporary character of
the self after the investigations of the earlier part of this chapter. A
self, we said, is one and the same only in virtue of teleological
continuity of interest and purpose. But exactly how much variation is
enough to destroy this continuity, and how much again may exist
without abolishing it, we found it impossible to determine by any
general principle. Yet the facts of individual development seemed to
make it clear that new selves—i.e. new unique forms of interest in
the world—come into being in the time-process, and that old ones
disappear.
And again, both from mental Pathology and from normal
Psychology, we found it easy to cite examples of the formation and
disappearance, within the life-history of a single man, of selves
which it seemed impossible to regard as connected by any felt
continuity of interest with the rest of life. In the case of multiple
personality, and alternating personality, we seemed to find evidence
that a plurality of such selves might alternate regularly, or even co-
exist in connection with the same body. The less striking, but more
familiar, cases of the passing selves of our dreams, and of temporary
periods in waking life where our interest and characters are modified,
but not in a permanent way by exceptional excitements, belong in
principle to the same category. In short, unless you are to be content
with a beggarly modicum of continuity of purpose too meagre to be
more than an empty name, you seem forced to conclude that the
origination and again the disappearance of selves in the course of
psychical events is a fact of constant occurrence. No doubt, the
higher the internal organisation of our interests and purposes, the
more fixed and the less liable to serious modification in the flux of
circumstance our self becomes; but a self absolutely fixed and
unalterable was, as we saw, an unrealised and, on the strength of
our metaphysical certainty that only the absolute whole is entirely
self-determined, we may add, an unrealisable ideal. We seem
driven, then, to conclude that the permanent identity of the self is a
matter of degree, and that we are not entitled to assert that the self
corresponding to a single organism need be either single or
persistent. It is possible for me, even in the period between birth and
death, to lose my old self and acquire a new one, and even to have
more selves than one, and those of different degrees of individual
structure, at the same time. Nor can we assign any certain criterion
by which to decide in all cases whether the self has been one and
identical through a series of psychical events. Beyond the general
assertion that the more completely occupied our various interests
and purposes are, the more permanent is our selfhood, we are
unable to go.[195]
These considerations have an important bearing on the vexed
question of a future life. If they are justified, we clearly cannot have
any positive demonstration from the nature of the self of its
indestructibility, and it would therefore be in vain to demand that
philosophy shall prove the permanence of all selves. On the other
hand, if the permanence of a self is ultimately a function of its inner
unity of aim and purpose, there is no a priori ground for holding that
the physical event of death must necessarily destroy this unity, and
so that the self must be perishable at death. For Metaphysics, the
problem thus seems to resolve itself into a balancing of probabilities,
and, as an illustration of the kind of consideration which has to be
taken into account, it may be worth while to inquire what probable
arguments may fairly be allowed to count on either side.
 On the negative side, if we dismiss, as we fairly may, the unproved
assertions of dogmatic Materialism, we have to take account of the
possibility that a body may, for all we know, be a necessary condition
for the existence of an individual experience continuous in interest
and purpose with that of our present life, and also of the alleged
absence of any positive empirical evidence for existence after death.
These considerations, however, scarcely seem decisive. As to the
first, I do not see how it can be shown that a body is indispensable,
at least in the sense of the term “body” required by the argument. It
is no doubt true that in the experience of any individual there must
be the two aspects of fresh teleological initiative and of already
systematised habitual and quasi-mechanical repetition of useful
reactions already established, and further, that intercourse between
different individuals is only possible through the medium of such a
system of established habits. As we have already seen, what we call
our body is simply a name for such a set of habitual reactions
through which intercommunication between members of human
societies is rendered possible. Hence, if we generalise the term
“body” to stand for any system of habitual reactions discharging this
function of serving as a medium of communication between
individuals forming a society, we may fairly say that a body is
indispensable to the existence of a self. But it seems impossible to
show that the possibility of such a medium of communication is
removed by the dissolution of the particular system of reactions
which constitutes our present medium of intercourse. The dissolution
of the present body might mean no more than the individual
acquisition of changed types of habitual reaction, types which no
longer serve the purpose of communication with the members of our
society, but yet may be an initial condition of communication with
other groups of intelligent beings.
As to the absence of empirical evidence, it is, of course, notorious
that some persons at least claim to possess such evidence of the
continued existence of the departed. Until the alleged facts have
been made the subject of serious and unbiassed collection and
examination, it is, I think, premature to pronounce an opinion as to
their evidential value. I will therefore make only one observation with
respect to some of the alleged evidence from “necromancy.” It is
manifest that the only kind of continuance which could fairly be
called a survival of the self, and certainly the only kind in which we
need feel any interest, would be the persistence after death of our
characteristic interests and purposes. Unless the “soul” continued to
live for aims and interests teleologically continuous with those of its
earthly life, there would be no genuine extension of our selfhood
beyond the grave. Hence any kind of evidence for continued
existence which is not at the same time evidence for continuity of
interests and purposes, is really worthless when offered as testimony
to “immortality.” The reader will be able to apply this reflection for
himself if he knows anything of the “phenomena” of the vulgar
Spiritualism.[196]
When we turn to the positive side of the question, it seems
necessary to remark that though the negative considerations we
have just referred to are not of themselves enough to disprove
“immortality,” provided there is any strong ground for taking it as a
fact, they would be quite sufficient to decide against it, unless there
is positive reason for accepting it. That we have no direct evidence
of such a state of things, and cannot see precisely how in detail it
could come about, would not be good logical ground for denying its
existence if it were demanded by sound philosophical principles. On
the other hand, if there were no reasons for believing in it, and good,
though not conclusive, probable reasons against it, we should be
bound to come provisionally to a negative conclusion.
Have we then any positive grounds at all to set against the
negative considerations just discussed? Pending the result of
inquiries which have recently been set on foot, it is hard to speak
with absolute confidence; still, the study of literature does, I think,
warrant us in provisionally saying that there seems to be a strong
and widely diffused feeling, at least in the Western world, that life
without any hope of continuance after death would be an
unsatisfactory thing. This feeling expresses itself in many forms, but I
think they can all be traced to one root. Normally, as we know, the
extinction of a particular teleological interest is effected by its
realisation; our purposes die out, and our self so far suffers change,
when their result has been achieved. (And incidentally this may help
us to see once more that dissatisfaction and imperfection are of the
essence of the finite self. The finite self lives on the division of idea
from reality, of intent from execution. If the two could become
identical, the self would have lost the atmosphere from which it
draws its life-breath.) Hence, if death, in our experience, always took
the form of the dissolution of a self which had already seen its
purposes fulfilled and its aims achieved, there would probably be no
incentive to desire or believe in future continuance. But it is a familiar
fact that death is constantly coming as a violent and irrational
interrupter of unrealised plans and inchoate work. The self seems to
disappear not because it has played its part and finished its work,
but as the victim of external accident. I think that analysis would
show, under the various special forms which the desire for
immortality takes, such as the yearning to renew interrupted
friendships or the longing to continue unfinished work, as their
common principle, the feeling of resentment against this apparent
defeat of intelligent purpose by brute external accident.[197]
Now, what is the logical value of this feeling as a basis for
argument? We may fairly say, on the one hand, that it rests on a
sound principle. For it embodies the conviction, of which all
Philosophy is the elaboration, that the real world is a harmonious
system in which irrational accident plays no part, and that, if we
could only see the whole truth, we should realise that there is no final
and irremediable defeat for any of our aspirations, but all are
somehow made good. On the other side, we must remember that the
argument from the desire for continuance to its reality also goes on
to assert not only that our aspirations are somehow fulfilled and our
unfinished work somehow perfected, but that this fulfilment takes
place in the particular way which we, with our present lights, would
wish. And in maintaining this, the argument goes beyond the
conclusion which philosophical first principles warrant.
For it might be that, if our insight into the scheme of the world were
less defective, we should cease to desire this special form of
fulfilment, just as in growing into manhood we cease to desire the
kind of life which appeared to us as children the ideal of happiness.
The man’s life-work may be the realisation of the child’s dreams, but
it does not realise them in the form imagined by childhood. And
conceivably it might be so with our desire for a future life. Further, of
course, the logical value of the argument from feeling must to some
extent depend upon the universality and persistence of the feeling
itself. We must not mistake for a fundamental aspiration of humanity
what may be largely the effect of special traditions and training.
Hence we cannot truly estimate the worth of the inference from
feeling until we know both how far the feeling itself is really
permanent in our own society, and how far, again, it exists in
societies with different beliefs and traditions. In itself the sentiment,
e.g., of Christian civilisation, cannot be taken as evidence of the
universal feeling of mankind, in the face of the apparently opposite
feelings, e.g., of Brahmins and Buddhists.
I should conclude, then, that the question of a future life must
remain an open one for Metaphysics. We seem unable to give any
valid metaphysical arguments for a future life, but then, on the other
hand, the negative presumptions seem to be equally devoid of
cogency. Philosophy, in this matter, to use the fine phrase of Dr.
McTaggart, “gives us hope,”[198] and I cannot, for my own part, see
that it can do more. Possibly, as Browning suggests in La Saisiaz, it
is not desirable, in the interests of practical life, that it should do
more. And here I must leave the question with the reader, only
throwing out one tentative suggestion for his approval or rejection as
he pleases. Since we have seen that the permanence of the self
depends upon its degree of internal harmony of structure, it is at
least conceivable that its continuance as a self, beyond the limits of
earthly life, may depend on the same condition. Conceivably the self
may survive death, as it survives lesser changes in the course of
physical events, if its unity and harmony of purpose are strong
enough, and not otherwise. If so, a future existence would not be a
heritage into which we are safe to step when the time comes, but a
conquest to be won by the strenuous devotion of life to the
acquisition of a rich, and at the same time orderly and harmonious,
moral selfhood. And thus the belief in a future life, in so far as it acts
in any given case as a spur to such strenuous living, might be itself a
factor in bringing about its own fulfilment. It is impossible to affirm
with certainty that this is so, but, again, we cannot deny that it may
be the case. And here, as I say, I must be content to leave the
problem.[199]
 Consult further:—B. Bosanquet, Psychology of the Moral Self, lect.
5; F. H. Bradley, Appearance and Reality, chaps. 9 (The Meanings of
Self), 10 (The Reality of Self), 26 (The Absolute and its
Appearances,—especially the end of the chapter, pp. 499-511 of 1st
ed.), 27 (Ultimate Doubts); L. T. Hobhouse, Theory of Knowledge,
part 3, chap. 5; S. Hodgson, Metaphysic of Experience, bk. iv. chap.
4; Hume, Treatise of Human Nature, bk. i part 4, §§ 5, 6; W. James,
Principles of Psychology, vol. i. chap. 10; H. Lotze, Metaphysic, bk.
iii chaps. 1 (especially § 245), 5; Microcosmus, bk. iii. c. 5; J. M. E.
McTaggart, Studies in Hegelian Cosmology, chap. 2 (for a detailed
hostile examination of Dr. McTaggart’s argument, which I would not
be understood to endorse except on special points, see G. E. Moore
in Proceedings of Aristotelian Society, N.S. vol. ii. pp. 188-211); J.
Royce, The World and the Individual, Second Series, lects. 6, 7.

184. “Bodily identity” itself, of course, might give rise to difficult

problems if we had space to go into them. Here I can merely suggest
certain points for the reader’s reflection. (1) All identity appears in the
end to be teleological and therefore psychical. I believe this to be the
same human body which I have seen before, because I believe that
the interests expressed in its actions will be continuous, experience
having taught me that a certain amount of physical resemblance is a
rough-and-ready criterion of psychical continuity. (2) As to the ethical
problem of responsibility referred to in the text, it is obviously entirely
one of less and more. Our moral verdicts upon our own acts and
those of others are in practice habitually influenced by the conviction
that there are degrees of moral responsibility within what the
immediate necessities of administration compel us to treat as
absolute. We do not, e.g., think a man free from all moral blame for
what he does when drunk, or undeserving of all credit for what he
performs when “taken out of himself,” i.e. out of the rut of his habitual
interests by excitement, but we certainly do, when not under the
influence of a theory, regard him as deserving of less blame or
credit, as the case may be, for his behaviour than if he had
performed the acts when he was “more himself.” On all these topics
see Mr. Bradley’s article in Mind for July 1902.
 185. So “self-consciousness,” in the bad sense, always arises
from a sense of an incongruity between the self and some
contrasted object or environment.
186. Though, of course, it does appear in the process of framing
and initiating the scheme of concerted action; the other self is here
contrasted with my own, precisely because the removal of the
collision between my purpose and my environment is felt as coming
from without.
187. It might be said that it is not these features of the
environment themselves, but my “ideas” of them, which thus belong
to the self. This sounds plausible at first, but only because we are
habitually accustomed to the “introjectionist” substitution of
psychological symbols for the actualities of life. On the question of
fact, see Bradley, Appearance and Reality, chap. 8, p. 88 ff. (1st
ed.).
188. A colleague of my own tells me that in his case movements of
the eyes appear to be inseparable from the consciousness of self,
and are incapable of being extruded into the not-self in the sense
above described. I do not doubt that there are, in each of us, bodily
feelings of this kind which refuse to be relegated to the not-self and
that it would be well worth while to institute systematic inquiries over
as wide an area as possible about their precise character in
individual cases. It appears to me, however, as I have stated above,
that in ordinary perception these bodily feelings often are
apprehended simply as qualifying the perceived content without any
opposition of self and not-self. At any rate, the problem is one of
those fundamental questions in the theory of cognition which are too
readily passed over in current Psychology.
189. Of course, you can frame the concept of a “self” from which
even these bodily feelings have been extruded, and which is thus a
mere “cognitive subject” without concrete psychical quality. But as
such a mere logical subject is certainly not the self of which we are
aware in any concrete experience, and still more emphatically not
the self in which the historical and ethical sciences are interested, I
have not thought it necessary to deal with it in the text.
190. That we cannot imagine it does not appear to be any ground
for denying its actuality. It is never a valid argument against a
conclusion required to bring our knowledge into harmony with itself,
that we do not happen to possess the means of envisaging it in
sensuous imagery.
191. I venture to think that some of the rather gratuitous
hypotheses as to the rational selfhood of animal species quà species
put forward by Professor Royce in the second volume of The World
and the Individual, are illustrations of this tendency to unnecessary
over-interpretation.
192. Is it necessary to refer in particular to the suggestion that for
the Absolute the contrast-effect in question may be between itself
and its component manifestations or appearances? This would only
be possible if the finite appearances were contained in the whole in
some way which allowed them to remain at discord with one another,
i.e. in some way incompatible with the systematic character which is
the fundamental quality of the Absolute. I am glad to find myself in
accord, on the general principle at least, with Dr. McTaggart. See the
Third Essay in his recent Studies in Hegelian Cosmology.
193. It would be fruitless to object that “societies” can, in fact, have
a legal corporate personality, and so can—to revert to the illustration
used above—be sued and taxed. What can be thus dealt with is
always a mere association of definite individual human beings, who
may or may not form a genuine spiritual unity. E.g., you might
proceed against the Commissioners of Income Tax, but this does not
prove that the Commissioners of Income Tax are a genuine society.
On the other hand, the Liberal-Unionist Party probably possesses
enough community of purpose to enable it to be regarded as a true
society, but has no legal personality, and consequently no legal
rights or obligations, as a party. Similarly, the corporation known as
the Simeon Trustees has a legal personality with corresponding
rights and duties, and it also stands in close relation with the
evangelical party in the Established Church. And this party is no
doubt a true ethical society. But the corporation is not the evangelical
party, and the latter, in the sense in which it is a true society, is not a
legal person.
I may just observe that the question whether the Absolute is a self
or a person must not be confounded with the question of the
“personality of God.” We must not assume off-hand that “God” and
the Absolute are identical. Only special examination of the
phenomena of the religious life can decide for us whether “God” is
necessarily the whole of Reality. If He is not, it would clearly be
possible to unite a belief in “God’s” personality with a denial of the
personality of the Absolute, as is done, e.g., by Mr. Rashdall in his
essay in Personal Idealism. For some further remarks on the
problem, see below, Chapter V.
194. I suppose that any doctrine which denies the ultimate reality
of the finite self must expect to be confronted by the appeal to the
alleged revelation of immediate experience. Cogito, ergo sum, is
often taken as an immediately certain truth in the sense that the
existence of myself is something of which I am directly aware in
every moment of consciousness. This is, however, an entire
perversion of the facts. Undoubtedly the fact of there being
experience is one which can be verified by the very experiment of
trying to deny it. Denial itself is a felt experience. But it is (a)
probably not true that we cannot have experience at all without an
accompanying perception of self, and (b) certainly not true that the
mere feeling of self as in contrast with a not-self, when we do get it,
is what is meant by the self of Ethics and History. The self of these
sciences always embraces more than can be given in any single
moment of experience, it is an ideal construction by which we
connect moments of experience according to a general scheme. The
value of that scheme for any science can only be tested by the
success with which it does its work, and its truth is certainly not
established by the mere consideration that the facts it aims at
connecting are actual. Metaphysics would be the easiest of sciences
if you could thus take it for granted that any construction which is
based upon some aspect of experienced fact must be valid.
195. This is why Plato seems justified in laying stress upon the
dreams of the wise man as evidence of his superiority (Republic, bk.
ix. p. 571). His ideal wise man is one whose inner life is so
completely unified that there is genuine continuity of purpose
between his waking and sleeping state. Plato might perhaps have
replied to Locke’s query, that Socrates waking and Socrates asleep
are the same person, and their identity is testimony to the
exceptional wisdom and virtue of Socrates.
 If it be thought that at least the simultaneous co-existence within
one of two selves is inconceivable, I would ask the reader to bear in
mind that the self always includes more than is at any moment given
as actual matter of psychical fact. At any moment the self must be
taken to consist for the most part of unrealised tendencies, and in so
far as such ultimately incompatible tendencies are part of my whole
nature, at the same time it seems reasonable to say that I have
simultaneously more than one self. Ultimately, no doubt, this line of
thought would lead to the conclusion that “my whole nature” itself is
only relatively a whole.
196. Compare the valuable essay by Mr. Bradley on the “Evidence
of Spiritualism” in Fortnightly Review for December 1885.
197. Death, however, though the most striking, is not the only
illustration of this apparently irrational interference of accident with
intelligent purpose. Mental and bodily disablement, or even adverse
external fortune, may have the same effect upon the self. This must
be taken into account in any attempt to deal with the general
problem.
198. Dr. McTaggart’s phrase is more exactly adequate to describe
my view than his own, according to which “immortality” is capable of
philosophical proof. (See the second chapter of his Studies in
Hegelian Cosmology.) I have already explained why I cannot accept
this position. I believe Dr. McTaggart’s satisfaction with it must be
partly due to failure to raise the question what it is that he declares to
be a “fundamental differentiation” of the Absolute.
199. I ought perhaps to say a word—more I do not think necessary
—upon the doctrine that immortality is a fundamental “moral
postulate.” If this statement means no more than that it would be
inconsistent with the rationality of the universe that our work as
moral agents should be simply wasted, and that therefore it must
somehow have its accomplishment whether we see it in our human
society or not, I should certainly agree with the general proposition.
But I cannot see that we know enough of the structure of the
universe to assert that this accomplishment is only possible in the
special form of immortality. To revert to the illustration of the text, (1)
our judgment that the world must be a worthless place without
immortality might be on a level with the child’s notion that “grown-up”
life, to be worth having, must be a life of continual play and no work.
(2) If it is meant, however, that it is not “worth while” to be virtuous
unless you can look forward to remuneration—what Hegel,
according to Heine, called a Trinkgeld—hereafter for not having lived
like a beast, the proposition appears to me a piece of immoral
nonsense which it would be waste of time to discuss.
 CHAPTER IV

THE PROBLEM OF MORAL FREEDOM

§ 1. The metaphysical problem of free will has been historically created by extra
ethical difficulties, especially by theological considerations in the early
Christian era, and by the influence of mechanical scientific conceptions in the
modern world. § 2-3. The analysis of our moral experience shows that true
“freedom” means teleological determination. Hence to be “free” and to “will”
are ultimately the same thing. Freedom or “self-determination” is genuine but
limited, and is capable of variations of degree. § 4. Determinism and
Indeterminism both arise from the false assumption that the mechanical
postulate of causal determination by antecedents is an ultimate fact. The
question then arises whether mental events are an exception to the supposed
principle. § 5. Determinism. The determinist arguments stated. § 6. They rest
partly upon the false assumption that mechanical determination is the one and
only principle of rational connection between facts. § 7. Partly upon fallacious
theories of the actual procedure of the mental sciences. Fallacious nature of
the argument that complete knowledge of character and circumstances would
enable us to predict human conduct. The assumed data are such as, from
their own nature, could not be known before the event. § 8. Indeterminism.
The psychical facts to which the indeterminist appeals do not warrant his
conclusion, which is, moreover, metaphysically absurd, as involving the denial
of rational connection. § 9. Both doctrines agree in the initial error of
confounding teleological unity with causal determination.

§ 1. The problem of the meaning and reality of moral freedom is

popularly supposed to be one of the principal issues, if not the
principal issue, of Metaphysics as applied to the facts of human life.
Kant, as the reader will no doubt know, included freedom with
immortality and the existence of God in his list of unprovable but
indispensable “postulates” of Ethics, and the conviction is still
widespread among students of moral philosophy that ethical science
cannot begin its work without some preliminary metaphysical
justification of freedom, as a postulate at least, if not as a proved
truth. For my own part, I own I cannot rate the practical importance
of the metaphysical inquiry into human freedom so high, and am
rather of Professor Sidgwick’s opinion as to its superfluousness in
strictly ethical investigations.[200] At the same time, it is impossible to
pass over the subject without discussion, if only for the excellent
illustrations it affords of the mischief which results from the forcing of
false metaphysical theories upon Ethics, and for the confirmation it
yields of our view as to the postulatory character of the mechanico-
causal scheme of the natural sciences. In discussing freedom from
this point of view as a metaphysical issue, I would have it clearly
understood that there are two important inquiries into which I do not
intend to enter, except perhaps incidentally.
One is the psychological question as to the precise elements into
which a voluntary act may be analysed for the purpose of
psychological description; the other the ethical and juridical problem
as to the limits of moral responsibility. For our present purpose both
these questions may be left on one side. We need neither ask how a
voluntary act is performed—in other words, by what set of symbols it
is best represented in Psychology—nor where in a complicated case
the conditions requisite for accountability, and therefore for freedom
of action, may be pronounced wanting. Our task is the simpler one of
deciding, in the first place, what we mean by the freedom which we
all regard as morally desirable, and next, what general view as to the
nature of existence is implied in the assertion or denial of its
actuality.
That the examination of the metaphysical implications of freedom
is not an indispensable preliminary to ethical study, is fortunately
sufficiently established by the actual history of the moral sciences.
The greatest achievements of Ethics, up to the present time, are
undoubtedly contained in the systems of the great Greek moralists,
Plato and Aristotle. It would not be too much to say that subsequent
ethical speculation has accomplished, in the department of Ethics
proper as distinguished from metaphysical reflection upon the
ontological problems suggested by ethical results, little more than
the development in detail of general principles already recognised
and formulated by these great observers and critics of human life.
Yet the metaphysical problem of freedom, as is well known, is
entirely absent from the Platonic-Aristotelian philosophy. With Plato,
as the reader of the Gorgias and the eighth and ninth books of the
Republic will be aware, freedom means just what it does to the
ordinary plain man, the power to “do what one wills,” and the only
speculative interest taken by the philosopher in the subject is that of
showing that the chief practical obstacle to the attainment of freedom
arises from infirmity and inconsistency in the will itself; that, in fact,
the unfree man is just the criminal or “tyrant” who wills the
incompatible, and, in a less degree, the “democratic” creature of
moods and impulses, who, in popular phrase, “doesn’t know what he
wants” of life.
Similarly, Aristotle, with less of spiritual insight but more attention
to matters of practical detail, discusses the ἑχούσιον, in the third
book of his Ethics, purely from the standpoint of an ideally perfect
jurisprudence. With him the problem is to know for what acts an
ideally perfect system of law could hold a man non-responsible, and
his answer may be said to be that a man is not responsible in case
of (1) physical compulsion, in the strict sense, where his limits are
actually set in motion by some external agent or cause; and (2) of
ignorance of the material circumstances. In both these cases there is
no responsibility, because there has been no real act, the outward
movements of the man’s limbs not corresponding to any purpose of
his own. An act which does translate into physical movement a
purpose of the agent, Aristotle, like practical morality and
jurisprudence, recognises as ipso facto free, without raising any
metaphysical question as to the ontological implications of the
recognition.
Historically, it appears that the metaphysical problem has been
created for us by purely non-ethical considerations. “Freedom of
indifference” was maintained in the ancient world by the Epicureans,
but not on ethical grounds. As readers of the second book of
Lucretius know, they denied the validity of the postulate of rigidly
mechanical causality simply to extricate themselves from the position
into which their arbitrary physical hypotheses had led them. If
mechanical causality were recognised as absolute in the physical
world, and if, again, as Epicurus held, the physical world was
composed of atoms all falling with constant velocities in the same
direction, the system of things, as we know it, could never have
arisen. Hence, rather than give up their initial hypothesis about the
atoms, the Epicureans credited the individual atom with a power of