The field of physical medicine and rehabilitation (PM&R) emerged in the 1930s to focus on musculoskeletal and neurologic issues of patients, and further evolved after World War II as veterans returned to the United States with disabling injuries. Restoration of functional ability was established as a fundamental goal of this new field. In 1947, the American Board of Medical Specialties granted PM&R the title of an independent specialty, also known as physiatry.

PM&R focuses on the prevention, diagnosis, and treatment of disorders related to the nerves, muscles, and bones that may produce temporary or permanent impairment or disability. PM&R is often called the “quality of life profession,” because its goal is to enhance patient performance and improve function. The focus is on quality of life—medically, socially, emotionally, and vocationally—after an injury or disease. The approach to the patient is team based, with the physician, rehabilitation nurse, physical therapist, occupational therapist, speech language pathologist, rehabilitation psychologist, prosthetist/orthotist, social worker, therapeutic recreational therapist, and vocational counselor working in conjunction as a treatment team.

The team considers the patient’s progress, future needs, and discharge planning on a weekly basis. The role of the physiatrist is to act as a medical leader of the team and guide the medical and therapy treatment. The interdisciplinary team promotes regular structured communication among all the members of the team to establish and accomplish the treatment goals. The goal of an inpatient rehabilitation facility is the return of the patient to a safe and functional environment, preferably his or her home or a community-based facility.

Patient History

The PM&R history is a medicolegal document that follows the format used by other medical disciplines with the addition of key elements that are unique to physiatry. It serves as a tool of communication for members of the rehabilitation team, as well as nonrehabilitation health care professionals, the patient’s health insurance providers, and at times the facilities responsible for ongoing care postdischarge from an acute inpatient rehabilitation unit. Depending on the setting of patient care, the PM&R history may vary from a focused outpatient physiatric evaluation to a comprehensive inpatient assessment. Some patients, especially those being admitted to an acute inpatient rehabilitation unit, may have complex medical problems requiring input and confirmation of the history from the rehabilitation team members. Gathering a complete patient history can require several days as it often depends on input from the physiatrist, other members of the rehabilitation team, and the patient’s family members or caretakers.

A. Chief Complaint

The chief complaint of the rehabilitation patient is the primary concern that led the patient to seek medical and rehabilitation care. The chief complaint is purely subjective and when possible should be documented in the patient’s own words. In many cases, patients who have sustained stroke, traumatic brain injury or other diseases or injuries causing cognitive alterations will not be able to state a chief complaint. In these cases, it is acceptable for the physician gathering the history to specify the reason for admission as the chief complaint. The chief complaint for a patient admitted to an inpatient rehabilitation service is often associated with ambulation, activities of daily living, communication, or cognition. In the outpatient setting, the patient may have several reasons for seeking physiatric treatment. It is imperative to have the patient rank the complaints in order of most problematic to least bothersome, and to separate those problems that are unrelated to the chief complaint.

B. History of Present Illness

The history of present illness is a detailed account of the chief complaint for which the patient is seeking rehabilitation treatment. It examines information related to the chief complaint, including location, onset, quality, quantity, modifying factors, duration, and associated symptoms and signs. The history of present illness, when skillfully navigated by the physician, can be a valuable encounter between the patient and physician as it serves to establish the physician–patient relationship through the process of gathering information. As part of the history of present illness, details regarding current functional impairments, bowel and bladder impairments, and skin issues relating to the chief complaint should be solicited.

C. Past Medical and Surgical History

Details of the patient’s past medical and surgical history allow the rehabilitation team and the leading physician to formulate an appropriate rehabilitation plan of care that includes necessary precautions that should be in place given the patient’s previous history. This information can alter the patient’s rehabilitation course. When interviewing a patient with possible cognitive impairments, knowledgeable family members, friends, and caretakers should also be interviewed. The interviewer should ask about the patient’s history of cardiopulmonary disease and associated surgical treatments to ensure that the rehabilitation program does not exceed the patient’s cardiopulmonary limitations. Functional limitations from pulmonary or cardiac etiologies should be noted, as should the modifiable risk factors for cardiac disease, such as smoking, hypertension, and obesity. Similarly, a history of musculoskeletal and rheumatologic disorders and related procedures should be sought. The functional impact of any premorbid disorders should be noted as the patient’s baseline. The patient’s history of neurologic ailments should also be solicited as this can help paint a picture of the premorbid functional level.

D. Family History

It is important to ask about a family history of cardiac disease, cancer, stroke, arthritis, diabetes, neurologic disease, hypertension, psychiatric disorders, and substance abuse. Because rehabilitation patients frequently experience pain and require treatment with appropriate medications, it is important to determine any patient or family history of alcohol or drug abuse.

E. Medications

Documentation of all prescription and over-the-counter medications and supplements is an important element of the history as inaccurate medications can adversely impact the patient’s wellbeing and safety. In 2005, the Joint Commission established medication reconciliation—the process of comparing a patient’s medication orders to all of the medications the patient has been taking—as its National Patient Safety Goal number eight in an effort to minimize polypharmacy-related errors (omissions, duplications, inaccurate dosages, and drug interactions) and promote systematic implementation of medication reconciliation procedures across patient care settings, particularly those involving transitions from one type or level of care to another.

F. Allergies

The patient’s allergies to medications (including but not limited to major classes of antibiotics), intravenous dye, latex, and various foods should be obtained and carefully documented. The patient or the person providing the history should be questioned in detail regarding the past consequences of exposure to the particular allergen.

G. Social History

A social history describes the personal, vocational, and recreational aspects of the patient’s life that bear clinical significance. Information about the patient’s occupation, activities of daily living, social support, stresses, financial situation, insurance coverage, and recreational habits is included. Complete functional information is also obtained, such as the use of assistive devices, need for assistance, and ability to ambulate distances.

Particular importance should be given to the patient’s environment and living arrangements; for example, whether the patient lives in a house or an apartment, the number of stories in the house or floor on which the apartment is located, whether it is necessary to negotiate stairs to obtain access to the home, and how many steps there are. Relevant information includes whether the stairs have a handrail, and on which side; whether there is elevator access; and home wheelchair accessibility. The location of the bedroom and bathroom should be noted, along with the presence or absence of grab bars in the shower. Much of this information is unique to the field of PM&R because a patient’s functional status after discharge depends on his or her ability to negotiate the physical environment of the home. Prior to discharge, the occupational therapist may visit the home to assess the types of equipment or modifications to the home that will be necessary for a safe discharge. In all cases it is important to inquire about the patient’s support system, including family, friends, and caretakers, and the extent of assistance that can be provided upon discharge. The need for a home health aide or nursing staff to fill any voids in the care of the patient can then be identified.

Documentation of the patient’s recreational habits, including history of smoking, alcohol, and drug use, is imperative. This information should be sought in an open-ended and nonjudgmental manner. Similarly patients should be asked about their sexual history and any unsafe practices in the past. Data should be gathered regarding the patient’s hobbies and recreational pursuits. Level of education and occupation should also be documented. If the patient’s injuries prevent full return to his or her previous occupation, the need for vocational rehabilitation should be identified. Environmental modifications and assistive devices often make it possible for patients to return to their jobs.

H. Review of Systems

The end of the physiatric interview should include a complete symptom checklist addressing all of the vital physiologic systems (Table 1–1). The review of systems should generally begin with an open-ended question such as, “Are you having any other problems that we have not discussed?” The physician can then pose a series of questions about specific health-related problems, prompting the patient to elaborate on areas that are problematic for him or her. Each system should be approached in a systematic fashion. Patients who give a positive response throughout the review of systems, indicating problems in every health-related area, may be engaging in symptom amplification in an attempt to gain attention and emotional support.

Physical Examination

The physiatric examination is an extension of a thorough general, neurologic, and musculoskeletal physical examination. As in any physical examination an initial assessment and documentation of the patient’s vital signs (temperature, heart rate, blood pressure, and respiratory rate) is customary. An assessment of the cardiac, pulmonary, and abdominal systems is a necessary component of the physiatric examination. Specific areas that constitute a primary focus of the physiatrist are described in detail below.

A. Cognitive Function

1. Mental status

The patient’s mental status is evaluated with questions aimed at determining but not limited to the patient’s orientation, attention, recall, visuospatial abilities, and language. The patient’s responses during the mental status examination can also provide insight into his or her language ability, medical deficits, and coherence of thinking. During this time the patient’s speech and language pattern can be noted and documented.

2. Consciousness

It is essential to document the patient’s level of consciousness. Consciousness is the state of being aware of one’s surroundings. A lethargic patient shows general slowing of movements and speech but can be easily aroused. Obtundation describes a dulled or blunted state in which the patient is difficult to arouse and once aroused is still confused. Stupor is a state of semiconsciousness in which the patient can be temporarily aroused by stimuli such as pain or noise. In stupor, eye movements become purposeful when the stimulus is applied, wincing may be noted, or papillary constriction may occur. The patient has few or no voluntary motor responses. Delirium is a common condition noted in the inpatient setting. It is characterized by acute or subacute onset and a fluctuant or reversible course. Often a state of restlessness and insomnia ensues, followed by obtundation, emotional lability, and visual illusions. Symptoms may worsen at nighttime especially in the elderly, a manifestation referred to as sundowning.

The Glasgow Coma Scale—an objective method of documenting level of consciousness that assesses eye opening, motor response, and verbal response—is used to evaluate patients, particularly those with traumatic brain injury (see Chapter 13). Coma is the state of unresponsiveness in which the patient’s eyes are closed and in which there is an absence of sleep–wake cycles and no interaction of the patient with the environment. Comatose patients cannot be aroused and have no awareness of self or their surroundings. Those in a vegetative state lack awareness of self or the environment, but have intact sleep–wake cycles. In a minimally conscious state, patients have intact sleep–wake cycles and show evidence of inconsistent but reproducible awareness of self or the ­environment.

3. Orientation

Orientation is characterized by the awareness of one’s person, place, and time. This can be assessed during the mental status examination by asking the patient to state his or her name, specify the present location, and give the date (including year and day of the week). Orientation is typically lost in the following order: time, place, and finally, person.

4. Memory

The patient’s memory can be tested by asking him or her to recount information pertaining to recent and remote events. Details about illness, dates of hospitalization, and day-to-day recall can serve to test recent memory. When testing memory, especially in a patient who has been hospitalized for a prolonged period, it is best to test objective facts using questions such as, “Who won the World Series?”, or “Who is the president, now and previously?” Remote memory can be tested by asking the patient to relate personal details such as his or her date of birth, marriage date, and names of children. Additionally, the patient may be given a list of at least three words, and then asked to recall the given words after 5 and 10 minutes. In patients with obvious impairment, prompting may be necessary (ie, by giving the patient multiple choices, with one choice being the correct word).

5. Mood and affect

Patient mood and affect should be observed and documented. Mood refers to an inner state that is persistent. Affect refers to a feeling or emotion—often momentary—that is experienced in response to an external occurrence or thought. Mood alterations are common findings in patients with brain injuries. The examiner should assess for anxiety, depressed mood, fear, suspicion, irritability, aggression, lability, apathy, or indifference. Open-ended questions addressing the patient’s feelings and spirits can be helpful in assessing mood. Patients with alterations of affect are often described as having a flat, dull, or monotonous affect.

6. Abstract thinking

The patient should be asked to interpret abstract statements such as, “a stitch in time saves nine,” “a rolling stone gathers no moss,” or “people who live in glass houses shouldn’t throw stones.” Keep in mind that cultural and language barriers may prevent adequate testing of abstract thinking.

7. Judgment and insight

Insight is determined by evaluating the patient’s recognition of his or her medical problems. Judgment can be tested by asking open-ended questions such as, “Why are there laws?”, or “What would you do if you found a stamped, addressed envelope on the street?”

8. Attention and concentration

Attention is demonstrated when the patient is alerted by a significant stimulus and sustains interest in it. Concentration refers to the ability to maintain ongoing mental effort despite distractive stimuli. A patient who is inattentive ignores the examiner’s questions or loses interest in them quickly. A patient with impaired concentration is easily distracted by noises, sights, and thoughts while answering questions.

9. Apraxia

Apraxia is the inability to perform previously learned motor tasks correctly despite intact comprehension, complete cooperation, and intact motor and sensory function. In testing for apraxia, patients are usually asked to carry out a series of general activities or tasks that their injuries or illness should not have rendered them unable to physically perform. Patients with ideomotor apraxia are unable to carry out motor responses upon verbal command; however, these acts can be carried out spontaneously. For instance, a patient may be unable to brush his or her hair on command but can do so spontaneously. Ideational apraxia is an abnormality in the conception and sequencing of the movement patterns. Patients can be tested for this form of apraxia by asking them to demonstrate how to use a key, comb, or fork.

B. Communication

Language is a fundamental basic of human intelligence and key part of social interaction. All aspects of the patient’s language ability should be examined, including naming, spontaneous production of speech, comprehension, repetition, reading, and writing.

1. Aphasias

Aphasias are abnormalities of language functions that are not due to defects of vision, hearing, or motor dysfunction. They can be divided into three categories: fluent, nonfluent, and anomic. (Speech disorders are described in detail in Chapter 38.) Anomia, a deficit of naming, is a common finding in aphasic patients. When asked to name an object, patients often compensate for their deficit by describing the object with circumlocution. Patients with semantic paraphasia are able to identify the object; however, they offer an incorrect but related word in the same category. For example, a fork may be identified as a spoon. In phonemic paraphasia, the word approximates the correct answer but is phonetically incorrect; thus, a pencil may be described by the patient as a “pentil.” Aphasias should be distinguished from dysarthria (described below), which is indicative of a motor problem.