The History and Physical Examination of a Patient with Disability



The specialty of physical medicine and rehabilitation (physiatry) came into prominence after World War II (WWII). It was observed that wounded soldiers recovered faster after surgery with early postoperative mobilization. Fewer postoperative complications occurred with early mobility.1

The assessment of disability has evolved since WWII, with functional restoration becoming more of a focus. The World Health Organization (WHO) published its International Classification of Functioning, Disability and Health (ICF) in 2001 as its framework for defining, measuring, and classifying health and disability.2 Unlike previous classification models, the ICF had more of a focus on health and function.

Although the tendency of most medical specialties is to “cure,” the primary aim of physical medicine and rehabilitation is to maximize function in a person with permanent or temporary disability. The traditional history and physical examination serve as a foundation for the physiatric history and physical examination.

Central to the assessment of any patient with disability is the quantification of functional impairment. As noted in the previous chapter, impairment is defined as the loss or diminution of psychological, cognitive, physiological, or anatomic function. In the rehabilitative setting, this assessment is a complex endeavor, as many patients with disabilities have an underlying diagnosis that may cover a wide spectrum, ranging from diseases like spinal stenosis to stroke. Furthermore, there are many subspecialties within the field of physical medicine and rehabilitation (PM&R), including brain injury, palliative care, sports medicine, pediatric rehabilitation, pain management, spasticity management, and spinal cord injury. Each subspecialty requires its own skill set and knowledge base, but they are all tied together with their primary goal of functional restoration. Each subspecialty may modify the history and physical examination to fit its patient population.

The physiatric history and physical examination are also complex, as these incorporate the roles of other members of the health care team into the assessment and plan. An essential component of physiatric management is to work in a “team-based” approach with other medical specialties, therapists, and community providers. As physiatry operates best through this interdisciplinary approach, knowledge and coordination with other health care professionals are critical.

Also unique to the physiatric evaluation is the appreciation and attention given to personal well-being and its effect on function. Attention is therefore given to not only family and caregiver relationships, but also hobbies, passions, and even personal mood. For example, a rehabilitation patient afflicted with depression because of relationship issues (which is common in patients with disability) may have poor motivation to participate in physical therapy. Comorbidities such as depression and anxiety can interfere with attaining functional goals.3 The impact of the social, environmental, psychological, financial, vocational, and technological factors will influence the achievable outcome for the patient and ideally should be addressed (Fig. 2–1).

Figure 2–1

Factors influencing function in the rehabilitation patient.

Finally, an essential component of the physiatric examination is to achieve a rapport with the patient. Patients with disability need a safe environment in which they can freely voice their concerns without fear of judgement. It is critical for the rehabilitation health care provider to remember that many rehabilitation patients have had catastrophic injuries and changes to their bodies and function with severe psychological consequences—relationship building with the health care team is often the first step in the healing process.

The Physiatric History and Physical Examination

The physiatric history and physical examination are unique because of the emphasis on functional assessment. Standard components include the Chief Complaint, History of Present Illness, Functional and Psychosocial History, Past Medical History, Family History, Social History, Allergies, Medications, and Review of Systems sections.

Inpatient assessments often will have an emphasis on motor skills (ambulation, transfers), weight bearing, and transfer abilities; activities of daily living (ADLs); and cognition; an accurate functional assessment is required to deem if the patient can be safely discharged home. The ambulatory assessment may be more problem focused and often is prioritized because of time constraints. It is common for rehabilitation patients to have many active problems, typically the most pressing functional and pain management issues are prioritized and other issues are addressed on sequential visits.

It is important to appreciate that the complexities of an ambulatory assessment are different from those encountered in the acute inpatient rehabilitation setting. These are summarized in Table 2–1.

Table 2–1Physical Medicine and Rehabilitation History and Physical Exam: Inpatient vs. Ambulatory

Functional restoration may involve tools like Functional Independence Measure (FIM) scores, the American Spinal Injury Association (ASIA) measurement, Glasgow Coma Scale (GCS), and the Ashworth Scale. Some tests are more pertinent in inpatient rehab, whereas others can also be used in the ambulatory environment. Later chapters will provide more details of these and other tools frequently used in the rehabilitation evaluation.



Chief Complaint (CC)

The chief complaint should reflect the main issue that necessitated the care of the physiatrist. This is usually in the patient’s own words. Ideally, the chief complaint in the physiatric examination focuses on functional loss in the context of an illness; for example, the inability to stand after a recent stroke, or the inability to perform work-related lifting after a back injury.

History of Present Illness (HPI)

This section typically includes the age, sex, and handedness of the patient. Documentation of the chronological sequence of events leading up to the development of the presenting issue should be recorded. The HPI should include etiology, duration, intensity, frequency, and provocative or palliative factors. Importantly, the HPI should be recorded in a manner in which the functional implications of the illness are appreciated. Additionally, functional impairments prior to the illness/injury should be noted. Past failed or successful interventions, past medications, previous consultations, and results of diagnostic tests are all carefully recorded. Table 2–2 lists the standard components of a physiatric HPI.

Table 2–2History of Present Illness

Functional History

The functional history is a central portion of the physiatric examination. Current functional status within the home, community, and at work should be explored in depth. Functional skills both prior to the illness/injury and afterward should be described with attention paid to the amount of assistance necessary to perform a task. Additionally the patient’s functional goals should be explored. Standardized scales such as the FIM are commonly used to quantify the level of independence4 (Fig. 2–5).

Key components to the functional history include assessments of mobility, activities of daily living, household and community activities, cognition, communication, vocation, and assistive device use5 (Table 2–3).

Table 2–3Components of the Functional History

An assessment of current and past mobility is important. In the decline of the functional status of a patient, a number of sentinel events occur: (1) loss of the ability to navigate uneven surfaces or inclines during ambulation, (2) inability to ambulate, (3) inability to transition from sit to stand, (4) inability to sit, and finally (5) the inability to roll. These basic mobility milestones must be captured during the examination.

ADLs are defined as everyday personal care activities that are fundamental in caring for oneself. They include bathing, dressing, grooming, oral care, toileting, and eating. ADLs are a common portion of the mobility assessment. Household and community activities are explored in detail. This includes the ability to perform everyday household activities such as cleaning, cooking, driving, shopping, and religious worship. The vocational history is commonly reviewed within the functional assessment. Additionally, the functional tasks performed before and after the injury/illness should be reviewed in detail. Finally, a review of the current and past assistive devices should be included in this section.

Instrumental activities of daily living (IADLs) are not activities that are directly related to essential function (e.g., feeding and grooming); rather, they are activities related to independent living and include shopping, cooking, medication management, using a phone, housework, laundry, managing finances, and driving or using public transportation. Of note, IADLs are not included in the FIM scores.

Having an adequate understanding of a patient’s ability to complete ADLs and IADLs will allow a provider to have a more complete idea of a patient’s level of functional independence and help with planning future goals. Reliance on evaluation from other members of the health care team (such as physical and occupational therapists) is often necessary to obtain a clear picture of the current functional level. The ability to complete ADLs and IADLs also helps determine the level and type of supervision and/or assistance a patient may need in the community.

Past Medical History

Chronic medical issues are noted, with special attention paid to those that affect activity tolerance and intensity of therapies, which may result in functional limitations. For patients with cognitive or communication deficits, additional history must be elicited from the medical record or family members/caregivers. Special attention is given to cardiopulmonary, musculoskeletal, and neurologic conditions/history (Table 2–4).

Table 2–4Past Medical History

Preexisting cardiac conditions such as heart disease or cardiac surgery may severely restrict the rehabilitation program, and cardiac precautions may need to be employed. Pulmonary conditions such as chronic obstructive pulmonary disease additionally may change the rehabilitation prescription. In such cases attention is generally placed upon the interplay between exercise and vital signs (including the blood oxygen saturation). The need for and amount of supplemental oxygen in such cases should be documented. Past history of neurologic or musculoskeletal disease will also determine the future rehabilitation prescription. Critical in the assessment of the past medical history is to determine if any special precautions need to be undertaken in the rehabilitation of the patient.

Past Surgical History

The dates of surgeries and complications should be recorded. Depending on the location and extensiveness of the surgery, limitations of mobility may be present prior to the initial office visit.


All prescription and over-the-counter medications are detailed; typically for pain patients, a history of medications tried is also added. Ideally, discontinued medications are recorded.


The type of allergic reaction (e.g., hives, anaphylaxis) should be recorded with the medications. Intolerances to medications should be contrasted with allergies; past adverse reaction to medications should be noted with special attention to steroids, opiates, contrast and latex—all commonly utilized by physiatrists.

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Jan 15, 2019 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on The History and Physical Examination of a Patient with Disability

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