Chapter 1 The Physiatric History and Physical Examination

Michael W. O’Dell, C. David Lin, André Panagos

The physiatric history and physical examination (H&P) serves several purposes. It is the data platform from which a treatment plan is developed. It also serves as a written record that communicates to other rehabilitation and nonrehabilitation health care professionals. Finally, the H&P provides the basis for physician billing ¹⁶ and serves as a medicolegal document. Physician documentation has become the critical component in inpatient rehabilitation reimbursement under prospective payment, as well as proof for continued coverage by private insurers. The scope of the physiatric H&P varies enormously depending on the setting, 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. Physicians in training tend to overassess, but 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 (performance). The physiatric H&P also identifies those systems not affected that might be used for compensation.²² Familiarity with the 1980 and 1997 World Health Organization classifications is invaluable in understanding the philosophic framework for viewing the evaluation of persons with physical and cognitive disabilities (Table 1-1).^76,⁷⁷ Identifying and treating the primary impairments to maximize performance becomes the primary thrust of physiatric evaluation and treatment.

Table 1-1 World Health Organization Definitions

Term	Definition
1980
Impairment	Any loss or abnormality of psychologic, physiologic, or anatomic structure or function
Disability	Any restriction or lack resulting from an impairment of the ability to perform an activity in the manner or within the range considered normal for a human being
Handicap	A disadvantage for a given individual, resulting from an impairment or a disability, that limits or prevents the fulfilment of a role that is normal for that individual
1997
Impairment	Any loss or abnormality of body structure or of a physiologic or psychologic 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 1980 ⁷⁶ and 1997,⁷⁷ with permission of the World Health Organization.

Because patients cared for in rehabilitation medicine can be extremely complicated, the H&P is many times a work in progress. Confirmation of historical and functional items by other team members, health care professionals, and family members can take several days. Many of the functional items discussed in this chapter will actually be assessed and explored more fully by other interdisciplinary team members during the course of inpatient or outpatient treatment. It is imperative that the physiatrist stays abreast of additional information and findings as they become available, and that lines of verbal or written communication be directed through the medical leadership of the team.

The exact structure of the physiatric assessment is determined in part by personal preference, training background, and institutional requirements (physician billing compliance expectations, 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 essential elements of the physiatric H&P are summarized in Table 1-2. 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.

Table 1-2 Essential Elements of the Physiatric History and Physical Examination

Component	Examples
Chief complaint
History of present illness	Exploring location, onset, quality, context, severity, duration, modifying factors, and associated signs and symptoms
Functional history	Mobility: Bed mobility, transfers, wheelchair mobility, ambulation, driving, and devices required Activities of daily living: Bathing, toileting, dressing, eating, hygiene and grooming, etc. Instrumental activities of daily living: Meal preparation, laundry, telephone use, home maintenance, pet care, etc. Cognition Communication
Past medical and surgical history	Specific conditions: Cardiopulmonary, musculoskeletal, neurologic, and rheumatologic Medications
Social history	Home environment and living circumstances, family and friends support system, substance abuse, sexual history, vocational activities, finances, recreational activities, psychosocial history (mood disorders), spirituality, and litigation
Family history
Review of systems
General Medical Physical Examination
	Cardiac Pulmonary Abdominal Other
Neurologic Physical Examination
	Level of consciousness Attention Orientation Memory General fund of knowledge Abstract thinking Insight and judgment Mood and affect
Communication
Cranial nerve examination
Sensation
Motor control	Strength Coordination Apraxia Involuntary movements Tone
Reflexes	Superficial Deep Primitive
Musculoskeletal Physical Examination
Inspection	Behavior Physical symmetry, joint deformity, etc.
Palpation	Joint stability Range of motion (active and passive) Strength testing (see above) Painful joints and muscles
Joint-specific provocative maneuvers

An emergence in the use of electronic medical records (EMR) has significantly altered the landscape for documentation of the physiatric H&P in both the inpatient and outpatients settings.²³ Among the advantages of the EMR are increased legibility, time efficiency afforded by the use of templates and “smart phrases” that can be tailored to individual practitioners, and automated warnings regarding medication interactions or errors, as well as faster and more accurate billing. Disadvantages include overuse of the “copy and paste” function, leading to the appearance of redundancy among consecutive notes and the perpetuation 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 hospital and physician practice and billing increases, the EMR will become more important in ensuring the proper, and sometimes convoluted, documentation required for safety initiatives⁴⁰ and physician payment.¹⁵

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 treatment program to restore performance. In a person with stroke, for example, the most important questions for the physiatrist are not just the etiology or location of the lesion but also “What functional 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.

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 productive doctor–patient–family relationship and can also help the physician learn about such sensitive areas as the sexual history and substance abuse. It can also have an impact on outcome, as a trusting patient tends to be a more compliant patient.⁶² Assessing the tone of the patient and/or family (such as anger, frustration, resolve, and determination), 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 refocus are required.

Patients are generally the primary source of information. However, patients with cognitive or mood deficits (denial or decreased insight) or with communication problems, 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 professionals; or previous medical records. This can also have an impact on physician billing. Caution must be exercised in using previous medical records because inaccuracies are sometimes repeated from provider to provider, sometimes referred to as “chart lore.”

Chief Complaint

The chief complaint is the symptom or concern that caused the patient to seek medical treatment. The most common chief complaints seen in an outpatient physiatric practice are pain, weakness, or gait disturbance of various musculoskeletal or neurologic origins. On a physiatric consultation on an inpatient rehabilitation service, the predominant chief complaints are related to mobility, ADL, communication, or cognitive deficits and candidacy for inpatient rehabilitation. Unlike the relatively objective physical examination, the chief complaint is purely subjective and, when possible, the physician should use the patient’s own words. A patient can present with several related or unrelated complaints, in which case it is helpful to have the patient rank problems from “most bothersome” to “least bothersome.”

The specific circumstance of a patient offering a chief complaint can also allude to a degree of disability or handicap. For example, knowing that an obese mail carrier presents with the chief complaint of difficulty in walking because of knee pain could suggest not only the impairment but also an impact on his vocation and role as a provider for his family (participation, handicap).

History of the Present Illness

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 explore other information relating to the chief complaint such as recent and past medical or surgical procedures, complications of treatment, and potential restrictions or precautions. The HPI should include some or all of eight components related to the chief complaint: location, time of onset, quality, context, severity, duration, modifying factors, and associated signs and symptoms (see Table 1-2).

In this case example, the patient is a 70-year-old man referred by his neurologist for physical therapy because the patient cannot walk properly (chief complaint). Over the past few months (duration), he has noted slowly progressive weakness of his left leg (location). Subsequent workup by his neurologist suggested amyotrophic lateral sclerosis (context). The patient was active in his life and working up until a few months previously, ambulating without an assistive device (context). Now he uses a straight cane for fear of falling (modifying factor). Besides difficulty with walking, the patient also has some trouble swallowing foods (associated signs and symptoms).

Functional Status

Detailing the patient’s current and prior functional status is an essential aspect of the physiatric HPI. This generally entails better understanding the issues surrounding mobility, ADL, instrumental activities of daily living (I-ADL), communication, cognition, work, and recreation, among others. The data should be as accurate and detailed as possible to guide the physical examination and develop a treatment plan with reasonable short- and long-term goals.

Assessing the potential for functional gain or deterioration requires an understanding of the natural history, cause, and time of onset of the functional problems. For example, most spontaneous motor recovery after stroke occurs within 3 months of the event.⁶⁸ For a recent stroke patient with considerable motor impairments, there is a greater expectation for significant functional gain than in a patient with minor deficits related to a stroke that occurred 2 years ago.

It is sometimes helpful to assess functional status using a standardized scale. No single scale is appropriate for all patients, but the Functional Independence Measure (FIM) is the most commonly used in the inpatient rehabilitation setting (Table 1-3; see Chapter 8).³ Measuring only activity limitation (disability) or performance, each of 18 different activities is scored on a scale of 1 to 7, with a score of 7 indicating complete independence. Intermediate scores indicate varying levels of assistance from very little (from an assistive device, to supervision, to hands-on assistance) to a score of 1 indicating complete dependence on caregiver assistance. FIM scores also serve as a kind of rehabilitation shorthand among team members to quickly and accurately describe functional deficits.

Table 1-3 Levels of Function on the Functional Independence Measure

Level of Function	Score	Definition
Independent	7 6	Another person is not required for the activity (no helper). Complete independence: all the tasks described as making up the activity are performed safely, without modification, assistive devices, or aids, and within a reasonable amount of time. Modified independence—one or more of the following can be true: • The activity requires an assistive device. • The activity takes more than a reasonable time. • There are safety considerations.
Dependent		The patient requires another person for either supervision or physical assistance for the activity to be performed (requires helper).
	5 4 3 2 1	Supervision or set-up: the patient requires no more help than stand-up or cueing without physical contact, or the helper sets up needed items. Minimal contact assistance: the patient requires no more help than touching and expends 75% or more of the effort. Moderate assistance: the patient requires more help than touching and expends 50%-75% of the effort. Maximal assistance: the patient expends 25%-50% of the effort. Total assistance: the patient expends less than 25% of the effort.

From Anonymous ³ 1997, with permission of the State University of New York at Buffalo.

Mobility

Mobility is the ability to move about in one’s environment and is taken for granted by most healthy people. Because it plays such a vital role in society, any impairment related to mobility can have major consequences for a patient’s quality of life. A clear understanding of the patient’s functional mobility is needed to determine independence and safety, including the use of, or need for, mobility assistive devices. There is a range of mobility assistive devices that patients can use, such as crutches, canes, walkers, orthoses, and manual and electric wheelchairs (Table 1-4; see Chapters 15 and 17).

Table 1-4 Commonly Used Mobility Assistive Devices

Category	Example
Crutches	Axillary crutches Forearm crutches Platform crutches
Canes	Straight cane Wide- or narrow-based quad cane Hemiwalker or pyramid cane
Walkers	Standard or pick-up walker Rolling walker Platform walker
*Wheelchairs*
Types	Manual Powered Lightweight
Common modifications or specifications	Folding or solid frame Elevated or removable leg rests Removable armrests Reclining
*Off-the-Shelf Ankle-Foot Orthoses*
Common custom orthoses	Plastic ankle-foot orthosis Metal ankle-foot orthosis Knee orthosis Knee-ankle-foot orthosis

Bed mobility includes turning from side to side, going from the prone to supine positions, sitting up, and lying down. A lack of bed mobility places the patient at greater risk for skin ulcers, deep vein thrombosis, and pneumonia. In severe cases, bed mobility can be so poor as to require a caregiver. In other cases, bed rails might be appropriate to facilitate movement. Transfer mobility includes getting in and out of bed, standing from the sitting position (whether from a chair or toilet), and moving between a wheelchair and another seat (car seat or shower seat). Once again, the history taker should assess the level of independence, safety, and any changes in functional ability.

Wheelchair mobility can be assessed by asking if patients can propel the 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 wheelchair-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 their need for 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. Patients should be asked 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, elders who stop driving have an increase in depressive symptoms.⁵⁰ It is important to identify factors that might prevent driving, such as decreased cognitive function and safety awareness, and decreased vision or reaction time. Other factors affecting driving can include lower limb weakness, contracture, tone, or dyscoordination. 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 (dementia, 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, alternatives to driving should be explored, such as the use of public or assisted transportation. Laws differ widely from state to state on the return to driving after a neurologic impairment develops.

Activities of Daily Living and Instrumental Activities of Daily Living

ADL encompass activities required for personal care including 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 household, telephone use, meal preparation, house cleaning, laundry, and in some cases use of public transportation. In the Occupational Therapy Practice Framework, there are 11 activities for both ADL and I-ADL (Box 1-1).⁴

BOX 1-1 Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (I-ADL)

Modified from [Anonymous]: Occupational Therapy Practice Framework: domain and process. Am J Occup Ther 56:609-639, 2002 (Erratum in: Am J Occup Ther 2003; 57:115) with permission.

The clinician should identify and document ADL the patient can and cannot perform, and determine the causes of limitation. 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 frequently needed. For example, a patient might say “yes” to the question “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.

Cognition

Cognition is the mental process of knowing (see Chapters 3 and 4). Although objective assessment of cognition comes under physical examination (memory, orientation, and the ability to assimilate and manipulate information), impairments in cognition can also become apparent during the course of the history taking. Because persons with cognitive deficits often cannot recognize their own impairments (anagnosia), 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, sustaining 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, problem solving, and self-awareness. Executive functioning correlates with functional outcome because it is required in many real-world situations.⁴⁵

Communication

Communication skills are used to convey information including thoughts, needs, and emotions. Verbal expression deficits can be very 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 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.

Past Medical and Surgical History

The physiatrist should understand the patient’s past medical and surgical history. This knowledge allows the physiatrist to understand how preexisting illnesses affect current status, and how to tailor the rehabilitation program for precautions and limitations. The patient’s past medical history can also have a major impact on rehabilitation outcome.

Social History

Home Environment and Living Situation

Understanding the patient’s home environment and living situation includes asking if the patient lives in a house or an apartment, if there is 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 might be required to gain the best assessment. If there is no caregiver at home, the patient could require a home health aide. These factors help determine many aspects of the discharge plan.

Family and Friends Support

Patients who have lost function might require supervision, emotional support, or actual physical assistance. Family, friends, and neighbors who can provide such assistance should be identified. The clinician should discuss the level of assistance they 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 bladder hygiene.

Substance Abuse

Patients should be asked about their history of smoking, alcohol use or abuse, and 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 and an indirect cause of disability, and is often a contributing factor in traumatic brain injury.¹⁹ It can also have an impact on community reintegration, because patients with pain and/or depression 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 uncomfortable discussing the topic of sexuality, so developing a good rapport during history taking can be helpful. Discussion of this topic is made easier if the health care practitioner has a basic knowledge of how sexual function can be changed by illness or injury (see Chapter 31). Sexuality is particularly important to patients in their reproductive years (such as with many spinal cord– and brain-injured persons), but the physician should enquire about sexuality in adolescents and adults, as well as in the elderly. Sexual orientation and safer sex practices should be addressed when appropriate.

Vocational Activities

Vocation is not only a source of financial security; it also significantly relates to self-confidence and even identity. The history should include the patient’s educational level, recent work history, and the ability to fulfill job requirements subsequent to the injury or illness. If an individual cannot fully regain the previous function level, the vocational options available should be explored. 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.

Finances and Income Maintenance

Patients can have financial concerns that are due to or exacerbated by their illness or injury. These concerns can also be addressed by the rehabilitation team social worker. 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 placement might 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 helping 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 depression and anxiety. This can help accelerate the patient’s process of adjusting to a new disability.

Spirituality and Belief

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.17

Pending Litigation

Patients should be asked in a nonjudgmental fashion whether they are involved in litigation related to their illness, injuries, or functional impairment. The answer should not change the treatment 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

Patients should be asked 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. They should also be asked about any family history of heart disease, diabetes, cancer, stroke, arthritis, hypertension, or neurologic illness. This will help to identify genetic disorders within the family. Knowledge of the general health of family members can also provide insight into their ability to provide functional assistance to the patient.

Review of Systems

A detailed review of organ systems should be done discover any problems or diseases not previously identified during the course of the history taking. Table 1-5 lists some questions that can be asked about each system.²⁴ Note that this list is not comprehensive, and more detailed questioning might be necessary.

Table 1-5 Sample Questions for the Review of Systems

System	Questions
Systemic	Any general symptoms such as fever, weight loss, fatigue, nausea, and poor appetite?
Skin	Any skin problems? Sores? Rashes? Growths? Itching? Changes in the hair or nails? Dryness?
Eyes	Any changes in vision? Pain? Redness? Double vision? Watery eyes? Dizziness?
Ears	How are the ears and hearing? Running ears? Poor hearing? Ringing ears? Discharge?
Nose	How are your nose and sinuses? Stuffy nose? Discharge? Bleeding? Unusual odors?
Mouth	Any problems with your mouth? Sores? Bad taste? Sore tongue? Gum trouble?
Throat and neck	Any problems with your throat and neck? Sore throat? Hoarseness? Swelling? Swallowing?
Breasts	Any problems with your breasts? Lumps? Nipple discharge? Bleeding? Swelling? Tenderness?
Pulmonary	Any problems with your lungs or breathing? Cough? Sputum? Bloody sputum? Pain in the chest on taking a deep breath? Shortness of breath?
Cardiovascular	Do you have any problems with your heart? Chest pain? Shortness of breath? Palpitations? Cough? Swelling of your ankles? Trouble lying flat in bed at night? Fatigue?
Gastrointestinal	How is your digestion? Any changes in your appetite? Nausea? Vomiting? Diarrhea? Constipation? Changes in your bowel habits? Bleeding from the rectum? Hemorrhoids?
Genitourinary	Male: Any problems with your kidneys or urination? Painful urination? Frequency? Urgency? Nocturia?
	Bloody or cloudy urine? Trouble starting or stopping?
	Female: Number of pregnancies? Abortions? Miscarriages? Any menstrual problems? Last menstrual period? Vaginal bleeding? Vaginal discharge? Cessation of periods? Hot flashes? Vaginal itching? Sexual dysfunction?
Endocrine	Any problems with your endocrine glands? Feeling hot or cold? Fatigue? Changes in the skin or hair? Frequent urination? Fatigue?
Musculoskeletal	Do you have any problems with your bones or joints? Joint or muscle pain? Stiffness? Limitation of motion?
Nervous system	Numbness? Weakness? Pins and needles sensation?

From Enelow AJ, Forde DL, Brummel-Smith K: Interviewing and patient care, ed 4, New York, 1996, Oxford University Press,²⁴ with permission of Oxford University Press.

The Physiatric Physical Examination

Neurologic Examination

Neurologic problems are common in the setting of inpatient and outpatient rehabilitation, including functional deficits in persons with such conditions as stroke, multiple sclerosis, peripheral neuropathy, spinal cord injury, brain injury, and neurologic cancers. The neurologic examination should be conducted in an organized fashion to confirm or reconfirm the neurologic disorder, and subsequently to identify which components of the nervous system are the most and the least affected. The precise location of the lesion should be identified, if possible, and the impact of the neurologic deficits on the overall function and mobility of the patient should be noted. If a cause of the patient’s condition has not been identified at presentation to the rehabilitation service, 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 peripheral neuroanatomy before the examination.

Weakness is a primary sign in neurologic disorders and is seen in both upper (UMN) and lower motor neuron (LMN) disorders. UMN lesions involving the central nervous system (CNS) are typically characterized by hypertonia, weakness, and hyperreflexia without significant muscle atrophy, fasciculation, or fibrillation (on electromyography). They tend to occur in a hemiparetic, paraparetic, and tetraparetic pattern. UMN etiologies include stroke, multiple sclerosis, traumatic and nontraumatic brain and spinal cord injuries, and neurologic cancers, among others. LMN defects are characterized by hypotonia, weakness, hyporeflexia, significant muscle atrophy, fasciculations, and electromyographic changes. They occur in the distribution of the affected nerve root, peripheral nerve, or muscle. UMN and LMN lesions often coexist; however, the LMN system is the final common pathway of the nervous system. An example of this is an upper trunk brachial plexus injury on the same side as spastic hemiparesis in a person with traumatic brain injury.⁵¹

Mental Status Examination

The mental status examination (MSE) should be performed in a comfortable setting where the patient is not likely to be disturbed by external stimuli such as televisions, telephones, pagers, conversation, or medical alarms. The bedside MSE is often limited secondary to distractions from within the room. Having a familiar person such as a spouse or relative in the room can often help reassure the patient. The bedside MSE might need to be supplemented by far more detailed and standardized evaluations performed by neuropsychologists, especially in cases of vocational and educational reintegration (see Chapters 4 and 35). Language is the gateway to assessing cognition and is therefore limited in persons with significant aphasia.

Level of Consciousness

Consciousness is the state of awareness of one’s surroundings. A functioning pontine reticular activating system is necessary for normal conscious functioning. The conscious patient is awake and responds directly and appropriately to varying stimuli. Decreased consciousness can significantly limit the MSE and the general physical examination.

The examiner should understand the various levels of consciousness. Lethargy is the general slowing of motor processes (such as speech and movement) in which the patient can easily fall asleep if not stimulated, but is easily aroused. Obtundation is a dulled or blunted sensitivity in which the patient is difficult to arouse, and once aroused is still confused. Stupor is a state of semiconsciousness characterized by arousal only by intense stimuli such as sharp pressure over a bony prominence (e.g., sternal rub), and the patient has few or even no voluntary motor responses.⁵⁶ The Aspen Neurobehavioral Conference proposed, and several leading medical organizations have endorsed, three terms to describe severe alterations in consciousness.²⁹ In coma, the eyes are closed with absence of sleep-wake cycles and no evidence of a contingent relationship between the patient’s behavior and the environment.²⁹ Vegetative state is characterized by the presence of sleep-wake cycles but still no contingent relationship. Minimally conscious state indicates a patient who remains severely disabled but demonstrates sleep-wake cycles and even inconsistent, nonreflexive, contingent behaviors in response to a specific environmental stimulation. In the acute settings, the Glasgow Coma Scale is the most often used objective measure to document level of consciousness, assessing eye opening, motor response, and verbal response (Table 1-6).³⁹

Table 1-6 Glasgow Coma Scale

Function	Rating
Eye opening	E
Spontaneous	4
To speech	3
To pain	2
Nil	1
Best motor response	M
Obeys	6
Localizes	5
Withdraws	4
Abnormal flexion	3
Extensor response	2
Nil	1
Verbal response	V
Oriented	5
Confused conversation	4
Inappropriate words	3
Incomprehensible sounds	2
Nil	1
Coma score (E + M + V)	3-15

From Jennett B, Teasdale G: Assessment of impaired consciousness, Contemp Neurosurg 20:78, 1981 with permission.

Attention

Attention is the ability to address a specific stimulus for a short period without being distracted by internal or external stimuli.⁶⁵ Vigilance is the ability to hold attention over longer periods. For example, with inadequate vigilance a patient can begin a complex task but be unable to sustain performance to completion. Attention is tested by digit recall, where the examiner reads a list of random numbers and the patient is asked to repeat those numbers. The patient should repeat digits both forward and backward. A normal performance is repeating seven numbers in the forward direction, with fewer than five indicating significant attention deficits.^52,⁶⁵

Orientation

Orientation is necessary for basic cognition. Orientation is composed of four parts: person, place, time, and situation. After asking 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 person is typically the last to be lost. Temporary stress can account for a minor loss of orientation; however, major disorientation usually suggests an organic brain syndrome.⁶⁹

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 examination, normal individuals younger than 60 years should recall three of four items.⁶⁵

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 information can be confirmed, remote memory is tested by asking where the patient was born or the school or college attended.⁴⁶ 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 intellect 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 important elected officials, such as the current president of the United States or recent past presidents. It can be very 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 explanation 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 normal individuals should be able to provide abstract responses. A patient also demonstrates abstraction when he or she understands a humorous phrase or situation. Concrete responses are given by persons with dementia, mental retardation, or limited education. Abstract thinking should always be considered in the context of intelligence and cultural differences.⁶⁹

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.¹⁰ 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 distinguish 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?” Judgment is a complex function that is part of the maturational process and is consequently unreliable in children and variable in the adolescent years.⁶⁹ Assessment of judgment is important to assess the patient’s capacity for independent functioning.

Mood and Affect

Mood can be assessed by asking the “Yale question”: “Do you often feel sad or depressed?”⁷² Establishing accurate information pertaining to the length of a particular 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.¹¹

General Mental Status Assessment

The Folstein Mini-Mental Status Examination is a brief and convenient tool to test general cognitive function. It is useful for screening patients for dementia and brain injuries. Of a maximum 30 points, a score 24 or above is considered within the normal range.²⁵ Also available is the easily administered Montreal Cognitive Assessment.⁵⁴ The clock-drawing test is another quick test sensitive to cognitive impairment. The patient is instructed to “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 drawing is scored on the basis of whether the clock numbers are generally intact or not intact out of a maximum score of 10.⁶⁶ 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 popularity in screening for dementia. The Mini-Cog can usually be completed within 2 to 3 minutes.⁶⁰ The reader is referred to other excellent descriptions of the MSE for further reading.⁶⁵