The physiatric history and physical examination are the basis for precise diagnosis and recognition of the patient’s impairment, and they help in the development of a comprehensive treatment plan. They also serve as a medicolegal record and a basis for physician billing. They are documents used for communication between rehabilitation and nonrehabilitation health care professionals. The essential elements of the physiatric history and physical examination are summarized in this chapter and the accompanying eSlides.
The Physiatric History
The World Health Organization classification defines impairment as any loss or abnormality of body structure or a physiologic or psychological function. Activity is the nature and extent of functioning at the level of the person. Participation refers to the nature and extent of a person’s involvement in life situations in relation to impairments, activities, health conditions, and contextual factors. One of the unique aspects of physiatry is the recognition of functional deficits caused by illness or injury. Identifying and treating the primary impairments to maximize performance becomes the primary thrust of physiatric evaluation and treatment. Physicians in training tend to overassess, but with time the experienced physiatrist develops an intuition regarding the detail needed for each patient, given a particular presentation and setting. 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. Patients are the primary source of information, but if patients are not able to fully express themselves, the history takers might also rely on the patient’s family members and friends; other physicians, nurses, and professionals; or previous medical records.
Chief Complaint
The chief complaint is the symptom or concern that caused the patient to seek medical treatment. Unlike the relatively objective physical examination, the chief complaint is purely subjective, and the physician should use the patient’s own words.
History of the Present Illness
The history of the present illness details the chief complaint(s), and it should include some or all of these eight components related to the chief complaint: location, time of onset, quality, context, severity, duration, modifying factors, and associated signs and symptoms.
Functional Status and Activities of Daily Living
The patient’s functional status provides a better understanding of mobility, activities of daily living (ADL), instrumental activities of daily living (I-ADL) (eSlide 1.1) , communication, cognition, work, and recreation. Assessing the potential for functional gain or deterioration requires an understanding of the natural history, cause, and time of onset of the functional problems.
It is sometimes helpful to assess functional status with a standardized scale. No single scale is appropriate for all patients, but the Functional Independence Measure (FIM) is the scoring system most commonly used in the inpatient rehabilitation setting. Each of 18 different activities is scored on a scale of 1 to 7 (total score: 18 to 126) (eSlide 1.2) , and FIM serves as a kind of rehabilitation shorthand among team members to quickly and accurately describe functional deficits.
Mobility
Mobility is the ability to move about in one’s environment. Bed mobility includes turning from side to side, changing from the prone to supine positions, sitting up, and lying down. Transfer mobility includes getting in and out of bed, standing from the sitting position, and moving between a wheelchair and another seat.
Wheelchair mobility can be assessed by asking if patients can propel the wheelchair independently, how far or how long they can go without resting, whether they need assistance with managing the wheelchair parts, and 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 and stair mobility can be assessed by the patient’s walking distance and endurance, the patient’s requirement for assistive devices and need for breaks, the number of stairs the patient must routinely climb and descend at home or in the community, and the presence or absence of handrails in their daily lives. Identifying associated symptoms during ambulation and a history of falling or instability are also important.
Driving (a type of community mobility) is a crucial activity for many people, and older adults who stop driving face increased depressive symptoms. The risks of driving are weighed against the consequences of not being able to drive.
Cognition
Cognition is the mental process of knowing. Because persons with cognitive deficits often cannot recognize their own impairments (agnosia), it is important to also gather information from other individuals who are familiar with the patient. Cognitive deficits interfere with the patient’s rehabilitation and safety.
Communication
Communication skills are used to convey information, including thoughts, needs, and emotions. Verbal-expression deficits can be subtle. Patients who have deficits in verbal expression might or might not be able to communicate through other means, known as augmentative communication strategies. These strategies include writing and physicality (e.g., sign language, gestures, and body language) and the use of communication aids (e.g., picture, letter, word board, and electronic devices).
Past Medical and Surgical History
The past medical and surgical history allows the physiatrist to understand how preexisting illnesses affect the patient’s current status, the precautions and limitations that will be necessary during a rehabilitation program, and the impact on rehabilitation outcomes. Particularly, cardiopulmonary deficits can severely compromise mobility, ADL, I-ADL, work, and leisure.
All medications should be documented, including prescription medications, over-the-counter drugs, nutraceuticals, supplements, herbs, and vitamins. Drug and food allergies should be noted. Particular attention should be paid to commonly prescribed medications, such as nonsteroidal antiinflammatory agents.
Social History
Understanding the patient’s home environment and living situation includes asking whether the patient lives in a house or an apartment and whether elevators, stairs, or handrails are present. These factors, in conjunction with the level of support from the patient’s family and friends, will help determine the discharge plans.
Patients should be asked in a nonjudgmental manner about their history of smoking, alcohol use or abuse, and drug abuse. Sexuality is particularly important to patients in their reproductive years. Sexual orientation and safer sex practices should be addressed when appropriate.
Vocational Activities
Vocation is a source of financial security and provides self-confidence and even identity. The history should include the patient’s education level, recent work history, and ability to fulfill job requirements subsequent to injury or illness.
Finances and Income Maintenance
A social worker may help patients with financial concerns. Whether a patient has the financial resources or insurance to pay for adaptive devices can significantly affect discharge planning.
Recreation
Loss or limitation of the ability to engage in hobbies and recreational activities can be stressful to most people. Recreation is also a primary outcome in sports medicine. A recreational therapist can be helpful.
Psychosocial History, Spirituality, and Beliefs
Patients with impairment may feel a loss of overall health, body image, mobility, independence, or income. Providing assistance in developing coping strategies, especially for depression and anxiety, can help accelerate the process whereby the patient learns to adjust to a new disability.
Health care providers should be sensitive to the patient’s spiritual needs and provide appropriate referral or counseling.
Litigation
Litigation (active or pending) can be a source of anxiety, depression, or guilt. Patients should be asked in a nonjudgmental manner whether they are involved in litigation. The answer should not change the treatment plan.
Family History
Patients should be asked about the health, or cause and age of death, of parents and siblings. The family history will help identify genetic disorders within the family and potential assistance that may be obtained from family members.
Review of Systems
The review of systems identifies problems or diseases that have not yet been reviewed during the history taking.
The Physiatric Physical Examination
Neurologic Examination
Neurologic problems are common in rehabilitation medicine. The precise location of the lesion should be identified from an organized neurologic examination. An accurate and efficient neurologic examination requires that the examiner have a thorough knowledge of both central and peripheral neuroanatomy before the examination. Weakness may be seen in both upper motor neuron (UMN) and lower motor neuron (LMN) disorders. UMN lesions involving the central nervous system are typically characterized by hypertonia and hyperreflexia. LMN defects are characterized by hypotonia, hyporeflexia, significant muscle atrophy, fasciculations, and electromyographic changes. UMN and LMN lesions often coexist, as seen in amyotrophic lateral sclerosis or traumatic brain injury with a brachial plexus injury.
Mental Status Examination
The mental status examination (MSE) should be performed in a comfortable setting where the patient is not likely to be distracted by external stimuli. Bedside MSE might need to be supplemented by observations in therapy and evaluation by a neuropsychologist.
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 of 30 points, a score of 24 or above is considered within the normal range. The clock-drawing test is a quick and sensitive test of cognitive impairment. This task uses memory, visual spatial skills, and executive functioning. 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.
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.
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 is still confused after arousal. Stupor is a state of semi consciousness characterized by arousal only by intense stimuli, such as sharp pressure over a bony prominence (e.g., sternal rub); the patient also has few or even no voluntary motor responses.
In coma , the eyes are closed, sleep-wake cycles are absent, and there is no evidence of a contingent relationship between the patient’s behavior and the environment. 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 inconsistent, nonreflexive, contingent behaviors in response to a specific environmental stimulus. In acute settings, the Glasgow Coma Scale is the most commonly used objective measure to document level of consciousness (eSlide 1.3) .
Attention
Attention is the ability to address a specific stimulus for a short period of time without being distracted by internal or external stimuli. Vigilance is the ability to hold one’s attention over longer periods. Attention is tested by digit recall; repeating seven numbers in the forward direction is considered normal, with fewer than five indicating significant attention deficits.
Orientation
Orientation is composed of four parts: person, place, time, and situation. Sense of time is usually the first to be lost, and sense of person is typically the last. Temporary stress can account for a minor loss of orientation, but major disorientation usually suggests an organic brain syndrome.
Memory
The components of memory include learning, retention, and recall. The patient is typically asked to remember three or four objects or words and 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. Normal individuals younger than 60 years should be able to recall three of four items. Recent memory can be tested by asking questions about the past 24 hours. Remote memory is tested by asking where the patient was born or which school or college the patient attended.
General fundamentals of knowledge and abstract thinking
Intelligence is a global function encompassing both basic intellect and remote memory. The examiner should note the patient’s highest level of education. Abstraction is a higher cortical function and should always be considered in the context of intelligence and cultural differences. It can be tested by asking the patient to interpret a common proverb or explain a humorous phrase or situation.
Insight and judgment
Insight has been conceptualized into three components: awareness of impairment, need for treatment, and attribution of symptoms. Recognizing that one has an impairment is the initial step necessary for recovery. A lack of insight can severely hamper a patient’s progress in rehabilitation.
Judgment is an estimate of a person’s ability to solve real-life problems, and it is related to the patient’s capacity for independent functioning. Judgment can be evaluated by simply observing the patient’s behavior or by noting the patient’s responses to hypothetical situations.
Mood and affect
The examiner should document reactivity and stability of mood. Mood can be described in terms such as being 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.
Communication
Aphasia
Aphasia involves the loss of production or comprehension of language. Naming, repetition, comprehension, and fluency are the key components. Testing comprehension of spoken language should begin with single words, progress to sentences that require only yes/no responses, and then progress to complex commands. Visual naming, repetition of single words and sentences, word-finding abilities, reading and writing from dictation, and then spontaneous reading and writing should also be assessed. Some standardized aphasia measures include the Boston Diagnostic Aphasia Examination and the Western Aphasia Battery (see Chapter 3 ).
Dysarthria
Dysarthria refers to defective articulation but unaffected content of speech. Key sounds 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, pharynx, and palate.
Dysphonia
Dysphonia is a deficit in sound production, which can be secondary to respiratory disease, fatigue, or vocal cord paralysis. Indirect laryngoscopy is the best method to examine the vocal cords. Patients are asked to say “ah” to assess vocal cord abduction and “e” to assess adduction. Patients with weakness of both vocal cords will speak in a whisper and exhibit inspiratory stridor.
Verbal apraxia
Apraxia of speech involves a deficit in motor planning without impaired strength or coordination. It is characterized by inconsistent errors when speaking. Oromotor apraxia is seen in patients with difficulty organizing nonspeech oral motor activity. It can adversely affect swallowing. Tests for verbal and oral motor function are listed in Chapter 3 .
Cognitive linguistic deficits
Cognitive linguistic deficits involve the pragmatics and context of communication, such as confabulation. Cognitive linguistic deficits are distinguished from fluent aphasias (e.g., Wernicke aphasia) by the presence of relatively normal syntax and grammar.
Cranial Nerve Examination
Cranial nerve I: olfactory nerve
Both perception and identification of smell should be tested with aromatic, nonirritating materials that avoid stimulation of the trigeminal nerve. The olfactory nerve is the most commonly injured cranial nerve (CN) in head trauma.
Cranial nerve II: optic nerve
The optic nerve is assessed by testing visual acuity and visual fields. Visual acuity refers to central vision. Visual field testing assesses the integrity of the optic pathway. Testing visual fields is most commonly performed by confrontation. For patients with deficits, further assessment by a neuro-optometrist or visually trained occupational therapist can be helpful.
Cranial nerves III, IV, and VI: oculomotor, trochlear, and abducens nerves
The oculomotor nerve innervates the medial rectus muscle (adductor of the eye), superior rectus and inferior oblique muscles (elevators of the eye), and inferior rectus muscle (depressor of the eye). The trochlear nerve innervates the superior oblique muscle, which is responsible for the downward gaze, especially during adduction. The abducens nerve controls the lateral rectus muscle, which abducts the eye. The examiner should assess the alignment of the patient’s eyes while the eyes are at rest and when the eyes are following an object, observing the full range of horizontal and vertical eye movements in the six cardinal directions. The optic (afferent) and oculomotor (efferent) nerves are involved with the pupillary light reflex, which normally results in constriction of both pupils when a light stimulus is presented to either eye separately. A characteristic head tilt when looking downward is sometimes seen in CN IV lesions.
Cranial nerve V: trigeminal nerve
The three sensory branches of CN V can be tested along the forehead (ophthalmic branch), cheeks (maxillary branch), and jaw (mandibular branch) bilaterally. The motor branch of the trigeminal nerve innervates the muscles of mastication, which include the masseters, pterygoids, and temporalis muscles. The corneal reflex tests the ophthalmic division of the trigeminal nerve (afferent) and the facial nerve (efferent).
Cranial nerve VII: facial nerve
The facial nerve is first examined by observing the patient while he or she is talking, smiling, closing the eyes, flattening the nasolabial fold, and elevating one corner of the mouth. The patient is then asked to wrinkle the forehead (frontalis muscle function), close the eyes while the examiner attempts to open them (orbicularis oculi function), puff out both cheeks while the examiner presses on the cheeks (buccinator function), and show the teeth (orbicularis oris function). A peripheral injury to the facial nerve, such as Bell palsy, affects both the upper and lower face, whereas a central lesion typically affects mainly the lower face.
Cranial nerve VIII: vestibulocochlear nerve
The vestibulocochlear nerve comprises two divisions: the cochlear nerve, which is responsible for hearing, and the vestibular nerve, which is related to balance. The cochlear division can be tested by checking gross hearing by rubbing the thumb and index fingers near each ear of the patient. 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 (eSlide 1.4) .
Cranial nerves IX and X: glossopharyngeal nerve and vagus nerve
Hoarseness is usually associated with a lesion of the recurrent laryngeal nerve, a branch of the vagus nerve. Normally, the soft palate should elevate symmetrically, and the uvula should remain in the midline when the patient says “ah.” In UMN vagus nerve lesions, the uvula will deviate toward the side of the lesion, but in LMN lesions, the uvula will deviate to the contralateral side. Gag reflex can be tested by touching the pharyngeal wall with a cotton tip applicator until the patient gags. The examiner should compare the sensitivity of each side (afferent: glossopharyngeal nerve) and observe the symmetry of the palatal movement (efferent: vagus nerve). The presence of a gag reflex does not imply the ability to swallow without risk of aspiration.
Cranial nerve XI: accessory nerve
Atrophy or asymmetry of the patient’s trapezius and sternocleidomastoid muscles should be checked. Trapezius atrophy results in a laterally migrated scapula (“open door” winging). To test the strength of the sternocleidomastoid muscle, the patient should be asked to rotate the head against resistance.
Cranial nerve XII: hypoglossal nerve
The hypoglossal nerve is tested by asking the patient to protrude the tongue and noting evidence of atrophy, fasciculation, or deviation. Fibrillations in the tongue are common in patients with amyotrophic lateral sclerosis. The tongue typically points to the side of the lesion in peripheral hypoglossal nerve lesions but away from the lesion in UMN lesions.
Sensory Examination (eSlides 1.5 and 1.6)
Evaluation of the sensory system requires testing both superficial sensation (light touch, pain, and temperature) and deep sensation (position and vibration).
Light touch can be assessed with a fine wisp of cotton or a cotton tip applicator. Pain is assessed with a safety pin. Thermal sensation can be checked with two different cups, one filled with hot water and one filled with cold water and ice chips.
Proprioception is tested by passive vertical movement of the toes or fingers when the patient’s eyes are closed. The patient is asked whether the digit is being moved in an upward or downward direction. It is important to grasp the sides of the digit rather than the nailbed to avoid the patient perceiving pressure in this area.
Vibration is tested with a 128-Hz tuning fork, which is placed on a bony prominence, such as the dorsal aspect of the malleoli, olecranon, or terminal phalange of the great toe or finger. The patient is asked to indicate when the vibration ceases.
Two-point discrimination is tested by calipers with blunt ends. The patient (with closed eyes) is asked to indicate whether one or two stimulation points are felt. Commonly tested two-point discrimination areas and their normal values are as follows: lips (2–3 mm), fingertips (3–5 mm), dorsum of the hand (20–30 mm), and palms (8–15 mm).
Testing for graphesthesia, the ability to recognize numbers, letters, or symbols traced onto the palm, is performed by writing recognizable numbers on the patient’s palm while the patient’s eyes remain closed. Stereognosis is the ability to recognize common objects, such as keys or coins, when placed in the hand.
Motor Control
Strength
Manual muscle testing (eSlides 1.7 and 1.8) provides an important method of quantifying strength. Pain can result in give-way weakness. It is important to recognize the presence of substitution when muscles are weak or movement is uncoordinated. Patients who cannot actively control muscle tension (e.g., those with spasticity) are not appropriate for standard manual muscle testing methods. A muscle grade of 3 is functionally important because antigravity strength implies that a limb can be used for activity. Females’ strength typically increases up to 20 years, plateaus through the twenties, and then gradually declines after age 30 years. Males increase strength up to age 20 years and then plateau until older than 30 years before declining.
Tables 1.13 and 1.14 in Braddom’s Physical Medicine and Rehabilitation, Fifth Edition (ISBN: 978-0-323-28046-4), summarize joint movements, innervation, and manual strength testing techniques for all major muscle groups of the extremities. Examples of tests for shoulder abduction are shown in eSlide 1.9 .
Coordination
Ataxia or coordination deficits can be secondary to deficits of sensory, motor, or cerebellar connections. Dysdiadochokinesia describes an inability to perform rapidly alternating movements.
Lesions affecting the midline cerebellum usually produce truncal ataxia, whereas lesions that affect the anterior lobe of the cerebellum usually result in gait ataxia. Lateral cerebellar hemisphere lesions produce limb ataxia, which can be tested by the finger-to-nose test and heel-to-shin test.
The Romberg test can be used to differentiate a cerebellar deficit from a proprioceptive deficit. If loss of balance is present when the eyes are open or closed, it is indicative of cerebellar ataxia. If loss of balance occurs only when the eyes are closed, it is a positive Romberg sign, which indicates a proprioceptive (sensory) deficit.
Apraxia
Apraxia is the loss of the ability to carry out programmed or planned movements despite adequate understanding of the task and no weakness or sensory loss. Ideomotor apraxia occurs when a patient cannot carry out motor commands but can perform the required movements under different circumstances. Ideational apraxia refers to the inability to carry out sequences of acts, although each component can be performed separately. Dressing apraxia and constructional apraxia are the result of neglect rather than actual deficits in motor planning.
Involuntary movements
Tremor, the most common type of involuntary movement, is a rhythmic movement of a body part. Myoclonus is a quick jerking movement of a muscle or body part. Chorea constitutes movements that consist of brief, random, nonrepetitive movements in a fidgety patient who is unable to sit still. Athetosis 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. Hemiballismus occurs when there are repetitive violent flailing movements.
Tone
Tone is the resistance of a muscle to stretch or passively elongate (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).
Tone can be quantified by the Modified Ashworth Scale (MAS). A pendulum test can also be used to quantify spasticity. The Tardieu Scale has been suggested as a more appropriate clinical measure of spasticity than the MAS. Measurements are usually taken at three velocities (V1, V2, and V3). V1 is measured as slow as possible, V2 is measured at the speed of the limb falling under gravity, and V3 is measured when the limb is moving as fast as possible. Responses are recorded at each velocity and at the angles (in degrees) at which the muscle response occurs.
Reflexes
Superficial reflexes (eSlide 1.10)
The normal plantar reflex consists of flexion of the great toe or no response. With dysfunction of the corticospinal tract, there is a positive Babinski sign, which consists of dorsiflexion of the great toe with an associated fanning of the other toes. A positive Chaddock sign refers to dorsiflexion of the great toe after stroking from the lateral ankle to the lateral dorsal foot. A positive Stransky sign refers to an upgoing great toe after flipping the little toe outward.
Muscle stretch reflexes (eSlide 1.11)
Muscle stretch reflexes, which were called deep tendon reflexes in the past, are assessed by tapping the skin overlying the muscle tendon with a reflex hammer. The response is assessed as 0, no response; 1+, diminished but present and might require facilitation; 2+, usual response; 3+, brisker than usual; and 4+, hyperactive with clonus. Reinforcement maneuvers, such as the Jendrassik maneuver, assist examination.
Primitive reflexes
Primitive reflexes are abnormal reflexes that represent developmental regression, indicating significant neurologic abnormalities in adults. Examples of primitive reflexes include the sucking reflex, rooting reflex, grasp reflex, snout reflex, and palmomental response.
Gait
Gait is a series of rhythmic, alternating movements of the limbs and trunk that result in the forward progression of the center of gravity. Gait is dependent on input from several systems, including the visual, vestibular, cerebellar, motor, and sensory systems. Gait disorders have stereotypical patterns that reflect injury to various aspects of the neurologic system (eSlide 1.12) .
Musculoskeletal Examination
The musculoskeletal (MSK) examination incorporates inspection, palpation, passive and active range of movement (ROM), assessment of joint stability, manual muscle testing, joint-specific provocative maneuvers, and special tests. Readers may view Table 1.9 in Braddom’s Physical Medicine and Rehabilitation, Fifth Edition, for details and reliability of joint-specific provocative maneuvers.
Inspection
Inspection includes observing mood, signs of pain or discomfort, functional impairments, or evidence of malingering (e.g., Waddell signs). The spine should be inspected for scoliosis, kyphosis, and lordosis, whereas limbs should be examined for symmetry, circumference, and contour. Muscle atrophy, masses, edema, scars, skin breakdown, and fasciculations should also be checked. Joints should be inspected for deformity, visible swelling, and erythema.
Kinetic chain refers to the summation of individual joint movements linked in a series, leading to the production of a larger functional goal. 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 causing disease at seemingly unrelated sites.
Palpation
Palpation is used to identify tender areas and localize trigger points, muscle guarding, or spasticity. Joints and soft tissues should be assessed for effusion, warmth, masses, tight muscle bands, tone, and crepitus.
Assessment of joint stability
Bilateral examination is critical because assessment of the “normal” side establishes a patient’s unique biomechanics. Joint play or capsular patterns assess the integrity of the capsule in positions of minimal bony contact, sometimes referred to as an open-packed position.
Assessment of range of movement general principles
ROM testing is used to assess the integrity of a joint, monitor the efficacy of treatment regimens, and determine the mechanical cause of impairment. Normal ROM varies according to age, gender, conditioning, body habitus, and genetics. Passive ROM should be performed through all planes of motion. Active ROM is performed by the patient through all planes of motion, without assistance from the examiner. Range is measured with a universal goniometer (eSlide 1.13) . Correct patient positioning and planes of motion for testing shoulder and hip joint ROM are shown in eSlides 1.14 and 1.15 . For more comprehensive and detailed information regarding measurements of each joint, the reader may refer to [CR] in Braddom’s Physical Medicine and Rehabilitation, Fifth Edition .
Assessment, Summary, and Plan
Only after completing a thorough physiatric history and physical examination is the physiatrist able to develop a comprehensive treatment plan. The organization of the initial treatment plan and goals should clearly state the impairments, performance deficits (activity limitations), community or role dysfunction (participation level), medical conditions that can affect achieving both short-term and long-term functional goals, and goals for the interdisciplinary rehabilitation team. Follow-up treatment plans and notes are likely to be shorter and less detailed, but they must address important interval changes since the last documentation and any significant changes in treatment or goals.
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