Chapter 2: The History and Physical Examination of a Patient with Disability

INTRODUCTION

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).