Adult Physiatric History and Examination Introduction and Overview

Physiatry (pronounced fizz ee at' tree) is the term used to describe the specialty of physical medicine and rehabilitation and is derived from two Greek words, "physikos" (physical) and "iatreia" (art of healing).

Physical medicine is defined as the application of physical agents (eg. water, heat, cold, light, electricity) and techniques (eg. massage, stretching/traction, exercise) for the purpose of healing. Rehabilitation is defined as the restoration of the patient to a condition of health or useful and constructive activity. ^[1]

Through the first half of the last century, these two fields were not associated with each other. The confluence of these fields resulted from the introduction of technologic advances in the medical application of heat, massage, electrical stimulation, and radiography, as well as from the flood of debilitating injuries caused by two world wars, and from polio epidemics that affected even a US president.

The American Board of Medical Specialties designated physiatry as a specialty in 1947. Recognizing the work of such pioneers as John Stanley Coulter, Frank Krusen, known as the "father of Physical Medicine," and Howard Rusk, the "father of Rehabilitation Medicine," the Veterans Administration established physical medicine and rehabilitation services in each of its facilities. The Baruch Committee (1943-52) established medical residencies and fellowships in US medical schools and hospitals through a series of grants and awards. In the 1950s, physiatry received a tremendous boost from the US Office of Vocational Rehabilitation. Disabled people could have improved quality of life and the potential to return to productivity. The Americans with Disabilities Act (ADA), passed in 1990, leveled the playing field by striking down discriminatory practices that prevented disabled citizens from receiving the same rights that nondisabled citizens had to become productive members of society.

Physical medicine and rehabilitation residency programs produce approximately 400 physiatrists per year. As of 2016, there were more than 12,000 board-certified physiatrists in the United States, according to the American Board of Physical Medicine and Rehabilitation (ABPMR). ^[2]

A physiatrist must first earn a Doctor of Medicine (MD) or Doctor of Osteopathy (DO) degree. In the US, postgraduate training in physical medicine and rehabilitation consists of 1 year of internship in medicine followed by 3 years of residency training in a program recognized by the ABPMR. ^[2] Board certification in physical medicine and rehabilitation requires the successful completion of the 4 years of postgraduate training followed by successful completion of a written examination and a separate oral examination (taken 1 year after completion of residency). Specialized training is available in pediatric rehabilitation, electromyography, pain medicine, and spinal cord injury medicine that allows the practitioner to be formally recognized by accreditation for a higher level of skills.

Since 1992, the statute for physicians with board certification in physical medicine and rehabilitation has been limited to 10 years in recognition of the rapid changes in the practice of medicine. In order to maintain proficiency, physiatrists must take a Maintenance of Certification (MOC) examination every 10 years.

Physiatrists can branch out into a wide variety of practices and practice arrangements. In the outpatient setting, physiatrists have the widest variety of practice arrangements.

Just a few of the sample activities include (1) taking a comprehensive history and physical examination for medicolegal cases; (2) performing musculoskeletal examinations for sports team physicals; (3) performing electrodiagnostic studies of almost every type of disease or condition involving the musculoskeletal and nervous system ^[3] ; (4) using semi-invasive (ie, nonsurgical) procedures for the diagnosis, treatment, and management of pain; (5) evaluating an amputee for a prosthesis; (6) constructing treatment strategies for chronic diseases such as spinal cord injury, traumatic brain injury, and cerebrovascular accidents; (7) providing medical supervision and assistance to community nursing services; and (8) performing comprehensive disability evaluations at the request of referring governmental agencies, insurance companies, attorneys, or workers' compensation judges.

In the inpatient setting, physiatrists are consulted when the patient has progressed to medical stability but is not capable enough with regard to self-care, feeding, communicating, managing bowel and bladder function, and ambulating to be discharged home. The adult physiatric history and physical examination provides advice on the appropriate level of rehabilitation services required to assist the patient. The appropriate level of care may range from admitting the patient to an inpatient rehabilitation facility to outpatient therapy services to home health therapy services. This makes physiatrists the first choice for medical directorship in an inpatient rehabilitation facility.

Physiatrists typically practice in urban and suburban settings where the demand for services is greatest, but some have found success in rural settings. ^[4]

The physiatrist is expected to have mastered the established and evolving biomedical and clinical information applicable to the clinical care of patients with a wide range of impairments, disabilities, diseases, and disorders. In addition, the physiatrist is expected to demonstrate strong interpersonal skills to communicate effectively with allied health professionals such as physical, occupational, and speech therapists. Physiatrists are recognized as effective members or leaders of a multidisciplinary team.

The attributes of a successful physiatrist include the ability to review and synthesize historical information, perform a focused medical and functional examination, formulate a diagnosis that correlates to the clinical findings, and construct a comprehensive treatment and/or management program.

In summary, the adult physiatric history and examination represent a value-added service, recognizing functional ability as an important component of the overall picture of a patient's health.

The inpatient adult physiatric history contains the elements of a comprehensive medical history, with an emphasis on the details of the patient's functional history. The most common reason for an inpatient adult physiatry history and physical examination is to determine whether the patient's condition is appropriate for an inpatient rehabilitation program.

The adult physiatric history begins with the patient's report of the present illness. If the patient is unable to provide a report because of a disease or illness affecting communication, then the physiatrist can prepare a history based on review of the medical record or discussions with the patient's doctor, nurse, case manager/social worker, or family or with others with knowledge of the patient's condition.

Presenting symptoms (such as those that precede a stroke) may become important later as teaching points for educating the patient and family about managing a life-altering disease or illness and preventing or mitigating a reoccurrence. In the acute hospital setting, diagnostic studies, treatment interventions, and consultations from other specialists often are incorporated into the history of the present illness. The past medical history serves as a review of all the patient's significant medical treatments, previous hospitalizations, and surgical procedures.

The systems review screens for current and past symptoms that may represent concurrent problems not readily identified in the history of the present illness. Consider constitutional (fever, chills), head and neck (swallowing difficulties, visual/auditory changes), cardiovascular chest pain or palpitations), respiratory (shortness of breath), genitourinary (urinary retention or incontinence), gastrointestinal, neurological, and musculoskeletal symptoms in the review. The physiatrist elicits information about the presence of any allergies caused by medications or environmental sources, along with a brief description of allergic reactions.

The functional history characterizes the extent to which a disability may have resulted from an illness or chronic disease. The functional history details the patient's life in a chronological manner, starting with the level of education, domestic situation (eg, married, children), current employment/vocational history, avocational pursuits, dietary habits, tobacco and alcohol consumption, driving ability, and typical information regarding the patient's performance of activities of daily living (ADL). Consider describing instrumental activities of daily living (IADL), such as the ability to manage money, prepare meals, go grocery shopping, and perform household chores. This information may help the physiatrist place the disease, injury, or illness into the context of the patient's previous level of functioning in cases involving long-term care financing.

Questions about the domestic situation may include a description of the patient's home (eg, ranch-style versus colonial) and location of essential rooms, such as the bedroom, bathroom, and kitchen. Knowledge of the location of stairs is important since steps may represent potential architectural barriers to the patient returning home. In the case of a patient with a history of falling, knowledge of the floor surfaces (eg, carpet, rugs) may provide an insight into the factors contributing to falls.

Review of the patient's employment/vocational history contributes to a better understanding of how the recent illness or disease affects the patient's societal obligations. A self-employed patient may view any further hospitalization as an unnecessary expense and may forego needed rehabilitation services. On the other hand, a patient with a life-altering disease or illness may need future vocational rehabilitation services. The information collected initially plays an important role in instituting future vocational rehabilitation services.

The patient's avocational pursuits may have no immediate bearing on the decision to pursue inpatient rehabilitation services; however, the information obtained may contribute to the emotional well-being of the patient requiring further rehabilitation services and may provide positive reinforcement.

The designation activities of daily living refers to feeding, grooming, bathing, dressing, and toileting. The patient's ability to perform each of these activities with or without assistance is crucial to determining what future services the patient may need to return home. In the inpatient hospital setting, inability to perform these basic tasks may preclude discharging the patient directly home. Details on the patient's level of function prior to hospitalization help to establish a benchmark of performance that the patient may be expected to achieve as a condition for returning home. Information on functional level may determine the most appropriate alternative setting after discharge from the hospital and rehabilitation unit if the patient is deemed unable to return directly home. The medical history and general health of individuals close to the patient (eg, spouse) become important in discharge planning and/or long-term care.

The outpatient physiatric history is extremely broad, and the physiatrist may expect anything to be brought up during the information-gathering process. In general, the adult outpatient physiatric history tends to focus on an impairment or functional disability. In cases involving chronic pain from a personal injury, the physiatrist is often the last physician in a long string of healthcare professionals to encounter the patient. The histories may be complex and convoluted, making it difficult to extract a history that is clean, coherent, and cogent. Yet, the functional history often sheds light on the problems and may provide insights on how best to treat a patient with overwhelming complex medical and psychosocial issues.

The Independent Medical Examination (IME) best exemplifies the adult outpatient physiatric history and examination. The IME is performed for the purpose of clarifying issues and answering questions surrounding the patient's condition by a physician who is not directly involved in the patient's care. The IME generally addresses mechanism(s) of injury, diagnosis or diagnoses, causality, and subjective versus objective complaints. The physiatrist may address additional questions, such as the appropriateness of the treatment to date, need for further treatment, and prognosis. Furthermore, the physiatrist may be asked to formulate a treatment plan, determine physical capabilities, and assign a return-to-work status.

In the area of electrodiagnostic medicine, the physiatrist provides the most value to the requesting physician when a history and physical examination are attached to the nerve conduction and electromyographic report. ^[3] The information in the functional history and the physical examination actually may strengthen the correlation between the patient's presenting disabilities and the findings of impairment found in the electrodiagnostic studies.

In summary, the hallmark of the inpatient and outpatient adult physiatric history is a gathering of essential and accurate information that can be used together with the findings of the physical examination to make decisions about diagnostic and therapeutic interventions. ^[5]

The physical examination is the integration of information obtained by inspection, palpation, percussion, and auscultation of the patient to gather the physical findings in support of the diagnoses suggested from the history of the present illness. The examination may uncover physical findings not readily apparent to the patient or not suggested by the history. ^{[6, 7, 8]}

All physical examinations contain 1 or more elements of the following systems or body areas presented below in a general head-to-toe direction. When an impairment is identified, the appropriate regional examination is expanded.

• Constitutional - General appearance, deformities, development, and vital signs (eg, height, weight, temperature, blood pressure, pulse, respirations)

• Head, eyes, and ears - General appearance, deformities, assistive devices (eg, hearing aids, glasses), and visual/auditory acuity

• Mouth, throat, and nose - General appearance, general dental condition, and patency of airway

• Neck - General appearance, vascular distension, auscultation for bruits, and active range of motion (ROM) and passive ROM

• Cardiovascular - Auscultation of the heart, examination of peripheral pulses, and inspection of vascular refilling, varicosities, swelling, and edema

• Respiratory - General appearance of the chest, auscultation of lungs and upper airways, observation of breathing pattern, and examination for peripheral clubbing or cyanosis

• Gastrointestinal/genitourinary - Inspection of abdomen and pelvis, auscultation of bowels, palpation of abdominal organs, and rectal examination

• Musculoskeletal - Inspection and palpation of joints, bones, and muscles/tendons; assessment of active ROM and passive ROM and stability of joints; inspection of muscle mass; and assessment of muscle strength and tone ^[9]

• Neurologic - Inspection of general appearance including attention to grooming, assessment of mental status (eg, orientation, memory, attention and concentration, language and naming, fund of knowledge, insights into current condition), and assessment of cranial nerves

  • I - Smell

  • II - Visual acuity, and visual fields

  • III, IV, and VI - Pupil and eye movements

  • V - Facial sensation and corneal reflex

  • VII - Facial symmetry and strength

  • VIII - Hearing with tuning fork

  • IX - Palate movement

  • XI - Shoulder shrug

  • XII - Tongue protrusion

Neurologic examination also includes assessment of (1) sensation to pinprick, vibration, and proprioception, (2) assessment of sphincter tone and reflexes (eg, bulbocavernosus), (3) assessment of deep tendon reflexes in upper and lower extremities, including pathologic reflexes (eg, Babinski, Hoffman), and (4) assessment of coordination (eg, finger/nose, heel/shin, rapid, alternating movements).

• Integumentary - Inspection and palpation of scars, rashes, ulcers, and surgical incisions

• Functional

  • Assessment of transfer from supine to sitting position to standing position and of standing balance

  • Assessment of gait

  • Assessment of balance in static and dynamic situations

  • Assessment of nonphysiologic behaviors like Waddell signs (eg, superficial skin tenderness, stimulation of back pain by axial loading or truck rotation, differences in straight leg raising response between supine and sitting positions, regional nonanatomic weakness or numbness, and overreaction/disproportionate pain responses)

  • Caty et al found that self-assessments of locomotor ability by adult stroke patients, using the ABILOCO questionnaire, correlated closely with third-party assessments of these patients made by physical therapists and by an independent medical examiner. ^[10] The study utilized 28 patients, who answered the questionnaire between 3 weeks and almost 5 years after suffering a stroke. The investigators concluded that the ABILOCO questionnaire provides a valid means in clinical practice and research of assessing locomotion in patients who have had a stroke.

Assessment of the patient's condition following a physiatric history and examination enumerates the diagnostic findings (ie, impairments) and functional deficits (ie, disabilities), usually ranking them in order of the medical and functional severity.

For example, an elderly widowed woman presents to the emergency department with severe right hip pain that occurred immediately after she fell in her home. Radiographic films confirm a femoral neck fracture, and she undergoes a partial hip replacement (hemiarthroplasty). Because she lives alone, the case manager/social worker for the orthopedics service requests a consultation with physiatrist. Her medical history is significant for rheumatoid arthritis and phlebitis. Review of systems demonstrates a history of falls. She has not had a bowel movement since surgery. She needs assistance feeding and grooming herself.

The functional history reveals that she lives in a 2-story Cape Cod–style house with 5 steps leading to the front porch and that the bedroom and bathroom are on the second floor. She also was still driving prior to this surgery. Furthermore, she has no immediate family because her children all live out of state.

Physical examination reveals an alert and oriented 75-year-old woman with normal vital signs, rheumatoid arthritic changes in both hands, and normal heart/lung/abdominal examination findings. Her neurological examination reveals intact proprioception, decreased hearing, and normal eye movements. Standing is difficult due to hip pain and weakness in the hip girdle muscles.

The assessment might include the following:

• A 75-year-old woman with mobility deficits due to femur fracture necessitating right hip hemiarthroplasty

• Ambulation deficits secondary to right hip hemiarthroplasty

• Self-care deficits in feeding, grooming, and, possibly, dressing, secondary to rheumatoid arthritic changes in both hands

• Balance deficits secondary to postoperative hip pain

• Constipation secondary to use of narcotic pain medications

• History of falls, possibly due to antalgic gait pattern from rheumatoid arthritis and possible environmental factors (eg, throw rugs on floors)

• History of phlebitis in a patient with a right hemiarthroplasty and Coumadin use for prevention of deep vein thrombosis (DVT)

• Reactive depression to suggestions that she may not be able to return home or drive again

Plans for this patient would include the following recommendations:

• Transfer to acute rehabilitation unit for postoperative rehabilitation following right hip hemiarthroplasty

• Instructions for management of the patient's Coumadin medication for prophylaxis of DVT, including frequency of blood sampling for PT and international normalization ratio

• Instructions for management of pain medications to optimize pain control with minimal adverse effects

• Management of bowel function through judicious use of medications to promote regularity of bowel movements

• Physical therapy evaluation and training for (1) bed mobility, (2) transfer, (3) mat exercises to strengthen the right leg affected following surgery, while promoting strengthening and reconditioning following surgery, (4) promoting optimum gait patterns to maximize the use of the right leg while preventing antalgic gait patterns from affecting the contralateral hip further, (5) ascending and descending stairs, (6) balance, and (7) education in hip ROM and positioning to lessen the chances of hip dislocation

• Occupational therapy evaluation, teaching of techniques to conserve energy during homemaking activities to protect joints, evaluation of need for assistive devices (eg, large-handled eating utensils, reachers, tub bench), and treatment to improve (1) performance of ADL (eg, feeding, grooming, dressing), (2) transfers to and from a commode and bathtub or shower stall, and (3) transfers to and from a car

• Recreational therapy for evaluation and incorporation of community activities to promote a sense of well-being and independence

• Psychological evaluation and counseling for reaction to disabilities following surgery

A study by Haxby and Kingan indicated that the opinions formed by physiatrists regarding prognosis after clinical examination of patients with chronic or recurrent low back pain (LBP) offer a legitimate estimate of the functional outcome of these patients at one year. The prospective cohort study involved 89 patients with LBP, whose outcomes were assessed at one-year follow-up with the 18-item Roland-Morris Disability Questionnaire. Using backward stepwise linear regression modeling, the investigators found that the physiatrist’s prognostic opinion was a valid estimation of the one-year results on the questionnaire. ^[11]

The IME is presented here as an example of an outpatient PMR adult physical examination. The IME is a comprehensive history based on review of records and interviews with the patient combined with a thorough physical examination resulting in a report that responds to specific questions posed by an attorney, an insurance company claims adjuster, a worker's compensation adjudicator, or any individual representing these parties. ^[12]

Once produced, the IME becomes a medicolegal document read by all participants in the process. Physician-patient confidentiality is not associated with this type of examination, and no physician-patient relationship is established. The IME commences with the patient's account of the history of the events from the time of injury to the present. The physiatrist attempts to detail the mechanism of injury, symptoms at the time of injury, and the events that followed as described by the patient and compares this information with the medical records for consistency.

The patient's past medical history is scrutinized carefully for possible preexisting conditions that may have contributed to the symptoms by temporary exacerbation or by aggravation, which is considered a physical change and, therefore, is more serious. Current complaints are defined through the patient's report of the pain symptoms, their location, pattern, and intensity and an account of what aggravates and ameliorates the symptoms.

Functional status is assessed with the patient's report on tolerance to various activities (eg, sitting, standing, walking) and ability to perform ADL. The patient's representation of functional status may be compared to the physician's observations or the medical record for consistency of reporting. The occupational and psychosocial histories are reviewed in particular detail. Knowledge of the patient's job description at the time of injury can aid in determining causality. Likewise, a functional capacity assessment must start from the basis of the job requirements. The work history may illuminate the patient's feelings about work, which in turn may assist the physiatrist reach an objective evaluation of subjective complaints, formulate a prognosis, and establish a reasonable return-to-work determination.

The physical examination may be complete or regional. Both types of examinations should document positive, negative, and nonphysiologic findings. Document behavioral observations along with physical findings. Begin either type of physical examination with taking of vital signs (eg, height, weight, blood pressure, heart rate). Note behavior during the history-taking portion of the examination. In the history, address duration of sitting, general movements, and irregularities in ambulation. The patient also can be observed for aberrant behavior, unusual postures, or evidence of symptom magnification.

In appropriate settings, the patient's ability to undress in preparation for the examination may contribute information about functional ability and functional ROM. In all circumstances, however, the patient's privacy and dignity must be respected.

A structural examination begins with an inspection of the patient in the standing position, noting cervical, thoracic, and lumbar curvature. Document any scars, tattoos, assistive devices, or other individual physical features noted during physical examination. Identify sites of tenderness to palpation and percussion by anatomic landmarks.

Assessments of ROM of the spine are made with a goniometer or inclinometer positioned against the skin. ROM tests are performed for a minimum of 3 trials to obtain an average rating. A wide variation in each measurement may indicate lack of consistency on the patient's part. ROM is tested in all extremities for active and passive effort. Straight leg raising (SLR) exercises are used for the lower extremities to elicit back pain. The SLR may be performed in supine and sitting positions. Discrepancies in performance (eg, SLR supine measurements are inconsistent with SLR sitting measurements) may suggest a nonphysiologic finding and possible magnification of symptoms by the patient.

The neurologic portion of the examination reports strength on the basis of the Medical Research Council's ordinal scale of 0 to 5 (0=absent strength, 1=trace muscle movement, 2=poor strength, 3=antigravity strength only, 4=greater than antigravity strength, 5=normal strength). Reflexes are measured on a 0 to 4 ordinal scale (0=absent reflexes, 1=hyporeflexia, 2=normal reflexes, 3=hyperreflexia, 4=hyperreflexia with clonus). A study by Gladitz et al indicated that, as measured using Gwet’s AC1, there is good interrater and intrarater reliability for the flexor pollicis longus muscle stretch reflex (FPLR), making the FPLR “a reliable diagnostic neuromuscular test” that may have clinical use in evaluating “C8/T1 nerve root lesions or pathologies of the interosseous anterior nerve.” ^[13]

Sensation is measured for light touch (stroke skin with a cotton ball or tissue paper) and pin prick (using the sharp and blunt ends of a safety pin) on a 0-to-3 ordinal scale (0=no sensation, 1=decreased sensation, 2=normal sensation, 3=increased sensation). Sensation is tested by dermatome and compared from side to side.

Numerous eponymous tests (eg, Patrick test, Neer test, Spurling test) assess anatomical and physiological function selectively. These tests are incorporated into the regional physical examinations and may help to strengthen the consistencies of the examination or expose inconsistencies where behavior and findings on performance diverge.

Assessment is the critical feature of the IME because the report must respond to the question of causality and must establish the relationship of the injury to the patient's present condition. The physiatrist must be able to formulate an opinion based on a reasonable degree of medical certainty that the patient's condition is the probable result (>50% probability) of the accident or event described by the patient. The physiatrist also may be asked to apportion the contribution of various factors that may be related to the injury.

The physiatrist often is asked to state whether or not the patient has reached maximum medical improvement (MMI). The essence of MMI is that no further recovery is expected and no further functional restoration can be anticipated to a reasonable degree of medical certainty. The judgment made concerning MMI implies that a condition is permanent and static. Permanency of condition and static condition are legal terms that are not synonymous.

The physiatric history and physical examination, when used as part of an IME, provide an excellent review of the appropriateness of the patient's care. The conclusions often are used in recommending further treatment, arranging return-to-work programs, and determining the need for vocational rehabilitation services.