Beyond the Chart: Seeing Real Disability in Rehab

Claire Brooks

A seventy year old man walks into your clinic. Well, actually, that is the problem. He cannot walk the way he used to. He has been sent to you because of progressive left leg weakness. He now needs a cane. He is worried about falling. And somewhere during the conversation, he casually mentions he is also having a little trouble swallowing. So what is your job? Diagnose the neurologic disease? Test his strength? Write a physical therapy prescription?

Oliver Hart

All of those may matter. But if you are thinking like a physiatrist, there is another question sitting underneath all of them: What has happened to this person's ability to function? Can he get out of bed? Can he get to the bathroom? Can he climb the stairs in his house? Can he still work? Drive? Prepare food? Participate in the life he had before this illness? And if something has been lost, what intact abilities can we recruit to compensate?

Claire Brooks

So this is not just, "Where is the lesion?"

Oliver Hart

Exactly. It is: Where is the lesion? And what does the lesion mean for this person's life?

Claire Brooks

Okay. That feels like the thesis for the entire episode.

Oliver Hart

It pretty much is.

Claire Brooks

Let us start basic. Every physician takes a history and does an exam. So what makes the physiatric H and P special?

Oliver Hart

The framework. A traditional medical evaluation often moves from symptoms to disease: Chest pain. What is causing it? Weakness. Where is the lesion? Fever. What is the infection? Physiatry adds another layer. After identifying the pathology, we ask: What is the consequence of that pathology for function? And then: What can we do about that consequence?

Claire Brooks

Give me an example.

Oliver Hart

Take a stroke. Neurologically, you might describe a right middle cerebral artery infarction with left hemiparesis. Important. But the rehabilitation evaluation keeps going. Can the patient roll in bed? Can they transfer? Can they sit unsupported? Can they swallow? Can they communicate? Can they remember safety instructions? Can they dress themselves? Can they return home?

Claire Brooks

So the diagnosis is almost the beginning of the story.

Oliver Hart

Right. The diagnosis tells you what happened. The physiatric evaluation helps tell you what that event now means.

Claire Brooks

The chapter introduces impairment, activity, and participation. Those terms get thrown around constantly. Let us make them actually usable.

Oliver Hart

Think of three camera zoom levels. At the closest zoom you have the body. That is impairment. Zoom out and you have the person performing a task. That is activity. Zoom out again and you see the person functioning in society. That is participation.

Claire Brooks

Let us test it. A patient has right quadriceps weakness.

Oliver Hart

Impairment.

Claire Brooks

He cannot climb stairs.

Oliver Hart

Activity limitation.

Claire Brooks

He lives on the second floor and therefore cannot independently leave his apartment.

Oliver Hart

Participation consequence.

Claire Brooks

Beautiful. Another one. Expressive aphasia.

Oliver Hart

Impairment.

Claire Brooks

Difficulty communicating on the phone.

Oliver Hart

Activity limitation.

Claire Brooks

Unable to resume a job that requires frequent client conversations.

Oliver Hart

Participation restriction.

Claire Brooks

And the mistake would be documenting only "aphasia."

Oliver Hart

Exactly. Because that describes the damaged system but not the lived disability.

Claire Brooks

Rapid fire. A person has knee osteoarthritis. Painful knee extension?

Oliver Hart

Impairment.

Claire Brooks

Cannot walk three hundred feet?

Oliver Hart

Activity.

Claire Brooks

Stops attending church because the walk from the parking lot is too far?

Oliver Hart

Participation.

Claire Brooks

And that distinction actually changes the treatment plan.

Oliver Hart

Completely. You could treat the knee pain perfectly and still fail the patient if they remain unable to do the activity that matters to them.

Claire Brooks

I think residents sometimes treat the history as the annoying thing standing between them and the physical exam.

Oliver Hart

And in rehabilitation medicine, that is dangerous. Because you are examining the patient from the moment you meet them. Before you have touched a reflex hammer, you have already learned things. Did they maneuver their wheelchair into the room independently? Did their spouse answer every question? Did they need repeated redirection? Did they remember why they are seeing you? Are they minimizing their disability? Are they afraid? Frustrated? Determined?

Claire Brooks

So the conversation itself contains neurologic and functional data.

Oliver Hart

Exactly. And sometimes the patient is not the most reliable historian. Cognitive impairment, aphasia, impaired insight, mood disorders, developmental age, all of those may require collateral information. Family. Caregivers. Therapists. Nurses. Prior clinicians. Medical records.

Claire Brooks

Although the chapter warns us about something every resident has encountered. Chart lore.

Oliver Hart

Yes. One inaccurate statement gets copied into another note. Then another. Then another. Eventually everyone assumes it is true because it has been documented twelve times.

Claire Brooks

The medical version of a rumor becoming a historical fact.

Oliver Hart

Exactly.

Claire Brooks

Let us build the actual history. Chief complaint first.

Oliver Hart

And whenever possible, preserve the patient's own framing. Outpatient PM and R complaints commonly involve things like pain, weakness, or gait difficulty. But inpatient rehabilitation consultation often centers around something different: mobility, ADLs, communication, cognition, and whether the patient can participate in rehabilitation.

Claire Brooks

And then the HPI. We have all memorized the standard pieces. Location. Onset. Quality. Severity. Duration. Context. Modifying factors. Associated symptoms.

Oliver Hart

But PM and R adds: What function changed? And: What was baseline? That second question is enormous.

Claire Brooks

Why is prior function so important?

Oliver Hart

Because "needs assistance walking" is almost meaningless without context. Imagine two patients. Patient one walked five miles every morning until last week and now needs a walker. Patient two has used a walker for six years and is unchanged. Their current mobility might look identical. Their clinical stories are completely different.

Claire Brooks

So you are constantly asking: What could this person do before? What can they do now? Why did it change?

Oliver Hart

And what trajectory should we expect?

Claire Brooks

I want to camp here because this is where documentation can get hilariously vague. "Patient ambulates with walker."

Oliver Hart

Which raises about fifteen additional questions. How far? How safely? On what surface? With how much assistance? Can they turn? Do they fatigue? Do they need rest breaks? Do they get short of breath? Do they have pain? Do they fall? Can they walk outside? Can they climb stairs?

Claire Brooks

And before walking, there is bed mobility.

Oliver Hart

Exactly. Mobility is a chain. Bed mobility. Transfers. Wheelchair mobility if applicable. Ambulation. Stairs. Community mobility. Driving.

Claire Brooks

Why should a physician care whether somebody can roll in bed?

Oliver Hart

Because inability to reposition is not trivial. It affects pressure injury risk. Pulmonary health. Thrombotic risk. Caregiver burden. And independence. A patient who can walk thirty feet with therapy but requires two people to turn in bed still has a major mobility limitation.

Claire Brooks

What counts as a transfer?

Oliver Hart

Think transitions between support surfaces. Supine to sitting. Sit to stand. Bed to wheelchair. Wheelchair to toilet. Wheelchair to car. Wheelchair to shower bench. And again, the key dimensions are independence and safety.

Claire Brooks

Quick misconception. If a patient can propel a wheelchair, they are independently mobile.

Oliver Hart

Not necessarily. Can they manage the brakes? Footrests? Armrests? Can they propel far enough for real life? Can they navigate ramps? Doorways? Carpet? The community? And is the home accessible?

Claire Brooks

When you are asking about walking, what do you really want to know?

Oliver Hart

Distance. Duration. Assistive device. Assistance level. Rest requirements. Falls. Uneven surfaces. Associated symptoms. And stairs. Do not forget stairs.

Claire Brooks

Because "independent at home" means something very different if the bedroom is up fourteen steps.

Oliver Hart

Exactly.

Claire Brooks

Patient can walk two hundred feet but becomes dizzy every time. Independent?

Oliver Hart

Not safely.

Claire Brooks

Patient walks independently on level hospital flooring but cannot navigate the gravel driveway at home.

Oliver Hart

Community mobility remains limited.

Claire Brooks

Patient transfers independently from bed but cannot rise from a low toilet.

Oliver Hart

Transfer independence is task specific.

Claire Brooks

Patient uses a wheelchair but cannot independently manipulate the leg rests.

Oliver Hart

Not fully independent in wheelchair management.

Claire Brooks

Patient walks beautifully in therapy but has fallen four times at home.

Oliver Hart

The history wins. Functional performance must be evaluated in real world context.

Claire Brooks

Okay. Classic exam question. ADLs versus IADLs. Make it painless.

Oliver Hart

ADLs are basic personal care tasks. Eating. Feeding. Dressing. Bathing. Grooming. Toileting. Bowel and bladder management. Functional mobility. Those kinds of tasks. IADLs require more complex interaction with the environment. Meal preparation. Shopping. Managing finances. Managing the home. Caring for others. Community mobility. Health management.

Claire Brooks

So ADLs keep me personally functioning. IADLs help me independently run my life.

Oliver Hart

That is a useful way to remember it.

Claire Brooks

Here is a question that sounds straightforward. "Can you eat by yourself?" Patient says yes. Done?

Oliver Hart

No. This is exactly the type of superficial answer the chapter warns against. Maybe the patient can bring a fork to their mouth. But can they open containers? Cut meat? Prepare the meal? Position themselves safely? Maybe the limitation is not weakness at all. Maybe it is neglect. Apraxia. Visual field loss. Poor coordination. Pain. Balance impairment.

Claire Brooks

So one functional failure can have multiple candidate impairments underneath it.

Oliver Hart

Yes. That is a core physiatric reasoning skill. Ask: What component of the task is failing, and why?

Claire Brooks

Here is another trap. "Patient alert and oriented times four." Therefore cognition normal.

Oliver Hart

Absolutely not. Someone can know their name, location, date, and reason for hospitalization, and still be profoundly unsafe. Executive function matters. Can they plan? Sequence? Problem solve? Monitor their own behavior? Recognize mistakes? Understand limitations?

Claire Brooks

The chapter gives a great rehabilitation example. Someone has a hip replacement but lacks enough awareness to follow precautions.

Oliver Hart

Right. Suddenly cognition becomes an orthopedic safety issue. That is rehabilitation medicine in miniature. A brain problem changes the safety of a musculoskeletal recovery.

Claire Brooks

Rapid distinction. Attention versus vigilance.

Oliver Hart

Attention is selecting and addressing a stimulus over a relatively short period. Vigilance is sustaining that attention over time.

Claire Brooks

So someone might successfully start a task but fail halfway through because they cannot sustain attention.

Oliver Hart

Exactly.

Claire Brooks

Four components?

Oliver Hart

Person. Place. Time. Situation.

Claire Brooks

Which tends to disappear first?

Oliver Hart

Time orientation.

Claire Brooks

And which generally hangs on the longest?

Oliver Hart

Person.

Claire Brooks

Let us make memory testing conceptually cleaner.

Oliver Hart

Think: Learn it. Hold it. Retrieve it. Encoding or acquisition. Retention. Recall. You might present several words, confirm the patient initially registered them, and then test delayed recall several minutes later. If they cannot retrieve them spontaneously, you can assess whether cues or recognition help.

Claire Brooks

Which tells you more than simply saying "memory impaired."

Oliver Hart

Exactly.

Claire Brooks

Insight and judgment get bundled together constantly. Separate them.

Oliver Hart

Insight is fundamentally about understanding one's condition. Do I recognize that I have an impairment? Do I understand that treatment is needed? Do I appropriately attribute my symptoms? Judgment is more about: Given reality, what will I do? Can I make reasonable decisions in real world situations?

Claire Brooks

So a patient might understand they have left sided weakness,

Oliver Hart

Insight.

Claire Brooks

but still repeatedly attempt to walk without assistance despite falling.

Oliver Hart

Poor judgment.

Claire Brooks

And either can wreck a discharge plan.

Oliver Hart

Correct. In rehabilitation, cognition is not abstract. It often determines whether someone can safely live independently.

Claire Brooks

Time for one of my favorite confusion clusters. Aphasia. Dysarthria. Dysphonia. Apraxia of speech. Let us clean this up.

Oliver Hart

Start with the system that is failing. Aphasia: language. Dysarthria: motor execution of speech. Dysphonia: voice production. Apraxia of speech: motor planning.

Claire Brooks

Patient knows what they want to say but cannot produce the language appropriately.

Oliver Hart

Could be aphasia, depending on the pattern. Language production or comprehension is impaired.

Claire Brooks

Language intact, but articulation is distorted.

Oliver Hart

Dysarthria. The message is there. The mechanical production is impaired. Think of a radio station transmitting the correct program through a damaged speaker.

Claire Brooks

Hoarse, weak, abnormal voice quality.

Oliver Hart

Dysphonia. Now you are thinking about sound production and the phonatory apparatus.

Claire Brooks

And apraxia?

Oliver Hart

Motor planning. Strength may be adequate. Coordination may be adequate. But the brain has difficulty programming the sequence required to produce the intended speech. Errors may be inconsistent. You can hear patients searching, or groping, for the correct articulation.

Claire Brooks

Cannot name a watch?

Oliver Hart

Think language impairment, aphasia.

Claire Brooks

Knows it is a watch but speech is slurred.

Oliver Hart

Dysarthria.

Claire Brooks

Normal language and articulation but voice is breathy or hoarse.

Oliver Hart

Dysphonia.

Claire Brooks

Inconsistent articulatory errors despite preserved strength.

Oliver Hart

Apraxia of speech.

Claire Brooks

That is exactly the type of distinction I want burned into memory.

Claire Brooks

The PM and R social history gets huge. Home setup. Caregivers. Work. Finances. Sexuality. Substance use. Recreation. Mood. Why so much?

Oliver Hart

Because disability occurs in an environment. A patient does not discharge to "home." They discharge to: a third floor apartment with no elevator, or a ranch house, or a home with six entrance steps, or a bathroom too narrow for their wheelchair.

Claire Brooks

That is one of those things that seems obvious only after you see a discharge fail.

Oliver Hart

Exactly.

Claire Brooks

Another dangerous phrase: "Family available."

Oliver Hart

Available to do what? A seventy eight year old spouse may be emotionally supportive but unable to provide a maximal assist transfer. A family member may be willing to help with meals but not bowel care. Someone may work twelve hours a day. Caregiver support must be translated into actual capacity.

Claire Brooks

And work is not just income.

Oliver Hart

Correct. Vocation can be a source of financial security but also identity and self confidence. So ask what the job physically and cognitively demands. Sometimes rehabilitation is not about returning the patient to their old body. It is about modifying the environment enough to restore the role.

Claire Brooks

And ask what they do for fun.

Oliver Hart

Absolutely. If your patient tells you, "I just want to get back to playing cards with my friends," that is a rehabilitation goal. If another says, "I want to run again," that is a rehabilitation goal. Participation is not limited to employment.

Claire Brooks

Now we get to the physical exam. And this chapter gets detailed.

Oliver Hart

Very. But do not lose the governing principle. The neurologic examination should help you: identify the affected neurologic systems, localize the lesion when possible, characterize severity, and understand how those abnormalities influence function.

Claire Brooks

Let us do a board style classic. Upper motor neuron versus lower motor neuron.

Oliver Hart

Upper motor neuron lesion: Weakness. Increased tone. Increased reflexes. Typically less dramatic denervation type atrophy early on. Think central nervous system. Stroke. Spinal cord disease. Multiple sclerosis. Brain injury. Lower motor neuron lesion: Weakness. Reduced tone. Reduced reflexes. Muscle atrophy. Fasciculations. And electrodiagnostic evidence of denervation may be present depending on the process.

Claire Brooks

Weak, hyperreflexic, spastic leg.

Oliver Hart

UMN pattern.

Claire Brooks

Weak, areflexic, atrophied muscle with fasciculations.

Oliver Hart

LMN pattern.

Claire Brooks

Can UMN and LMN findings coexist?

Oliver Hart

Absolutely. Do not force the patient into a single box when the anatomy supports multiple lesions.

Claire Brooks

I am not sure anyone needs us to recite all twelve cranial nerves for twenty minutes.

Oliver Hart

Agreed. More valuable is understanding what the exam is trying to answer. Vision. Eye movements. Facial sensation. Facial motor function. Hearing and vestibular function. Palatal and pharyngeal function. Shoulder and neck strength. Tongue movement. And critically: How could deficits in those systems affect rehabilitation?

Claire Brooks

Vision affects mobility. Vestibular dysfunction affects balance. Facial and bulbar abnormalities affect communication and swallowing.

Oliver Hart

Exactly. That is how a physiatrist should connect the exam.

Claire Brooks

Rapid fire trap. Patient has a gag reflex. Therefore swallowing is safe. True or false?

Oliver Hart

False. Presence of a gag reflex does not establish safe swallowing.

Claire Brooks

That is absolutely worth remembering.

Claire Brooks

Sensory examination. What are we trying to do besides poking the patient with things?

Oliver Hart

Pattern recognition. Does the deficit follow: a peripheral nerve? a dermatome? a spinal cord pattern? a cortical distribution? And you are not testing a single sensory pathway. You have superficial sensation, light touch, pain, temperature. Then deeper sensory modalities like vibration and joint position. Then cortical sensory processing, things like stereognosis and graphesthesia.

Claire Brooks

So if somebody cannot identify a key placed in their hand,

Oliver Hart

First confirm their primary sensation is intact. Otherwise you cannot interpret failure of stereognosis as a cortical sensory problem.

Claire Brooks

Important exam principle: a higher order test depends on lower order systems functioning.

Oliver Hart

Exactly. And the chapter makes a broader version of that point throughout the neurologic exam.

Claire Brooks

Now, strength. Let us talk about the most abused phrase in inpatient documentation. "Five out of five throughout."

Oliver Hart

Especially when nobody actually tested "throughout."

Claire Brooks

Exactly. Walk me through the scale.

Oliver Hart

Zero: no contraction. One: trace contraction. Two: full available motion with gravity eliminated. Three: full available motion against gravity. Four: motion against gravity plus moderate resistance. Five: motion against gravity plus maximal resistance. And grade three is a particularly important functional threshold.

Claire Brooks

Why three?

Oliver Hart

Because that is antigravity strength. Once the patient can move the limb through available range against gravity, that dramatically changes how the limb can participate in functional activity.

Claire Brooks

Here is another common issue. How precise is our distinction between four and five?

Oliver Hart

Not as precise as people sometimes pretend. Resistance depends on examiner strength, patient positioning, pain, effort, technique, and the muscle being tested.

Claire Brooks

Let us make these practical.

Oliver Hart

Watch for substitution. Watch positioning. Watch pain. Watch sedation. Watch contracture. Watch spasticity. And do not confuse limited range with weakness. If a joint physically cannot move through the expected range because of a contracture, you need to distinguish that from inability to generate force.

Claire Brooks

And standard manual muscle testing is not ideal when the patient cannot voluntarily regulate contraction because of severe spasticity.

Oliver Hart

Correct.

Claire Brooks

This is a distinction that medical learners regularly blur. Tone and strength.

Oliver Hart

Completely different constructs. Strength asks: How much voluntary force can the person generate? Tone asks: What is the resistance to passive movement? A patient can have severe spasticity and profound weakness simultaneously.

Claire Brooks

Which is why saying, "The leg is strong because it is stiff," makes no physiologic sense.

Oliver Hart

Exactly.

Claire Brooks

Reflexes. Residents sometimes document them almost ceremonially. Two plus everywhere, moving on.

Oliver Hart

But reflexes are localization information. You need symmetry. Distribution. Context. Hyperreflexia can support an UMN pattern. Hyporeflexia can support peripheral or LMN involvement. And then you interpret them alongside tone, strength, sensation, and the rest of the exam.

Claire Brooks

No neurologic finding should live alone.

Oliver Hart

That is the key.

Claire Brooks

Suppose the patient has enough strength but still cannot perform the movement correctly. Now what?

Oliver Hart

Now you are asking whether the problem is: coordination, motor planning, involuntary movement, sensory feedback, or another system entirely. Cerebellar testing often depends on visual and motor systems functioning normally. Severe visual impairment can confound apparent cerebellar performance.

Claire Brooks

Another reminder that the exam is an interconnected system.

Claire Brooks

Okay. Switching from neuro to musculoskeletal. What is the sequence?

Oliver Hart

Start with observation. Inspect. Then palpate. Assess active and passive range of motion. Assess strength. Evaluate painful structures. Then use focused provocative maneuvers based on your differential.

Claire Brooks

That "based on your differential" part matters.

Oliver Hart

Very much. A provocative maneuver is not a party trick. It should answer a clinical question.

Claire Brooks

Let us say active range is limited. What does passive range tell me?

Oliver Hart

It helps determine why. Imagine shoulder elevation. Active range is severely restricted. But passive range is nearly full. Now you should think about weakness, pain inhibition, motor control, tendon dysfunction, or neurologic causes. If active and passive range are both restricted, structural joint limitation, contracture, or other mechanical restriction becomes more relevant.

Claire Brooks

So the gap between active and passive movement is information.

Oliver Hart

Exactly.

Claire Brooks

One thing I want residents to remember: the painful location may not be the only relevant location.

Oliver Hart

Absolutely. Human movement occurs through linked segments. A deficit at the hip can alter mechanics at the knee. Weak scapular stabilizers can affect shoulder mechanics. An ankle limitation can change gait upstream. You evaluate the body as a linked system rather than twelve unrelated joints.

Claire Brooks

Let us talk gait. Because this is PM and R.

Oliver Hart

And gait is one of the richest pieces of examination data you can collect. Before measuring anything sophisticated, observe. Base of support. Step length. Symmetry. Cadence. Foot clearance. Initial contact. Trunk posture. Arm swing. Assistive device use. Balance. Endurance.

Claire Brooks

And what is nice about gait is that multiple systems become visible simultaneously.

Oliver Hart

Exactly. Strength. Tone. Sensation. Coordination. Pain. Range of motion. Balance. Vision. Cognition. Cardiopulmonary endurance. All interacting in real time.

Claire Brooks

Let us test everything. Seventy two year old woman. Right hemispheric stroke two weeks ago. Left hemiparesis. She is awake and oriented. She tells you she is "basically fine" and wants to go home alone tomorrow. She requires moderate assistance with transfers. She repeatedly attempts to stand without calling for help. Her daughter says she does not seem to recognize how weak her left side is. How do you think through this?

Oliver Hart

First, impairment level. Motor weakness from the stroke. Potentially abnormal tone. Potential sensory or visuospatial impairment. Possibly impaired awareness. Then activity. She needs assistance transferring. We need walking status. ADLs. Toileting. Dressing. Mobility. Then participation. Can she safely live alone? Can she return to her previous community activities? Then cognition. Being oriented does not equal safe cognition. Her inability to recognize her deficits raises concern for impaired insight. Her repeated unsafe attempts to stand raise concern for judgment and safety awareness.

Claire Brooks

So if I write: "Alert and oriented times four. Left hemiparesis." I have missed the thing that may actually determine discharge.

Oliver Hart

Exactly. That is why the physiatric H and P is different.

Claire Brooks

I am giving you fifteen. No essays. Ready?

Oliver Hart

Go.

Claire Brooks

One. Difference between impairment and activity limitation?

Oliver Hart

Impairment is dysfunction of body structure or function; activity is difficulty performing a task.

Claire Brooks

Two. Most important comparison in functional history?

Oliver Hart

Current function versus prior function.

Claire Brooks

Three. Patient says "I can eat independently." Stop questioning?

Oliver Hart

No. Determine the specific components of the task and what assistance is required.

Claire Brooks

Four. Basic self care: ADL or IADL?

Oliver Hart

ADL.

Claire Brooks

Five. Managing finances?

Oliver Hart

IADL.

Claire Brooks

Six. Oriented times four means executive function intact?

Oliver Hart

No.

Claire Brooks

Seven. Attention versus vigilance?

Oliver Hart

Attention selects and addresses a stimulus; vigilance sustains attention over time.

Claire Brooks

Eight. Hypertonia, weakness, hyperreflexia.

Oliver Hart

Upper motor neuron pattern.

Claire Brooks

Nine. Atrophy, fasciculations, hyporeflexia.

Oliver Hart

Lower motor neuron pattern.

Claire Brooks

Ten. Aphasia affects?

Oliver Hart

Language.

Claire Brooks

Eleven. Dysarthria affects?

Oliver Hart

Motor articulation of speech.

Claire Brooks

Twelve. Apraxia of speech?

Oliver Hart

Motor planning.

Claire Brooks

Thirteen. MMT grade three means?

Oliver Hart

Full available movement against gravity without added resistance.

Claire Brooks

Fourteen. Active ROM limited, passive ROM preserved. Think broadly about?

Oliver Hart

Weakness, pain inhibition, motor control, or tendon/neurologic dysfunction rather than a fixed passive restriction.

Claire Brooks

Fifteen. Gag reflex present. Swallow safe?

Oliver Hart

No.

Claire Brooks

Okay, that last one is going on the test.

Oliver Hart

It should.

Claire Brooks

There is another theme in the chapter that I think becomes much more obvious once you have worked on an inpatient rehabilitation unit. Your admission H and P is not the final word.

Oliver Hart

Exactly. Rehabilitation assessment is dynamic. The physician gets information from therapists. Nursing. Neuropsychology. Speech language pathology. Family. Prior records. The patient over time. Someone may look independent in a ten minute physician encounter and demonstrate profound executive dysfunction during an hour long occupational therapy session.

Claire Brooks

Or tell you they are independent with dressing when nursing sees something very different every morning.

Oliver Hart

Exactly.

Claire Brooks

Let us end the deeper discussion with documentation. Because the EMR makes things both easier and worse.

Oliver Hart

Templates can improve completeness. Smart phrases can improve efficiency. Medication checks can improve safety. But copy and paste can propagate error. Imported data can create the illusion that something was personally reviewed when it was not. And excessive templating can produce a note that is enormous but clinically useless.

Claire Brooks

So a long note is not automatically a good physiatric note.

Oliver Hart

Correct. The best note captures the information that changes: diagnosis, functional interpretation, safety, goals, and treatment.

Claire Brooks

I want one mental checklist I can carry into clinic tomorrow. Not fifty questions. One framework.

Oliver Hart

Then use five questions. One: What is wrong? Meaning the disease, injury, or pathophysiology. Two: What impairment did it create? Weakness? Pain? Spasticity? Aphasia? Sensory loss? Contracture? Three: What activity is now difficult? Walking? Dressing? Transferring? Communicating? Eating? Four: What participation has been lost? Work? Parenting? Driving? Recreation? Community life? Five: What preserved ability or environmental modification can help compensate? That is the rehabilitation move.

Claire Brooks

Disease. Impairment. Activity. Participation. Compensation.

Oliver Hart

Exactly.

Claire Brooks

All right. Three things. If listeners remember nothing else from this chapter, what are the three?

Oliver Hart

1. The physiatric H and P is fundamentally a functional evaluation. Don't stop at pathology. Translate disease into impairment, activity limitation, participation, safety, and potential for recovery. 2. Always establish the patient's functional baseline and interrogate function specifically. "Independent" isn't enough. "Walks with walker" isn't enough. "Can feed self" isn't enough. Ask what the person actually does, how they do it, how safely they do it, and how that compares with their previous level. 3. Integrate the systems. Strength doesn't exist separately from tone. Gait doesn't exist separately from sensation. Discharge planning doesn't exist separately from cognition. ADLs don't exist separately from the environment. The neurologic exam, musculoskeletal exam, cognitive exam, social history, and functional history all converge on one question: How can this person function as safely, independently, and meaningfully as possible?

Claire Brooks

And that is the shift from simply describing disease,

Oliver Hart

to practicing rehabilitation medicine.

Claire Brooks

That is Chapter One. We will see you next time.

Oliver Hart

And please stop writing "five out of five throughout" if you didn't actually test throughout.

Claire Brooks

There it is.

Claire Brooks

Before you leave, ten questions. Answer out loud before Host B gives you the answer. One: Weakness is an impairment, activity limitation, or participation restriction?

Oliver Hart

Impairment.

Claire Brooks

Unable to climb stairs?

Oliver Hart

Activity limitation.

Claire Brooks

Unable to return to a second floor job because of that limitation?

Oliver Hart

Participation restriction.

Claire Brooks

Name the four orientation domains.

Oliver Hart

Person, place, time, situation.

Claire Brooks

Language impairment?

Oliver Hart

Aphasia.

Claire Brooks

Motor articulation impairment with preserved language?

Oliver Hart

Dysarthria.

Claire Brooks

Motor planning disorder of speech?

Oliver Hart

Apraxia of speech.

Claire Brooks

Manual muscle grade three?

Oliver Hart

Full available range against gravity without additional resistance.

Claire Brooks

Hyperreflexia plus hypertonia suggests?

Oliver Hart

Upper motor neuron involvement.

Claire Brooks

And the question that should follow almost every abnormal finding in PM and R?

Oliver Hart

What does this mean for function?