Introduction to the Physiatric Examination

1. Introduction to the Physiatric Examination John M Lavelle, D.O. Spine Physiatrist

2. Rehabilitation Evaluation • Evaluation of Function • Encompasses the entire general medical history and physical examination • Must ascertain the functional consequence of the medical diagnosis/disease that constitutes the rehabilitation diagnosis • Determine impairment and treat to prevent or minimize disability and handicap

3. Rehabilitation Evaluation • It is comprehensive – not limited to a single organ system • Attention paid to whole person • Return person to the fullest possible mental physical social and economic independence

4. Patient History • Chief Complaint • HPI • Functional History • PMHx • FHx • SHx • SxHx • Meds • ROS

5. Chief Complaint • Pt’s primary concern in his or her own words • Typically an impairment in the form of a symptom that implies a certain disease • “My hands ache and go numb when I drive” • Carpal Tunnel

6. HPI • Story of the medical problem • LISTEN • Gently guide the conversation • Document handedness • Onset, location, duration, quality, context, severity, modifying factors (aggravating/alleviating), and associated S&S, other treatments

7. Functional Hx • Characterizes the disabilities that have resulted from the disease and documents remaining capabilities. • Also document level of function prior to disease. • Discuss: Communication, eating, grooming, bathing, toileting, dressing, transfers, mobility.

8. ADL’s/iADL’s • Activities of daily living (ADLs)- bathing, toileting, dressing, eating, hygiene & grooming • Instrumental ADLs- meal preparation, laundry, telephone use, home maintenance, pet care

9. Communication • Hearing • Speaking • Reading • Writing

10. Eating • Difficulty leads to aspiration pneumonitis, malnutrition and depression. • Can tolerate solids vs liquids?

11. Grooming • Inability can impact body image and self esteem, social sphere and vocational opportunities.

12. Bathing • Can lead to obvious psychosocial issues. • Inability causes skin maceration and ulceration, infections and spread of diseases.

13. Toileting • Incontinence of stool or urine to the cognitively intact person can be very detrimental psychosocially. • Impairs social and employment opportunities. • “Loss of dignity” • Leads to skin breakdown, infections, ulcers. • Check indwelling caths

14. Dressing • We dress to go out of the house. • Dependence in dressing causes severe limitations in independence.

15. Transfers/Mobility • How get around? • Bed mobility • Around house/community • Wheelchair mobility, ambulation, driving & devices required

16. PMHx • Comorbidities important • Characterize the patient's baseline functional level. • Diagnosis and Impact of specific conditions- cardiopulmonary, musculoskeletal, neurologic & rheumatologic

17. ROS • Need 10! • HEENT • Neuro • CV • Resp • GI • GU • Skin • MSK • Endo • ID

18. Social Hx • Family: married, kids • Home environment: architectural barriers- stairs, elevator, small house • Support: family and friends support systems • Psychiatric History • How deal with stress, anxiety issues, depression • Diet – adequate nutrition important

19. Social Hx • Substance abuse: EtOH, Illicits, Tobacco • Vocation: work/education • Sexual history • Lifestyle: • Recreational activities: reading sports, etc • Exercise • Spirituality • Finances: disability, unemployment • Litigation

20. Family Hx • Hereditary diseases • h/o anxiety, depression, chronic pain, arthritis, CVA, MI, etc

21. Physical Examination • Vitals: Temp, Hr, RR, BP, SiO2, I/O’s, Pain • Skin/lymphatics: turgor, color, swelling • Head: lacerations, deformities, inequalities • Eyes: ptosis, symmetric, vision • Ears: hearing, wax, bleeding • Mouth and Throat: Moist membranes, masses, tongue/uvula midline, gag • Neck: JVD, ROM

22. PE • Chest: symmetric, excursion • Heart and Lungs: Auscultate! • Abdomen: BS, palpate • GU: Urinating (I/O’s), foley, ED? • GI: Rectal, hemorrhoids

23. MSK • Inspect: asymmetry, wasting • A/PROM • Palpate: muscles, joint stability

24. Neuro • Mental Status: • LOC: • Orientation • Attention • Recall • Gen fund of knowledge • Calculations • Proverbs • Leave no stone unturned • A rolling rock never grow moss • If you play with fire you get burned. • Judgements • What would you do if a fire alarm goes off • What do if you found stamped, addressed envelope

25. Neuro • Speech and Language • Wernicke: receptive aphasia-impaired comprehension • Broca: expressive aphasia - non-fluent • Global: non-fluent, poor comprehension • Transcortical motor: good comprehension, preserved repetition, reduced speech • Transcortical sensory; poor comprehension, good repetition, fluent speech • Conduction: reduced repetition

26. Neuro • Cranial Nerves

27. Neuro • Muscle tone – spasticity, rigidity, hypotonicity • Coordination – FNF, HTS • Involuntary movt’s • Perception – agnosia, Rt/Lt neglect • MMT, DTR’s, Sensation

28. Functional Exam • Eating, groomin, bathing, dressing, toileting • Transfers • Mobility

29. Functional capability • Level of independence in: • Ambulating • Communicating • Dressing • Eating,Personal Hygiene • Transfers

30. Assesment • Diagnosis & Description of status (improving, stable, declining)…ie: improving Lt hemi 2/2 Rt MCA CVA due to hypertensive episode. • Eligibility for Acute rehabilitation (ability to participate in 3 hours of rehabilitation per day, as well as identifiable benefit from OT/PT/Speech Therapy) • Setting for further interventions if not acute • Home: 24hr supervision, Day Rehab, outpatient PT/OT/RN • SNF • LTAC

31. PLAN • List by system or problem with treatment plan: • Neuro: • CVA- admit to acute rehab for …. • CV: • HTN – con’t metorpolol, goal SBP 140-160… • Provide prognosis: • Good recovery: able to return to work or school • Moderate disability: able to live independently; unable to return to work or school • Severe disability: able to follow commands/unable to live independently • Persistent vegetative state: unable to interact with environment; unresponsive • Recommendation goals: short and long term

32. History of PM&R • Physiatry derives from the Greek words physikos (physical) and iatreia(art of healing). • Separate medical specialty since 1947. • Written accounts of physical techniques for healing can be seen as far back as the writings of Hippocrates in 400 B.C. • Formal education for Physiatry had its beginning in 1926 when, after service in the U.S. Army during World War I, Dr. John Stanley Coulter joined the faculty of Northwestern University Medical School as the first full-time academic physician in physical medicine.

33. History of PM&R • Dr. John Stanley Coulter initiated the first continuing teaching program in physical medicine. • Consisting of short courses of three to six month's duration for physicians in practice • 1930's brought further organization and purpose to the field of rehabilitation. • Training programs for physical therapy technicians existed, but these were standardized by the formation of The American Registry of Physical Therapists • Frank Krusen, MD, established the Physical Medicine Program at the Mayo Clinic in 1936 and initiated the first three-year residency in Physical Medicine. • Drs. Coulter and Krusen led the organization of the American Academy of Physical Medicine in 1938

34. History of PM&R • Dr. Krusen coined the word "Physiatrist“ • Described the small group of physicians who were dedicated to the approach of adding physical medicine to medical therapeutics to treat neurological and musculoskeletal disorders • Krusen wrote the first textbook on Physical Medicine in 1941. • He is recognized as the "Father of Physical Medicine." • In 1946, the AMA Council on Physical Medicine voted to sponsor the term "physiatrist" (fizz-ee-at'-trist) and physiatry (fizz-ee-at'-tree) with the accent on the third syllable

35. History of PM&R • Howard A. Rusk, MD, an internist, as a result of his experience in the Army Air Corps Convalescent and Rehabilitation Services at Jefferson Barracks in World War II, recognized that passive, inactive, non-physical convalescence resulted in both physical and emotional deterioration of soldiers recovering from accident or illness. • Dramatic and more rapid recovery of strength and endurance and the much more rapid return to active duty due to the benefits of planned aggressive rehabilitation • Army Air Corps extended the program to all of its hospitals, and shortly thereafter, it was extended throughout the military services. • The Medical War Manpower Board recognized the great value of active rehabilitation and introduced it into civilian medical practice.

36. History of PM&R • Rusk went to New York's Bellevue Hospital where he began his 30-year campaign to train physicians and establish rehabilitation programs to treat the whole patient. • Rusk's earned recognition as "the Father of Rehabilitation Medicine.“

37. History of PM&R • By 1946, 25 medical residencies or fellowships in PM&R had been established. • In January 1947, the Advisory Board of Medical Specialties (now the American Board of Medical Specialties) formally recognized the American Board of Physical Medicine. • Two years later, at the urging of Dr. Rusk, the name was changed to include "Rehabilitation."

38. Thank You