Clinical Evaluation

Clinical Evaluation (3)

The rehabilitation evaluation of chronic disease often shows lost function. Through the functional history, the physician characterizes the disabilities that have resulted from disease and identifies remaining capabilities. The functional history is considered part of the history of the present illness by some physicians and a separate segment of the patient interview by others. The examiner must know not only the functional status associated with the present illness but also the level of function at one or more times before the present illness; therefore, we prefer to consider it separately. 

Although the specific organization of the activities of daily living varies somewhat, the following elements of personal independence remain constant: communication, eating, grooming, bathing, toileting, dressing, bed activities, transfers, and mobility. 

When obtaining the functional history, the physician may record in a descriptive paragraph the patient's level of independence in each activity. However, functional stability is best communicated, followed over time, and made accessible for study when the physician uses a standard functional assessment scale. 


A major component of rehabilitation is education; thus, communication is critical. The interviewer must assess the patient's communication options. In the clinical situation, this aspect of the evaluation blurs the distinction between history and physical examination. It is difficult to interact with the patient in a meaningful way without coincidentally examining his or her ability to communicate; significant speech and language deficiencies become obvious. However, for purposes of discussion, certain facets of the assessment relate more specifically to the history and will be discussed here. Additional facets are presented below in the section on the physical examination. 

Speech pathology has provided clinicians with numerous classification systems for speech and language disorders. From a functional view, the elements of communication hinge on four abilities  (2): 

  1. Listening 
  2. Reading 
  3. Speaking 
  4. Writing 

By assessing these factors, the examiner can determine a patient's communication abilities. Representative questions include the following: 

  1. Do you have difficulty hearing? 
  2. Do you use a hearing aid? 
  3. Do you have difficulty reading? 
  4. Do you need glasses to read? 
  5. Do others find it hard to understand what you say? 
  6. Do you have problems putting your thoughts into words? 
  7. Do you have difficulty finding words? 
  8. Can you write? 
  9. Can you type? 
  10. Do you use any communication aids? 


The abilities to present solid food and liquids to the mouth, to chew, and to swallow are basic skills taken for granted by able-bodied people. However, in individuals with neurologic, orthopedic, or oncologic disorders, these tasks can be formidable. Dysfunctional eating can be associated with far-reaching consequences, such as malnutrition, aspiration pneumonitis, and depression. As in the assessment of other skills for activities of daily living, inquiries about eating function should be specific and methodical. 

Representative questions include the following: 

  1. Can you eat without help? 
  2. Do you have difficulty opening containers or pouring liquids? 
  3. Can you cut meat? 
  4. Do you have difficulty handling a fork, knife, or spoon? 
  5. Do you have problems bringing food or beverages to your mouth? 
  6. Do you have problems chewing? 
  7. Do you have difficulty swallowing solids or liquids? 
  8. Do you ever choke? 
  9. Do you regurgitate food or liquids through your nose? 

Patients with nasogastric or gastrostomy tubes should be asked who helps them prepare and administer their feedings. The type, quantity, and schedule of feedings should be recorded. 


Grooming may not be considered as important as feeding. However, the inability to make oneself attractive and presentable can have injurious effects on body image and self-esteem, social sphere, and vocational options. Consequently, grooming skills should be of real concern to the rehabilitation team. 

Representative questions include the following: 

  1. Can you brush your teeth without help? 
  2. Can you remove and replace your dentures without help? 
  3. Do you have problems fixing or combing your hair? 
  4. Can you apply your makeup independently? 
  5. Do you have problems shaving? 
  6. Can you apply deodorant without assistance? 


The ability to maintain cleanliness also has far-reaching psychosocial implications. In addition, deficits in cleaning can result in skin maceration and ulceration, skin and systemic infections, and the spread of disease to others. Information about independence in bathing should be sought. 

Representative questions include the following: 

  1. Can you take a tub bath or shower without assistance? 
  2. Do you feel safe in the tub or shower? 
  3. Do you use a bath bench or shower chair? 
  4. Can you accomplish a sponge bath without help? 
  5. Are there parts of your body you cannot reach? 

For patients with sensory deficits, bathing is also a convenient time for skin inspection, and inquiry about the patient's inspection habits should be made. For patients using a wheelchair, architectural barriers to bathroom entry should be determined. 


To the cognitively intact person, incontinence of stool or urine can be the most psychologically devastating deficit of personal independence. Ineffective bowel or bladder control has an adverse impact on self-esteem, body image, and sexuality, and it often impairs or prevents employment and social relationships. Dignity may even prohibit the person from venturing from the house for fear of an accident. Soiling of skin and clothing often results in ulceration, infection, and urologic complications. The rehabilitation physician should vigorously pursue questioning about toileting dependency with sensitivity. 

Representative questions include the following: 

  1. Can you use the toilet without assistance? 
  2. Do you need help with clothing before or after using the toilet? 
  3. Do you need help with cleaning after a bowel movement? 

For patients with indwelling urinary catheters, the usual management of the catheter and leg bag should be examined. If bladder emptying is accomplished by intermittent catheterization, the examiner should learn who performs the catheterization and should have a clear understanding of the technique. For patients who have had ostomies for urine or feces, the examiner should determine who cares for the ostomy and should ask the patient to describe the technique. 

Feminine hygiene is generally performed while on or near the toilet, so at this point in the interview, it may be convenient to inquire about problems with the use of sanitary napkins or tampons. 


We dress to go out into the world: to be employed in the workplace, to dine in restaurants, to be entertained in public places, and to visit friends. Even at home, convention dictates that we dress to entertain anyone except close friends and family. We dress for protection, warmth, self-esteem, and pleasure. Dependency in dressing obviously results in a severe limitation to personal independence and should be investigated thoroughly during the rehabilitation interview. 

Representative questions include the following: 

  1. Do you dress daily? 
  2. What articles of clothing do you regularly wear? 
  3. Do you require assistance putting on or taking off your underwear, shirt, slacks, skirt, dress, coat, stockings, panty hose, shoes, tie, or coat? 
  4. Do you need help with buttons, zippers, hooks, snaps, or shoelaces? 
  5. Do you use clothing modifications? 

Bed Activities

The most basic stage of functional mobility is independence in bed activities. The importance of this functional level should not be underestimated. Persons who cannot turn from side to side to redistribute pressure and periodically expose skin to the air are at high risk of developing pressure sores over bony prominences and skin maceration from heat and occlusion. For the person who cannot stand upright to dress, bridging (lifting the hips off the bed in the supine position) will allow the donning of underwear and slacks. Independence is likewise enhanced by an ability to move between a recumbent position and a sitting position. Sitting balance is required to accomplish many other activities of daily living, including transfers. 

Representative questions include the following: 

  1. Can you turn onto your front, back, and sides without assistance? 
  2. Can you lift your hips off the bed when supine? 
  3. Do you need help to sit or lie down? 
  4. Do you have difficulty maintaining a seated position? 
  5. Can you operate the bed controls on an electric hospital bed? 


The second stage of functional mobility is independence in transfers. Skills to move between a wheelchair and the bed, toilet, bath bench, shower chair, standard seating, or car seat often serve as precursors to independence in other areas. Although a male patient can use a urinal to void without transferring, a female patient cannot be independent in bladder care without the ability to transfer to the toilet and will probably require an indwelling catheter. Travel by airplane or train is difficult without the ability to transfer from the wheelchair to other seating. Bathing or showering is not independent without the ability to move to the bath bench or shower chair. The inability to transfer to a car seat precludes the use of a motor vehicle with standard seating. Also included in this category is the ability to move from a seated position to a standing position. Low seats without arm supports present a much greater problem than straight-backed chairs with arm supports. 

Representative questions include the following: 

  1. Can you move to and from the bed, toilet, bath bench, shower chair, standard seating, or car seat and the wheelchair without assistance? 
  2. Can you get out of bed without difficulty? 
  3. Do you require assistance to rise to a standing position from low or high seats? 
  4. Can you get on and off the toilet without help? 


Wheelchair Mobility 

Although wheelchair independence is more likely than walking to be inhibited by architectural barriers, it provides excellent mobility for the nonwalking person. With today's manual wheelchairs of lightweight materials and efficient engineering, the energy expenditure of wheeling on flat ground is only slightly greater than that of walking. With the addition of a motorized drive, battery power, and controls for speed and direction, a wheelchair can be propelled even by a person without the upper extremity strength necessary to propel a manual wheelchair and, thus, can help maintain independence in mobility. 

Quantification of manual wheelchair skills can be accomplished several ways. Patients may report in feet, yards, meters, or city blocks the distance they are able to traverse before resting. Alternatively, the number of minutes they can continuously propel the chair can be specified, or the environment in which they are able to use the chair can be described (e.g., within a single room, around the house, or throughout the community). 

Representative questions include the following: 

  1. Do you propel a wheelchair? 
  2. Do you need help to lock the wheelchair brakes before transfers? 
  3. Do you require assistance to cross high-pile carpets, rough ground, or inclines? 
  4. How far or how many minutes can you wheel before you must rest? 
  5. Can you move independently about your living room, bedroom, and kitchen? 
  6. Do you go out to stores, to restaurants, and to friends' homes? 

With any of these functional levels of wheelchair mobility, patients should be asked what keeps them from going farther and whether help is needed to lift the wheelchair into an automobile. 


The final level of mobility is ambulation. In the narrow sense of the word, ambulation is walking, and we have used this definition to simplify the following discussion. However, within the sphere of rehabilitation, ambulation may be any useful means of movement from one place to another. In the view of many rehabilitation professionals, the person with a bilateral above-knee amputation ambulates with a manual wheelchair, the patient with C-4 tetraplegia ambulates with a motorized wheelchair, and the survivor of polio in an underdeveloped country might ambulate by crawling. To some, driving a motor vehicle also is a form of ambulation. Ambulation ability can be quantified the same way wheelchair mobility is quantified. Persons may report the distance they are able to walk, the duration between necessary rest periods, or the scope of the environment within which they walk. 

Representative questions include the following: 

  1. Do you walk unaided? 
  2. Do you use a cane, crutches, or a walker to walk? 
  3. How far or how many minutes can you walk before you must rest? 
  4. What stops you from going farther? 
  5. Do you feel unsteady, or do you fall? 
  6. Can you go upstairs and downstairs unassisted? 
  7. Do you go out to stores, to restaurants, and to friends' homes? 
  8. Can you use public transportation (e.g., bus, subway) without assistance? 

Operation of a Motor Vehicle 

In the perception of many patients, full independence in mobility is not attained without the ability to operate a motor vehicle independently. Although driving skills are by no means necessary for urban dwellers with readily available public transportation, they may be essential to persons living in a suburban or rural environment. Driving skills should always be assessed in patients of driving age. 

Representative questions include the following: 

  1. Do you have a valid driver's license? 
  2. Do you own a car? 
  3. Do you drive your car to stores, to restaurants, and to friends' homes? 
  4. Do you drive in heavy traffic or over long distances? 
  5. Do you use hand controls or other automobile modifications? 
  6. Have you been involved in any motor vehicle accidents or received any citations for improper operation of a motor vehicle since your illness or injury? 


Source: Physical Medicine and Rehabilitation - Principles and Practice

Tiếng Việt >>

Ordinarily, the patient history is obtained in an interview of the patient by the physician. If communication disorders and cognitive deficits are encountered during the rehabilitation evaluation, additional collaborative information must be obtained from significant others accompanying the patient. The spouse and family members are valuable resources. The physician also may find it necessary to interview other caregivers, such as paid attendants, public health nurses, and home health agency aides. 

The major components of the history are the chief report of symptoms, history of the present illness, functional history, past medical history, review of systems, patient profile, and family history. 

Chief Report of Symptoms 

The goal in assessing the chief report of symptoms is to document the patient's primary concern in his or her own words. The report often is an impairment in the form of a symptom that implies a certain disease or group of diseases. The report of “chest pain when I walk up a flight of stairs” suggests cardiac disease, and a report that “ my hands ache and go numb when I drive” hints at carpal tunnel syndrome. 

Of equal importance is recognition that a chief report of lost function also may be the first implication of a disability or handicap. The homemaker's report that “my balance has been getting worse and I've fallen several times” may be related to disease involving the vestibular system and to disability created by unsafe ambulation. Similarly, the farmer's declaration that “I can no longer climb up onto my tractor” not only suggests a neuromuscular or orthopedic disease but also conveys to the physician that the disorder has resulted in a handicap by virtue of the patient's inability to accomplish vocational expectations. 

History of the Present Illness 

The history of the present illness is obtained when the patient tells the story of the medical predicament. All physicians at some time during their medical education have no doubt been admonished to “listen to your patients, for they will tell you their diagnosis” Few maxims are so true. When necessary, patients should be asked to define the specific words they use. It is often surprising to find out what “numbness” or “weakness” really means. Specific questions relating to a particular symptom may also help focus the interview. Using these techniques, the physician gently guides the patient to follow a chronological sequence and to describe fully the symptoms and their consequences.  

Above all, the patient should be allowed to tell the story. More than one symptom may be elicited during the interview, and the physician should document each problem in an orderly fashion (Table 1-2) (1). 

TABLE 1-2. Analysis of Symptoms
1. Date of onset  

2. Character and severity  

3. Location and extension  

4. Time relationships  

5. Associated symptoms  

6. Aggravating and alleviating factors  

7. Previous treatment and effects  

8. Progress, noting remissions and exacerbations  

A complete list of current medications should be obtained. Polypharmacy is encountered commonly in people with chronic disease, at times with striking adverse effects. Side effects of medications can further impede cognition, psychological state, vascular reflexes, balance, bowel and bladder control, muscle tone, and coordination already impaired by the present illness or injury. 

The history of the present illness should include a record of handedness, which is important in many areas of rehabilitation. 


Source: Physical Medicine and Rehabilitation - Principles and Practice

Tiếng Việt >>

As with other branches of medicine, the cornerstone of rehabilitation medicine is a meticulous and germane patient evaluation. Therapeutic intervention must be based on proper patient assessment. The disability cannot be isolated from preexisting and concurrent medical problems. Although the rehabilitation evaluation encompasses all elements of the general medical history and physical examination, its scope is more comprehensive; thus, the rehabilitation evaluation provides a broader perspective. 

Evaluation of Function 

Medical diagnosis concentrates on the historical clues and physical findings that lead the examiner to the correct identification of disease. After the medical diagnosis is established, the rehabilitation physician must then ascertain the functional consequences of disease that constitute the rehabilitation diagnosis. An adept functional assessment requires the examiner to have a clear understanding of the distinctions among disease, impairment, disability, and handicap. 

If the disease cannot be challenged directly through medical or surgical means, measures are used to minimize the impairment. For example, a weak muscle can be strengthened or a hearing impairment can be minimized by an electronic aid. With chronic disorders, disease and impairment are not reducible; hence, intervention must address the disability and the handicap. The identification of intact functional capabilities is essential to successful rehabilitation. When intact capabilities can be augmented and adapted to new uses, functional independence can be enhanced. 

Case 1 

AW had gained much enjoyment and self-esteem as a competitive runner before his spinal cord injury. During and after inpatient rehabilitation, he vigorously pursued a cardiovascular and upper extremity conditioning program. After obtaining an ultra-lightweight sport wheelchair, he resumed competitive athletics as a wheelchair racer, winning several regional races. 

Comment: AW's intact capabilities included normal arm strength, a competitive spirit, and self-discipline. Through augmentation and adaptation, he regained enjoyment and self-esteem in his athletic endeavors. 

Despite their best efforts, physicians are occasionally unable to ascertain the specific disease responsible for a patient's constellation of historical, physical, and laboratory findings. Medical management must then be symptomatic. Although highly desirable, diagnosis is not a necessary prerequisite to the identification and subsequent management of functional loss. To determine expectations of future disease activity based on past activity, the rehabilitation physician should attempt to characterize historically the temporal nature of the disease process. 


FZ, a 62-year-old woman, presented with difficulty climbing stairs. Questioning revealed that she and her husband had been in the habit of taking a 30-minute evening walk for many years, but 2 years earlier, fatigue began to limit her to no more than a few blocks. During the previous year, she had had difficulty rising from low seating, and 6 months previously, she reluctantly quit taking walks. During the preceding few weeks, she had found that climbing stairs was a burden, and she had started taking showers because she needed assistance getting out of the bathtub. 

FZ reported no sensory deficits. Physical examination showed hypotonic muscle stretch reflexes and predominantly proximal muscle weakness. Electrodiagnostic studies and muscle biopsy demonstrated a noninflammatory myopathy; however, further extensive evaluation failed to determine a cause. FZ was provided with a bath bench, a toilet seat riser, a lightweight folding wheelchair for long-distance mobility, and a cane for short distances. She was instructed in safe ambulation with the cane, operation of the wheelchair, energy conservation techniques, and the proper placement of bathroom safety bars. Safe automobile operation was documented, and she was provided with a handicapped parking sticker. The philosophy of rehabilitation medicine concerning her potentially progressive muscle weakness was discussed with her, and she was given supportive counseling. 

When FZ returned for a follow-up examination 1 month later, muscle testing showed only slight progression of her weakness, and her functional capabilities had not changed. Another follow-up examination was scheduled for 6 weeks later. 

Comment: Although a specific diagnosis was not established, rehabilitation intervention specific to FZ's functional losses was accomplished. Such extrapolation is not always accurate; however, serial evaluations performed at regular follow-up intervals allow the rehabilitation physician to identify and minimize future functional loss. 

Comprehensiveness of Evaluation

Unlike some medical specialties, rehabilitation medicine is not limited to a single organ system. Attention to the whole person is a rehabilitation absolute. The goal of the rehabilitation physician is to restore handicapped people to the fullest possible physical, mental, social, and economic independence; this requires analysis of a diverse aggregate of information. Consequently, the person must be evaluated in relation not only to the disease but also to the way the disease affects and is affected by the person's family and social environment, vocational responsibilities and economic state, avocational interests, hopes, and dreams. 


CC, a 63-year-old piano tuner, had a left cerebral infarction manifested only as minimal dysfunction of the dominant right hand. Despite demonstrating discrete digit function in the involved hand on physical examination, he was psychologically devastated to find that he could no longer accomplish the fine but elegant motor patterns necessary to continue in his profession. 

BD, a 63-year-old corporate attorney, had a left cerebral infarction resulting in severe spastic weakness of his nondominant upper extremity. He did some paperwork every day during his inpatient rehabilitation and returned to full-time employment shortly after completing treatment. 

Comment: For each person, the degree of impairment has little or no relationship to the severity of resultant disabilities and handicaps. 

Interdisciplinary Nature of Evaluation

Although most of this chapter addresses the patient history and physical examination as they relate to the rehabilitation evaluation, these are only part of the comprehensive rehabilitation assessment. This statement is not meant to deprecate the usefulness of these traditional tools of the physician. Both are of critical importance and serve as the basis for further evaluation; yet, by their nature, they also are limited. Speech and language disorders can inhibit communication. Subjective interpretation of the facts by the patient and the family can cloud the objective assessment of function. Performance is not assessed optimally by interview. 

For example, inquiring about ambulation skills during the interview may identify a potential problem, but such skills can be assessed objectively and reliably only by having the physician and physical therapist observe the patient during ambulation in various situations. Likewise, the occupational therapist must assess the performance of activities of daily living, and the rehabilitation nurse must assess the safety and judgment of the patient while in the ward. The speech therapist furnishes a measured assessment of language function and, through special communication skills, may obtain information from the patient that was missed during the interview. The rehabilitation psychologist provides a quantified and standardized assessment of cognitive and perceptual function and a skilled assessment of the patient's current psychological state. Through interaction with the patient's family and employer, the social worker can provide useful information that is otherwise unavailable regarding the patient's social support system and economic resources. The concept of the rehabilitation team applies not only to evaluation of the patient but also to ongoing management of the rehabilitation process. 

Setting and Purpose 

Because of the expanding scope of rehabilitation medicine, the evaluation setting can be diverse. A necessary corollary to the setting is the purpose of the evaluation. Both the setting and the purpose will affect the format and extent of the evaluation. Traditionally, the inpatient rehabilitation unit has been the optimal setting for a comprehensive evaluation by the entire rehabilitation team. However, in these days of increasing medical costs and intervention by the government and other third-party payers, creativity must be used to accomplish comprehensive rehabilitation evaluations in the clinic and elsewhere in the community (Table 1-1). 


Source: Physical Medicine and Rehabilitation - Principles and Practice

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