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.
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.
CASE 3 AND 4
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).