THE PHYSIATRIC HISTORY AND PHYSICAL

EXAMINATION

Initial evaluation  more detailed & comprehensive than subsequent / follow-up evaluations.
Exception : when a patient is seen for a follow-up visit with new signs/symptoms.
Physiatric H&P  traditional format + additional emphasis on history, signs, symptoms that affect
function (performance).
 also identifies those systems not affected that might be used for compensation.
Identifying & treating primary impairments to maximize performance
The Physiatric History
 Recognition of functional deficits caused by illness/injury  design of a treatment program to
restore performance.
 E.g. In a person with stroke : most important questions not just etiology/location of lesion but also
“What functional deficits are present as a result of stroke?” The answer : deficits in swallowing,
communication, mobility, cognition, ADL, or combination.
 Establishing rapport & trust (learn about sensitive areas), Assessing the tone of patient and/or
family (such as anger, frustration, resolve, determination), understanding of illness, insight into
disability, coping skills.

Chief Complaint
 symptom / concern that caused patient to seek medical treatment.
 Outpatient : pain, weakness, gait disturbance of various musculoskeletal / neurologic origins.
 Inpatient : mobility, ADL, communication, cognitive deficits & candidacy for inpatient rehab.
 specific circumstance of a patient offering a chief complaint  can also allude to a degree of
disability/handicap  example, obese mail carrier with chief complaint of difficulty in walking
because of knee pain could suggest not only impairment but also impact on his vocation & role as a
provider for his family (participation, handicap).

History of the Present Illness

details the chief complaint & any related/unrelated functional deficits, other information relating to
chief complaint (recent & past medical/surgical procedures, complications of treatment, potential
restrictions/precautions).
 include some/all of 8 components related to chief complaint: location, time of onset, quality,
context, severity, duration, modifying factors, associated signs&symptoms.
 Example: 70-year-old man referred by neurologist for physical therapy because cannot walk
properly (chief complaint). Over past few months (duration), slowly progressive weakness of his
left leg (location). Subsequent workup suggested amyotrophic lateral sclerosis (context). patient
was active in his life & working up until a few months previously, ambulating without an assistive
device (context). Now he uses straight cane for fear of falling (modifying factor). Besides difficulty
with walking, patient also has some trouble swallowing foods (associated signs&symptoms).

Functional Status
 Detailing current & prior functional status  better understanding issues surrounding mobility,
ADL, instrumental activities of daily living (I-ADL), communication, cognition, work, recreation, etc
 guide PE & develop treatment plan with reasonable short- & long-term goals.
 Assessing potential for functional gain / deterioration : requires understanding of natural history,
cause, time of onset of functional problems (example, most spontaneous motor recovery after Mobility
stroke occurs within 3 months of event. Recent stroke patient with considerable motor impairment Mobility : ability to move about in one’s environment.
↑ expectation for significant functional gain than in a patient with minor deficits related to a Functional mobility  independence & safety, including the use of / need for mobility assistive
stroke that occurred 2 years ago). devices (crutches, canes, walkers, orthoses, manual & electric wheelchairs)
 Functional Independence Measure (FIM) : most commonly used in inpatient rehabilitation setting.
Measuring only activity limitation (disability) / performance, each of 18 different activities is
scored on a scale of 1 to 7. Intermediate scores indicate varying levels of assistance from very little
(from an assistive device, to supervision, to hands-on assistance) to a score of 1 indicating
complete dependence on caregiver assistance.
 Driving
 means of transportation, indicator & facilitator of independence (example: elders who stop driving
have ↑ depressive symptoms).
 factors that might prevent driving: ↓cognitive function & safety awareness, ↓vision/reaction time
 Other factors: lower limb weakness, contracture, tone, dyscoordination  Some might require use
of adaptive hand controls for driving.
 Cognitive impairment affect ability to drive: due to medications/organic disease (dementia, brain
injury, stroke, severe mood disturbance)  risks of driving > consequences of not able to drive.
 If patient not able to drive alternatives should be explored: use of public/assisted transportation

Activities of Daily Living and Instrumental Activities of Daily Living

ADL  activities required for personal care : feeding, dressing, grooming, bathing, toileting.
I-ADL  more complex tasks required for independent living in immediate environment : care of
others in household, telephone use, meal preparation, house cleaning, laundry, & in some cases use of
public transportation.
 Identify & document ADL can & cannot perform, determine causes of limitation.
 Example: a woman with stroke might state that she cannot put on her pants  could be due to a
combination of factors such as a visual field cut, balance problems, weakness, pain, contracture,
hypertonia, or deficits in motor planning  Some of these factors can be confirmed later in PE.
 A more detailed follow-up to a positive response to the question is frequently needed. (example:
patient might say “yes” to “Can you eat by yourself?”  further questioning, it might be learned
that she cannot prepare food by herself / cut food independently.

Bed mobility
 turning from side to side, going from prone to supine positions, sitting up, lying down.
 lack  greater risk for skin ulcers, deep vein thrombosis, pneumonia.
 In severe cases  bed mobility can be so poor as to require a caregiver.
In other cases  bed rails to facilitate movement.
 Transfer mobility : getting in&out of bed, standing from sitting position (whether from a chair /
toilet), moving between a wheelchair & another seat (car seat / shower seat).
 assess the level of independence, safety, any changes in functional ability.
Wheelchair mobility
 if patients can propel wheelchair independently, how far / how long can go without resting,
whether they need assistance with managing wheelchair parts.
 the extent to which they can move about at home, in community, up&down ramps.
 in cases of new onset of severe disability  Whether the home is potentially wheelchair-accessible
Ambulation
 how far / for how long patients can walk, whether require assistive devices, need for rest breaks.
 any symptoms associated with ambulation: chest pain, shortness of breath, pain, dizziness.
 history of falling / instability while walking, ability to navigate uneven surfaces.
 Stair mobility, along with the number of stairs patient must routinely climb & descend at home / in
community, presence/absence of handrails.
Cognition
 mental process of knowing
 objective assessment : PE (memory, orientation, ability to assimilate & manipulate information),
history taking.
 persons with cognitive deficits often cannot recognize their own impairments (anagnosia) 
gather information from family members & others familiar.
 Cognitive deficits & limited awareness  interfere with patient’s rehabilitation program unless
specifically addressed, safety risk.
 Executive functioning : another aspect of cognition, includes mental functions required for
planning, problem solving, self-awareness.  correlates with functional outcome
Communication
 to convey information including thoughts, needs, emotions.
 Verbal expression deficits  subtle & might not be noticed in 1st encounter.
 If speech / communication has been affected by a recent event  ask family members if they have
noticed recent changes.
 Patients who cannot communicate through speech might/might not be able to communicate
through other means  augmentative communication, depending on the type of communication
dysfunction and & physical and cognitive limitations  writing & physicality (sign language,
gestures, body language), augmentative communication aids from simple picture, letter, word
boards to electronic devices.
Past Medical and Surgical History
 allows physiatrist to understand how preexisting illnesses affect current status, how to tailor the
rehabilitation program for precautions & limitations.
Cardiopulmonary
 can severely compromise Mobility, ADL, I-ADL, work, leisure.
 history of CHF, recent & distant myocardial infarction, arrhythmias, coronary artery disease.
 Past surgical procedures (bypass surgery, heart transplantation, stent placement) & recent
diagnostic testing (stress test / ECG).  to ensure that exercise prescriptions do not exceed
cardiovascular activity limitations.
 activity tolerance, surgery (lung volume reduction/lung transplant), if require home oxygen.
 modifiable risk factors for cardiac disease: smoking, hypertension, obesity.
Musculoskeletal
 from acute traumatic injuries to gradual functional decline with chronic osteoarthritis.
 history of trauma, arthritis, amputation, joint contractures, musculoskeletal pain, congenital/
acquired muscular problems, weakness, instability.
 Patients with chronic physical disability  develop overuse musculoskeletal syndromes, such as
development of shoulder pain secondary to chronically propelling a wheelchair.
Neurologic Disorders
 Preexisting congenital/acquired neurologic disorders  impact on patient’s function & recovery
from both neurologic & nonneurologic illness.
 neurologic disorder : congenital vs acquired, progressive vs nonprogressive, central vs peripheral,
demyelinating vs axonal, sensory vs motor.  understanding pathophysiology, location, severity,
prognosis, implications for management.
 premorbid need for assistive device, orthoses, degree of speech, swallowing, cognitive impairment
Rheumatologic
 type of rheumatologic disorder, time of onset, number of joints affected, pain level, current disease
activity, past orthopedic procedures.
 whether medication changes could improve activity tolerance in a rehabilitation.
Medications
 prescription, OTC drugs, nutraceuticals, supplements, herbs, vitamins.
 Drug & food allergies
 nonsteroidal anti-inflammatory agents  commonly prescribed by physiatrists for
musculoskeletal disorders, care must be taken not to double-dose the patient.
 indications, precautions, side effects of all drugs prescribed should be explained to patient.
Social History
Home Environment and Living Situation
 home environment & living situation : lives in a house / apartment, elevator access, wheelchair
accessible, stairs, bathroom accessible from bedroom, bathroom has grab bars/handrails (on
which side).
 If no caregiver at home  home health aide.
Family and Friends Support
 Patients who have lost function  require supervision, emotional support, / physical assistance.
(Family, friends, neighbors)  level of assistance they are willing and able to provide.
Substance Abuse
 history of smoking, alcohol use/abuse, drug abuse.
 can be direct & indirect cause of disability, often a contributing factor in traumatic brain injury.
 patients with pain and/or depression are at risk for further abuse  referred to social work
Sexual History
 easier if practitioner has basic knowledge of how sexual function can be changed by illness/injury.
 important to patients in reproductive years (ex: with many spinal cord– & brain-injured persons),
Vocational Activities
 source of financial security; relates to self-confidence & identity.
 education, recent work history, ability to fulfill job requirements subsequent to injury/illness.
 If cannot fully regain previous function level  vocational options available should be explored.
 work environment can be modified to compensate for functional loss / ↓musculoskeletal pain
complaints. (ex: installation of a wheelchair ramp for accountant with paraplegia)
Finances and Income Maintenance
 financial concerns due to / exacerbated by illness/injury.
 financial resources / insurance to pay for adaptive devices (a
ramp / mobility equipment).
 If patients cannot safely be discharged home  skilled nursing
facility placement.
Recreation
 ability to engage in hobbies & recreational activities  any
loss/limitation can be stressful.
 primary outcome in sports medicine.
 recreational activity affected : physical exercise (sporting), or
more sedentary (playing cards)
Psychosocial History
 patient can also feel a loss of overall health, body image,
mobility, or independence.
 loss of function & possibly of income as well  great stress on
family unit & caregivers.
Spirituality and Belief
 important part of many patients, can have positive effects on
rehab, life satisfaction, quality of life.
Pending Litigation
 whether they are involved in litigation related to their illness,
injuries, or functional impairment.
 The answer should not change treatment plan, but litigation can
be a source of anxiety, depression, or guilt.
Family History
 the health, or cause&age of death, of parents and siblings 
ability to provide functional assistance
 family history of heart disease, diabetes, cancer, stroke, arthritis,
hypertension, neurologic illness.  identify genetic disorders
within family.
Review of Systems The Physiatric Physical Examination
Neurologic Examination
 confirm/reconfirm neurologic disorder, identify which
components of nervous system are the most & least affected.
 precise location of lesion, the impact of neurologic deficits on
overall function & mobility of patient
 If cause of patient’s condition has not been identified 
differential diagnosis, neurologic examination, consultations
 Weakness : primary sign in neurologic disorders, seen in both
UMN & LMN disorders.
 UMN lesions involving CNS
- hypertonia, weakness, hyperreflexia without significant
muscle atrophy, fasciculation, / fibrillation (on EMG).
- tend to occur in a hemiparetic, paraparetic, tetraparetic
pattern.
- etiologies : stroke, multiple sclerosis, traumatic&nontraumatic
brain & spinal cord injuries, neurologic cancers, etc.
 LMN defects
- hypotonia, weakness, hyporeflexia, significant muscle atrophy,
fasciculations, electromyographic changes.
- occur in the distribution of affected nerve root, peripheral
nerve, /muscle.
- UMN and LMN lesions often coexist  however, LMN system
is final common pathway of nervous system  example: an
upper trunk brachial plexus injury on the same side as spastic
hemiparesis in a person with traumatic brain injury.
 testing of 1 neurologic system is often predicated by normal
functioning of other systems.  example: severe visual
impairment can be confused with cerebellar dysfunction, as
many cerebellar tests have a visual component  integrated
functions of all organ systems should be considered to provide
accurate clinical assessment.
Mental Status Examination
 MSE should be performed in a comfortable setting where
patient is not likely to be disturbed by external stimuli such as
televisions, telephones, pagers, conversation, or medical alarms.
 Language is gateway to assessing cognition  limited in persons
with significant aphasia.
Level of Consciousness
 Consciousness = state of awareness of one’s surroundings.
 A functioning pontine reticular activating system is necessary
for normal conscious functioning.
 conscious patient is awake & responds directly & appropriately
to varying stimuli.
 ↓ consciousness can significantly limit MSE & general PE.
 various levels of consciousness:
- Lethargy : general slowing of motor processes (speech,
movement)  patient can easily fall asleep if not stimulated,
but is easily aroused.
- Obtundation : dulled/blunted sensitivity  patient is difficult
to arouse, once aroused is still confused.
- Stupor : state of semiconsciousness characterized by arousal
only by intense stimuli such as sharp pressure over a bony
prominence (e.g., sternal rub), patient has few/even no
voluntary motor responses.
 severe alterations in consciousness:
- coma  eyes are closed with absence of sleep-wake cycles &
no evidence of a contingent relationship between patient’s
behavior & environment.
- Vegetative state  presence of sleep-wake cycles but still no
contingent relationship.
- Minimally conscious state  remains severely disabled but
demonstrates sleep-wake cycles & inconsistent, nonreflexive,
contingent behaviors in response to a specific environmental
stimulation.
 In acute settings  GCS most often used to document level of
consciousness
Attention
 Attention = ability to address a specific stimulus for a short
period without being distracted by internal/external stimuli.
 Vigilance = ability to hold attention over longer periods.
 Example: with inadequate vigilance a patient can begin a
complex task but unable to sustain performance to completion.
 Attention is tested by digit recall  examiner reads a list of
random numbers & patient is asked to repeat those numbers
(patient should repeat digits both forward&backward) 
normal performance is repeating 7 numbers in forward
direction, <5 indicating significant attention deficits.
Orientation
 necessary for basic cognition.
 composed of 4 parts : person, place, time, situation.
 patient’s name, location the patient is currently in / home
address, time of day/date/day of week/year, why the patient is
in hospital/clinic.
 Time sense is usually 1st component lost, person is typically the
last to be lost.
 Temporary stress can account for a minor loss of orientation 
major disorientation usually suggests organic brain syndrome.
Memory
 components : learning, retention, recall.
 asked to remember 3-4 objects/words  repeat the items
immediately to assess immediate acquisition (encoding) of
information.
 Retention : recall after a delayed interval, usually 5-10 minutes.
 If patient is unable to recall: examiner can provide a prompt
 If still cannot recall: examiner can provide a list  Although
abnormal scores must be interpreted within context of
remaining neurologic examination, normal individuals < 60
years should recall 3 of 4 items.
 Recent memory  asking about past 24 hours, “How did you
travel here?” / “What did you eat for breakfast?”
 Remote memory  asking where the patient was born/school
 Visual memory  identify (after a few minutes) 4 or 5 objects
hidden in clear view.
General Fundamentals of Knowledge
 Intelligence : global function derived from general tone&content
of exam & encompasses both basic intellect & remote memory
 Examples of questions : names of important elected officials,
current president/recent past presidents
 can be very difficult when a patient with a very high intelligence
premorbidly drops to a more average level after injury/illness.
Abstract Thinking
 Abstraction : higher cortical function, can be tested by
interpretation of common proverbs / asking similarities /
understands humorous phrase or situation
 Most normal individuals  able to provide abstract responses.
 Concrete responses are given by persons with dementia, mental
retardation, or limited education.
Insight and Judgment
Insight
 3 components: awareness of impairment, need for treatment,
attribution of symptoms.
 asking what brought the patient into hospital/clinic.
 Recognizing that one has an impairment is initial step for
recovery  lack of insight can severely hamper a patient’s
progress in rehabilitation.
Judgment
 estimate of a person’s ability to solve real-life problems.
 best indicator : observing patient’s behavior.
 noting patient’s responses to hypothetical situations in relation
to family, employment, /personal life.
 complex function that is part of maturational process 
unreliable in children & variable in adolescent years.
Mood and Affect
Mood
 asking “Yale question”: “Do you often feel sad /depressed?” 
information pertaining to length of particular mood
 if the mood has been reactive (sadness in response to a recent
disabling event / loss of independence), whether the mood has
been stable/unstable.
 can be described in terms of being: happy, sad, euphoric, blue,
depressed, angry, anxious.
Affect
 describes how a patient feels at a given moment: blunted, flat,
inappropriate, labile, optimistic, pessimistic.
 It can be difficult to accurately assess mood in the setting of
moderate to severe acquired brain injury.
 A patient’s affect is determined by the observations made by the
examiner during the interview.
General Mental Status Assessment
 Folstein Mini- Mental Status Examination
- test general cognitive function.
- for screening dementia & brain injuries.
- Of maximum 30 points, a score ≥24 within normal range.
 Montreal Cognitive Assessment.
 Clock-drawing test
- patient is instructed to “Without looking at your watch, draw
face of a clock, mark hands to show 10 minutes to 11 o’clock.”
- uses memory, visual spatial skills, executive functioning.
- drawing is scored : whether clock numbers are generally
intact/not intact out of a maximum score of 10.
 Threeword recall test + clock-drawing test  Mini-Cog Test
Communication
Aphasia
 loss of production / comprehension of language.
 cortical center for language : in dominant hemisphere.
 Naming, repetition, comprehension, fluency  listen to content
& fluency of speech.
 Testing of comprehension of spoken language : begin with single
words, then sentences that require only yes–no responses, then Cognitive Linguistic Deficits
progress to complex commands.  also assess visual naming,
repetition of single words&sentences, word-finding abilities,
reading&writing from dictation & then spontaneously.
 Circumlocutions : phrases/sentences substituted for a word the
person cannot express, ex responding “What you tell time with
on your wrist” when asked to name a watch.
 Alexia without agraphia : in dominant occipital lobe injury 
patient is able to write letters&words from a spoken command
but is unable to read the information after dictation.
 commonly used standardized aphasia measures : Boston
Diagnostic Aphasia Examination & Western Aphasia Battery
Dysarthria
 defective articulation, but with content of speech unaffected.
 listen to spontaneous speech, then ask patient to read aloud.
 Key sounds that can be tested : “ta ta ta,” which is made by the
tongue (lingual consonants); “mm mm mm,” which is made by
lips (labial consonants); “ga ga ga,” which is made by larynx,
pharynx, palate.
 subtype of dysarthria : spastic, ataxic, hypokinetic, hyperkinetic,
flaccid.
Dysphonia
 deficit in sound production, can be secondary to respiratory
disease, fatigue, /vocal cord paralysis.
 best method to examine vocal cords : indirect laryngoscopy.
 Asking patient to say “ah” while viewing the vocal cords  to
assess vocal cord abduction. When patient says “e,” vocal cords
will adduct.
 Patients with weakness of both vocal cords  speak in whispers
with presence of inspiratory stridors.
Verbal Apraxia
 involves a deficit in motor planning (i.e., awkward & imprecise
articulation in the absence of impaired strength/coordination of
motor system).
 characterized by inconsistent errors when speaking.
 A difficult word might be spoken correctly, but trouble is
experienced when repeating it.
 often appear to be “groping” for right sound/word, & might try
to speak a word several times before saying it correctly.
 ask patient to repeat words with increasing number of syllables.
 Oromotor apraxia : difficulty organizing nonspeech, oral motor
activity.  can adversely impact swallowing
- Tests : asking patients to stick out tongue, show their teeth,
blow out their cheeks, /pretend to blow out a match.
 involve pragmatics & context of communication.
 Examples : confabulation after a ruptured aneurysm of anterior
communicating artery, disinhibited/sexually inappropriate
comments from a patient with frontal lobe damage after a
traumatic brain injury.
 distinguished from fluent aphasias (Wernickeʼs) by : presence of
relatively normal syntax & grammar.
Cranial Nerve Examination
CN I: Olfactory Nerve
 test both perception & identification of smell using aromatic
nonirritating materials that avoid stimulation of trigeminal
nerve fibers in nasal mucosa.
 Irritant substances (ammonia) should be avoided.
 close eyes while opposite nostril is compressed separately 
patient should identify smell in a test tube containing a common
substance with a characteristic odor (coffee, peppermint, soap).
 most commonly injured cranial nerve (CN) in head trauma,
resulting from shearing injuries that can be associated with
fractures of cribiform plate.
CN II: Optic Nerve
 testing for visual acuity & visual fields, by performing
ophthalmologic examination.
 Visual acuity  central vision; visual field  assess integrity of
optic pathway as it travels from retina to primary visual cortex.
 Testing visual fields by confrontation  most common
- patient faces examiner while covering 1 eye so the other eye
fixates on opposite eye of examiner directly in front.
- examiner wiggles a finger at outer boundaries of 4 quadrants
of vision while patient points to the quadrant where he/she
senses movement.  More accurately, red 5-mm pin can be
used to map out visual field.
 visual field&extraocular movement deficitsfurther assessment
by neurooptometrist / visually trained occupational therapists
CN III, IV, VI: Oculomotor, Trochlear, Abducens Nerves
 best tested together because they all involved in ocular motility.
 oculomotor nerve (III)
- innervation to all extraocular muscles except superior oblique
& lateral rectus [innervated by trochlear (IV) & abducens
nerves (VI), respectively]
- also innervates levator palpebrae muscle (elevates eyelid),
pupilloconstrictor muscle (constricts pupil), ciliary muscle
(controls the thickness of lens in visual accommodation).
 primary action of medial rectus  adduction (looking in);
lateral rectus  abduction (looking out).
 superior rectus & inferior oblique  elevate eye;
inferior rectus & superior oblique  depress eye.
 superior oblique muscle  controls gaze looking down,
especially in adduction.
 Examination of extraocular muscles : assessing alignment of
patient’s eyes while at rest & when following an object/finger
held at an arm’s length.  observe the full range of horizontal &
vertical eye movements in 6 cardinal directions
 optic (afferent) & oculomotor (efferent) nerves  involved with
pupillary light reflex.  normal pupillary light reflex (CN II &
III) should result in constriction of both pupils when a light
stimulus is present to either eye separately.
 A characteristic head tilt when looking down is sometimes seen
in CN IV lesions.
CN V: Trigeminal Nerve
 provides sensation to face & mucous membranes of nose,
mouth, tongue.
 3 sensory division : ophthalmic, maxillary, mandibular branches.
 can be tested by pinprick sensation, light touch, temperature
along the forehead, cheeks, jaw on each side of face.
 motor branch  also innervates muscles of mastication
(masseters, pterygoids, temporalis).
- clamp the jaws together  examiner will try to open patient’s
jaw by pulling down on lower mandible  observe & palpate
for contraction of both temporalis & masseter muscles.
 - pterygoids are tested by asking patient to open the mouth  If
1 side is weak, the intact pterygoid muscles will push the weak
muscles, resulting in a deviation toward the weak side.
 corneal reflex  tests ophthalmic division of trigeminal nerve
(afferent) & facial nerve (efferent).
CN VII: Facial Nerve
 provides motor innervation to all muscles of facial expression;
provides sensation to anterior 2/3 of tongue & external acoustic
meatus; innervates stapedius muscle, which helps dampen loud
sounds by ↓ excessive movements of ossicles in inner ear;
provides secretomotor fibers to lacrimal & salivary glands.
 first by watching patient as she/he talks & smiles, specifically
for eye closure, flattening of nasolabial fold, asymmetric
elevation of 1 corner of mouth.  then asked to wrinkle
forehead (frontalis), close eyes while examiner attempts to open
them (orbicularis oculi), puff out both cheeks while examiner
presses on cheeks (buccinator), show teeth (orbicularis oris).
 Peripheral injury (eg Bell’s palsy) affects both upper&lower
face, central lesion typically affects mainly lower face.
CN VIII: Vestibulocochlear Nerve (Auditory Nerve)
 2 divisions : cochlear nerve (responsible for hearing), vestibular
nerve (related to balance).
 Cochlear division  checking gross hearing.
rapid screen  examiner rubs thumb & index fingers near each
patient ear  normal hearing have no difficulty hearing this.
 Vestibular  seldom included in routine neurologic exam.
- Patients with dizziness/vertigo associated with changes in
head position / suspected of having BPPV  assessed with
Dix-Hallpike maneuver.
- absence of nystagmus  normal vestibular nerve function.
- peripheral vestibular nerve dysfunction  patient complains
of vertigo, rotary nystagmus appears after 2- to 5-second
latency, toward direction in which the eyes are deviated.
- With repetition of maneuvers  nystagmus & sensation of
vertigo fatigue & ultimately disappear.
- In central vestibular disease (eg from a stroke)  nystagmus
has latency & non-fatigable.
 test strength of trapezius  patient is asked to shrug shoulders
 test strength of sternocleidomastoid muscle  ask patient to
CN XII: Hypoglossal Nerve
Sensory Examination
CN IX & X: Glossopharyngeal Nerve & Vagus Nerve
 glossopharyngeal nerve  taste to posterior 1/3 of tongue,
along with sensation to pharynx & middle ear.
 glossopharyngeal & vagus nerve are usually examined together.
 patient’s voice quality  hoarseness is usually associated with a
lesion of recurrent laryngeal nerve, a branch of vagus nerve.
 open mouth & say “ah”  examiner inspect soft palate, which
should elevate symmetrically with uvula in midline.
- LMN vagus nerve lesion  uvula will deviate to the side that is
contralateral to lesion.
- UMN lesion  uvula deviating toward the side of lesion.
 gag reflex  depressing patient’s tongue with tongue depressor
& touching pharyngeal wall with a cotton tip applicator until
patient gags.
- compare sensitivity of each side (afferent: glossopharyngeal
nerve) & observe the symmetry of palatal contraction
(efferent: vagus nerve).
- absence  loss of sensation and/or loss of motor contraction.
- presence  does not imply ability to swallow without risk of
aspiration
CN XI: Accessory Nerve
 innervates trapezius & sternocleidomastoid muscles.
 standing behind patient, examiner look for atrophy/spasm in
trapezius & compare the symmetry of both sides.
& hold them in this position against resistance (ipsilateral
muscle brings the ear to shoulder)
rotate the head against resistance (ipsilateral muscle turns the
head to contralateral side).
 a pure motor nerve innervating muscles of tongue.
 protrude tongue  note atrophy, fasciculation, deviation.
- Fibrillations  amyotrophic lateral sclerosis.
- peripheral hypoglossal nerve lesions  tongue points to the
side of lesion; UMN lesions such as stroke  toward the
opposite side of lesion.
 normal dermatomal & peripheral nerve sensory distribution.
 Evaluatin: superficial sensation (light touch, pain, temperature)
& deep sensation (involves perception of position & vibration
from deep structures such as muscle, ligaments, bone)
 Light touch  with a fine wisp of cotton / cotton tip applicator.
- examiner touch the skin lightly, avoiding excessive pressure.
- patient is asked to respond when a touch is felt, & say whether
there is a difference between the 2 sides.
 Pain & temperature both travel via spinothalamic tracts  using
a safety pin /other sharp sanitary object.
- Patient w/ peripheral neuropath  delayed pain appreciation
& often change their minds a few seconds after initial stimuli.
- use single/double pinprick of brief duration to test for pain,
continuous sustained pinprick to better test for delayed pain.
- Temperature testing : not often used & rarely provides
additional information, but sometimes easier for patients to
delineate insensate areas.
- Thermal sensation  2 different test tubes, 1 filled with hot
water (not hot enough to burn), 1 filled with cold water
 Joint position sense / proprioception travel via dorsal columns
along with vibration sense.
 Proprioception  tested by vertical passive movement of toes /
fingers.
- examiner holds the sides of patient’s fingers/toes  asks
patient if the digits are the upward/downward direction.
(grasp the sides of digits rather than nailbed, because patient
might be able to perceive pressure in these areas, ↓accuracy)
- Most normal persons make no errors on these maneuvers.
 Vibration  tested in limbs with a 128-Hz tuning fork.
- tuning fork is placed on a bony prominence (dorsal aspect of
terminal phalange of great toe/finger, malleoli, or olecranon)
 patient is asked to indicate when the vibration ceases.
- vibration stimulus can be controlled by changing the force
used to set tuning fork in motion, or by noting amount of time
that a vibration is felt as stimulus dissipates.
- Assuming examiner is normal, both patient & examiner should
feel the vibration cease at the same time.
 Two-point discrimination  using calipers with blunt ends.
- patient is asked to close eyes & indicate if 1 or 2 stimulation
points are felt.
- normal distance of separation that can be felt as 2 distinct
points depends on area of body being tested  lips sensitive
to point separation of 2-3 mm, normally identified as 2 points.
- Commonly tested normal 2-point discrimination areas :
fingertips (3-5mm), dorsum of hand (20-30), palms (8-15mm)
 Graphesthesia : ability to recognize numbers, letters, or symbols
traced onto palm  performed by writing recognizable
numbers on patient’s palm with his/her eyes closed.
 Stereognosis : ability to recognize common objects placed in
hand (such as keys/coins)  requires normal peripheral
sensation & cortical interpretation.
Motor Control
Strength
Manual muscle testing  quantifying strength
Coordination
 Cerebellum controls movement by comparing intended activity
with actual activity that is achieved.
 cerebellum smoothes motor movements & intimately involved
with coordination.
 Ataxia / motor coordination can be secondary to deficits of
sensory, motor, or cerebellar connections  Ataxic patients who
have intact function of sensory&motor pathways usually have
cerebellar compromise.
 Cerebellum 3 areas: midline, anterior lobe, lateral hemisphere.
- Lesions affecting midline  truncal ataxia (patient cannot
sit/stand unsupported)  tested by asking patient to sit at the Involuntary Movements
edge of bed with arms folded so cannot be used for support
- Anterior lobe lesions  gait ataxia (patient is able to sit/stand  Lesions in basal ganglia  characteristic movement disorders.
unsupported but has noticeable balance deficits on walking)
- Lateral hemisphere lesions  limb ataxia (loss of ability to
coordinate movement)  affected limb usually has diminished  Athetosis : twisting & writhing movements, commonly seen in
ability to correct & change direction rapidly.
 Limb coordination tests : finger-to-nose test & heel-to-shin test.
 Rapid alternating movements  tested by observing amplitude,
rhythm, precision of movement.
- patient is asked to place hands on the thighs & then rapidly
turn the hands over & lift them off the thighs for 10 seconds.
- Normal individuals can do this without difficulty.
- Dysdiadochokinesis : inability to perform rapidly alternating
movements.
 Romberg test  to differentiate cerebellar deficit from
proprioceptive one
- patient is asked to stand with the heels together  examiner
notes any excessive postural swaying / loss of balance.
- If loss of balance is present when eyes are open&closed 
cerebellar ataxia.
- If loss of balance occurs only when eyes are closed  positive changes / mood, some patients demonstrate little tone at rest
Romberg sign indicating proprioceptive (sensory) deficit.
Apraxia
 loss of ability to carry out programmed/planned movements
despite adequate understanding of the tasks
 present even though the patient has no weakness / sensory loss
 To accomplish a complex act, there first must be an idea /
formulation of a plan  formulation of plan then must be
transferred into motor system where it is executed.
 examiner watch for motor-planning problems during PE  a
patient might be unable to perform transfers & other mobility
tasks but has adequate strength on formal MMT.
 Ideomotor apraxia : lesion of dominant parietal lobe, patient
cannot carry out motor commands but can perform the required
movements under different circumstances  usually can
perform many complex acts automatically but cannot carry out
the same acts on command.
 Ideational apraxia : inability to carry out sequences of acts,
although each component can be performed separately.
 Other forms of apraxia : constructional, dressing, oculomotor,
oromotor, verbal, gait apraxia.
 Dressing & constructional apraxia : impairments of
nondominant parietal lobe, result of neglect rather than actual
deficit in motor planning.
 Tremor most common type, rhythmic movement of body part.
 Chorea : movements that consist of brief, random, nonrepetitive
movements in a fidgety patient unable to sit still.
cerebral palsy.
 Dystonia : sustained posturing that can affect small / large
muscle groups  example: torticollis, in which dystonic neck
muscles pull the head to 1 side
 Hemiballismus : repetitive violent flailing movements that are
usually caused by deficits in subthalamic nucleus.
Tone
 resistance of muscle to stretch / passive elongation.
 Spasticity : velocity-dependent ↑ in stretch reflex,
Rigidity : resistance of the limb to passive movement in relaxed
state (non–velocity dependent).
 Variability in tone is common  patients with spasticity can
vary in their presentation throughout the day & with positional
(static tone) but a surge of tone when attempt to move the
muscle during a functional activity (dynamic tone).
 Accurate assessment might require repeated examinations 
Initial observation usually shows abnormal posturing of limbs
/trunk  Palpation of muscle also provides clues: hypotonic
muscles feel soft & flaccid, hypertonic muscles feel firm&tight.
 Passive ROM provides information about the muscle in response
to stretch  examiner provides firm & constant contact while
moving limbs in all directions (limb should move easily &
without resistance when altering direction & speed).
- Hypertonic limbs feel stiff & resist movement,
- Flaccid limbs are unresponsive.
- patient should relax because these responses should be
examined without any voluntary control.
 Clonus : cyclic alternation of muscular contraction in response
to a sustained stretch, assessed using quick stretch stimulus that
is then maintained.
 Myoclonus : sudden, involuntary jerking of a muscle/group.
- can be normal  occasionally happen in normal individuals &
typically part of normal sleep cycle.
- can result from : hypoxia, drug toxicity, metabolic disturbance.
- Other causes : degenerative disorders affecting basal ganglia &
certain dementias.
 Tone can be quantified by Modified Ashworth Scale, a 6-point
ordinal scale.
 Pendulum test  can be used to quantify spasticity.
- in supine position, patient is asked to fully extend knee & then
allow the leg to drop and swing like a pendulum.
- normal limb swings freely for several cycles, hypertonic limb
quickly returns to initial dependent starting position.
 Tardieu Scale  more appropriate measure of spasticity than
Modified Ashworth Scale.
 - involves assessment of resistance to passive movement at both slow&fast speeds.
- Measurements are usually taken at 3 velocities (V1, V2, V3)
V1 : as slow as possible, slower than natural drop of limb segment under gravity
V2 : at the speed of limb falling under gravity.
V3 : limb moving as fast as possible, faster than natural drop under gravity.
- Responses are recorded at each velocity & degrees of angle at which the muscle reaction occurs.
Reflexes
Superficial Reflexes
 Plantar reflex  most common superficial reflex examined.
- A stimulus (usually by handle end of reflex hammer) is applied on sole of foot from lateral border
up & across the ball of foot
- Normal reaction : flexion of great toe / no response.
- Abnormal response : dorsiflexion of great toe with associated fanning of other toes  Babinski
sign, indicates dysfunction of corticospinal tract but no further localization.
- Stroking from lateral ankle to lateral dorsal foot can also produce dorsiflexion of great toe 
Chaddock sign
- Flipping little toe outward can also produce upgoing great toe  Stransky sign.
Muscle Stretch Reflexes (deep tendon reflexes)
 assessed by tapping over the muscle tendon with reflex hammer.
 In order to elicit a response, patient is positioned into the midrange of arc of joint motion & relax.
 Tapping of tendon results in visible movement of joint  response is assessed as
(0) : no response
(1+) : diminished but present & might require facilitation
(2+) : usual response
(3+) : more brisk than usual
(4+) : hyperactive with clonus
 If difficult to elicit  response can be enhanced by reinforcement maneuvers, such as hooking
together fingers of both hands while attempting to pull them apart (Jendrassik maneuver)  while
pressure is still maintained, lower limb reflexes can be tested.
 Squeezing knees together & clenching teeth can reinforce responses to upper limbs.
Primitive Reflexes
 abnormal adult reflexes that represent regression to more infantile level of reflex activity.
 Redevelopment of infantile reflex in adult  significant neurologic abnormalities.
 Sucking reflex : patient sucks the area around which the mouth is stimulated.
 Rooting reflex : elicited by stroking cheek  patient turning toward that side & making sucking
motions with mouth.
 Grasp reflex : examiner places a finger on patient’s open palm  attempting to remove the finger
causes the grip to tighten.
 Snout reflex : lip-pursing movement occurs when there is a tap just above/below mouth.
 Palmomental response : elicited by quickly scratching palm of hand  positive reflex is indicated
by sudden contraction of mentalis (chin) muscle  unilateral damage of prefrontal area of brain.
Gait
 a series of rhythmic, alternating movements of limbs&trunks that result in forward progression of
the center of gravity.
 input from several systems : visual, vestibular, cerebellar, motor, sensory.
 cause of dysfunction  determined by understanding the aspects of gait involved.
 starts : asking patient to walk across the room in a straight line (can also be assessed by observing
the patient walking from waiting area into examination room)  patient is then asked to stand
from a chair, walk across the room, and come back toward examiner.
 examiner should pay particular attention to:
1. Ease of arising from a seated position.
- Difficulty  proximal muscle weakness, movement disorders with difficulty initiating
movements, or a balance problem.
2. Balance.
- Does the patient lean / veer off to 1 side, which is an indication of cerebellar dysfunction?
- Patients with medullary lesions & cerebellar lesions  push to the side of lesion.
- Diffuse disease affecting both cerebellar hemispheres  generalized loss of balance.
 - cerebellar disorders  balance issues with / without their eyes open. Inspection and Palpation
- proprioceptive dysfunction  can use visual input to compensate for their sensory deficit.  Inspection
3. Walking speed  mood, signs of pain/discomfort, functional impairments, evidence of malingering.
- Does the patient start off slow & then accelerate uncontrollably?  spine : scoliosis, kyphosis, lordosis.
- Parkinson’s disease  problems initiating movements, but then lose their balance once  Limbs : symmetry, circumference, contour.
they are in motion.  persons with amputation : level, length, shape of residual limb
- Patients with pain such as knee / hip arthritis  limitations of ROM affecting gait speed.  Depending on clinical situation : muscle atrophy, masses, edema, scars, fasciculations.
(self-selected gait speed < 0.8 m/s  risk factor for falls in stroke population; walking  Joints : abnormal positions, swelling, fullness, redness.
speed remains stable until about age 70 when there is 15% decline per decade  because  These isolated findings can coalesce to influence global movement patterns that affect kinetic
elderly people take shorter steps). chain  kinetic chain : fact that joints of human body are not isolated but are linked in a series.
4. Stride and step length - Joint motion is always accompanied by motion at adjacent as well as distant joints 
- Does the patient take a small step / shuffle while walking?
asymmetric patterns causing pathology of seemingly unrelated sites.
- normal pressure hydrocephalus & Parkinson’s disease  take small steps / shuffle (↓
- especially true with a fixed distal limb  For example, very tight hamstring muscles ↓
their step & stride length). lumbar lordosis, resulting in ↑ risk of LBP.
- Stride length = linear distance between successive corresponding points of heel contact of
 Palpation
the same foot  confirm initial impressions from inspection, help determine : structural origins of soft tissue /
- step length = distance between corresponding successive contact points of opposite feet.
bony pain & localize trigger points, muscle guarding, spasm & referred pain.
(average : 2 feet for women & 2.5 feet for men).
 Joints & muscles : swelling, warmth, masses, tight muscle bands, tone, crepitus.
5. Attitude of arms & legs.
 Tone  typically determined while assessing ROM.
- How does the patient hold his/her arms & legs?
 limbs&cranium : evidence of fracture in patients with mental status change after a fall/trauma
- Loss of movement as in a spastic / contracted patient should be assessed.
- knee extension weakness  swing their knees into terminal extension, thereby locking
Assessment of Joint Stability.
their knee (genu recurvatum).
 judges the capacity of structural elements to resist forces in nonanatomic directions.
- patient is then asked to also walk heel to toe in a straight line  ask to walk in a straight
 Stability is determined by : bony congruity, capsular & cartilaginous integrity, strength of
line by putting 1 heel of 1 foot directly in front of the toe of the other  tandem gait (test
ligaments & muscles.
of higher balance)
 Assessing “normal” side establishes patient’s unique biomechanics.
- Tandem gait can be difficult for older patients, and in some other medical conditions (even
 1st identifies pain & resistance in affected joint  followed by evaluation of joint play to assess
without neurologic disease).
“end feel,” capsular patterns, hypomobility / hypermobility.
- Other tests : observing patients walk on their toes and heels.
 Radiographic imaging  ex: flexion-extension spine films to assess vertebral column instability /
- Balance can also be assessed by asking patients to hop in place & do a shallow knee bend.
MRI to visualize the degree of anterior cruciate ligament rupture.
- Gait disorders  stereotypical patterns that reflect injury to various aspects of neurologic
 Joint play / capsular patterns assess integrity of capsule in open-packed position (positions in
system (Table 1-9).
which there is minimal bony contact with maximum capsular laxity).
 Voluntary movement of a joint (active ROM) does not generally exploit fullest range of that joint.
 Extreme end ranges of joint movements not under voluntary control  assessed by passive ROM.
Musculoskeletal Examination (MSK examination)
Caveats
 confirms diagnostic impression & lays the foundation for physiatric treatment plan.
 inspection, palpation, passive & active ROM, assessment of joint stability, manual muscle testing &
joint-specific provocative maneuvers, / special tests (Table 1-10).
 functional unit of MSK system  joint.
 comprehensive examination of a joint  related structures : muscles, ligaments, synovial
membrane & capsule
 also indirectly test : coordination, sensation, endurance.
 overlap between examination (& clinical presentation) of neurologic and MSK systems : primary
impairment in many cases in neurologic disease is the secondary MSK complications of immobility
& suboptimal movement (in which concept of kinetic chain is important for evaluation).
 With muscle involuntary guarding/spasm  notes an abrupt stop associated with pain.
 differentiate between hypomobile & hypermobile joints.  reliability ↑ by knowing & using consistent surface landmarks and test positions.
- Hypomobile  ↑ risk for muscle strains, tendonitis, nerve entrapments  Joints are measured in their plane of movement with stationary arm parallel to long axis of
- hypermobile  ↑ risk for joint sprains & degenerative joint disease. proximal body segment / bony landmark.
 inflammatory synovitis  can c joint mobility & weaken capsule.  The moving arm should also be aligned with a bony landmark / parallel to moving body segment.
decreased muscle strength  ↑ risk of trauma & joint instability.  The impaired joint should always be compared with contralateral unimpaired joint, if possible.
 If joint instability is suspected  confirmatory diagnostic testing (e.g., radiography).  Sagittal, frontal, coronal planes divide body into 3 cardinal planes of motion.
 temporal relationship between pain & resistance on exam changes from acute to chronic injury.
- acute joint  pain before resistance to passive ROM.
- subacute joint  pain at the same time as resistance to passive ROM.
- chronic joint  pain occurs after resistance to ROM is noted.

Assessment of Range of Motion

General Principles.
 to document integrity of a joint, assess efficacy of treatment regimens, determine mechanical cause
of an impairment.
 Limitations  affect ambulation, mobility, ADL.
 Normal ROM varies based on age, gender, conditioning, obesity, genetics  males have a more
limited range, depending on age & specific joint action.
 Vocational & avocational patterns of activity potentially alter ROM  gymnasts generally have ↑
ROM at hips & lower trunk.  sagittal plane measurements  goniometer is placed on lateral side of joint, except for a few joint
 Passive ROM  performed through all planes of motion in a relaxed patient to thoroughly assess motions such as forearm supination and pronation.
end feel.  Frontal planes  measured anteriorly/posteriorly, with axis coinciding with axis of joint.
 Active ROM  through all planes of motion without assistance from examiner simultaneously  360-degree system denotes 0 degrees directly overhead and 180 degrees at the feet.
evaluates muscle strength, coordination of movement, functional ability.  In 360-degree system, shoulder forward flexion&extension ranges from 0-240 degrees
 Contractures
 American Academy of Orthopedic Surgeons uses 180-degree system.
- often obvious simply from visual inspection.
- affect the true, full ROM of a joint via either soft tissue / bony changes.
- soft tissue / muscle contracture ↓ with prolonged stretch, bony contracture does not.
- difficult to differentiate a contracture from severe hypertonia in CNS diseases  diagnostic
peripheral nerve block can eliminate hypertonia for a few hours to determine etiology of
contracture & guide correct treatment for impaired mobility/ADL.
Assessment Techniques
 performed before strength testing.
 function of joint morphology, capsule & ligament integrity, muscle & tendon strength.
 measured with universal goniometer  device that has a pivoting arm attached to a stationary
arm divided into 1-degree intervals.
 standard anatomic position : upright position with feet facing forward, arms at the side with palms
facing anterior.
 A joint at 0 degrees  in anatomic position, with movement occurring up to 180 degrees away
from 0 degrees in either direction.
 shoulder forward flexion  normal range for flexion in 180-degree system is 0-180 degrees, for
extension is 0-60 degrees.
 In joint deformity  the starting position is the actual starting position of joint motion.
 Spinal ROM
- more difficult to measure, reliability has been debated.
- most accurate method : radiographs (not practical in most clinical scenarios)
- next most accurate system : inclinometers (fluid-filled instruments with 180-/360-degree scale.
Assessment of Muscle Strength
General Principles.
 Manual muscle testing  establish baseline strength, determine functional abilities of / need for
adaptive equipment, confirm diagnosis, suggest a prognosis.
 Strength  rather generic term, can refer to a wide variety of assessments & testing situations.
 MMT  measures ability to voluntarily contract a muscle/muscle group at a specific joint.
 Isolated muscles can be difficult to assess  elbow flexion strength depends not only on biceps
muscle but also on brachialis & brachioradialis muscles.
 Strength is affected by many factors : number of motor units firing, functional excursion, cross-
sectional area of muscle, line of pull of muscle fibers, number of joints crossed, sensory receptors,
attachments to bone, age, sex, pain, fatigue, fear, motivational level, and misunderstanding.
 Pain can result in breakaway weakness caused by pain inhibition of function  important to
recognize presence of substitution when muscles are weak / movement is uncoordinated.
 Females typically ↑ strength up to age 20 years, plateau through 20s, and gradually ↓ in strength
after age 30. Males ↑ strength up to age 20 & then plateau until > 30 years before ↓.
 Muscles that predominantly type 1 / slow-twitch fibers (soleus muscle) tend to be fatigue resistant
& can require extended stress on testing (several standing toe raises) to uncover weakness.
 Type 2 / fast-twitch fibers (sternocleidomastoid) fatigue quickly, and weakness can be more
straightforward to uncover abnormalities.
 Patients who cannot actively control muscle tension (those with spasticity from CNS disease) 
not appropriate for standard MMT methods.
Assessment Techniques.
 MMT takes into account : weight of limb without gravity, with gravity, with gravity + additional
manual resistance.
 grades of 0-2  gravity-minimized positions, grades 3-5  ↑ degrees of resistance applied as an
isometric hold at the end of test range.
 grade of 3  functionally important (antigravity strength implies that a limb can be used for
activity); grade of <3  limb will require external support & prone to contracture.
 To ↓measurement errors  1 hand should be placed above & 1 below the joint being tested.
 examiner’s hands should not cross 2 joints, if possible.
 Placing a muscle at a mechanical disadvantage (flexing elbow beyond 90 degrees to assess triceps
strength)  can help demonstrate mild weakness.
 The use of dynamometer can add a degree of objectivity to measurements for pinch and grip.
 quick screen for upper extremity strength  have the patient grasp 2 of examiner’s fingers while
examiner attempts to free the fingers by pulling in all directions.
 proximal lower limb screen  deep knee bend (squat & rise),
distal lower extremity  walk on heels & toes.
 To make gait abnormalities more evident  ↑ speed of cadence, walk sideways & backward.
 Abdominal strength screen  observing patient’s ability to go from supine to sitting with the hips
& knees bent. (If hips & knees are extended, iliopsoas is tested as well).
Assessment, Summary, and Plan
 impairments, performance deficits (activity limitation, disability), community / role dysfunction
(participation, handicap), medical conditions that can affect achieving functional goals, and goals
for interdisciplinary rehabilitation team (if other disciplines are involved in patient’s care).
 Follow-up treatment plans  must address important interval changes since last documentation &
any significant changes in treatment/goals.
 separate medical & functional problems list  should make clear how medical issues alter
treatment approach (how diabetes, activity-induced angina, pain issues might affect mobilization).
 6 broad interventional categories : prevention/correction of additional disability, enhancement of
affected systems, enhancement of unaffected systems, use of adaptive equipment, use of
environmental modification, use of psychologic techniques to enhance patient performance &
education.
 short-&longer-term goals should be outlined, & estimated time frames for achieving those goals.