Overview and Description
Definition of the assessment/treatment procedure
Physical Medicine & Rehabilitation (PM&R) manages prevention, diagnosis and treatment of conditions and syndromes that result in impairment, leading to functional disability and impacting quality of life. Some of these disorders may include pathology of the nerves, muscles, bones and brain. 1 The specialty of PM&R moves from a general disease-oriented approach, to a comprehensive detailed approach, incorporating medical factors, physical impairments, barriers, and the individual goals. This overall approach leads to the planning and achievement of functional goals and improved quality of life.
The development of subspecialties training has continued to evolve to include: Brain Injury Medicine, Sports Medicine, Neuromuscular Medicine, Hospice & Palliative Medicine, Pediatric Rehabilitation Medicine, Pain Medicine, and Spinal Cord Injury Medicine.
In order to objectively understand the functional changes attained through methodic treatment interventions, the rehabilitation team will use assessment instruments allowing for a systematic evaluation and comparison of clinical changes in an objective manner. The use of instruments and outcome measures contributes to improved clinical decision making and evidence-based-practice. 2
There are numerous assessment instruments available. In order to select the appropriate instrument, it is important that clinicians determine what is being measured, the population under study, and reliability and validity of the instrument being applied. Most importantly, the physiatrist must comprehend that objective assessment tools should not be placed above clinical care and should only serve to enhance (or improve) therapeutic recommendations.
The rehabilitation field uses a biopsychosocial model of care; this implies that as specialists, we do not limit our practice to diagnosing and treating a pathology (biomedical model), but we expand into understanding and treating the secondary effects of injury and illness. To successfully address this, the physiatrist will see the whole patient, incorporating motor, cognitive and emotional dimensions to the assessment so that a full picture of goals and barriers can be identified early in the planning of the rehabilitation program. 3 These components, or dimensions, will be incorporated into the assessment tools, which will subsequently assist in this ongoing process of active change as individuals achieve and reset their functional goals.
The International Classification of Functioning, Disability and Health (ICF) endorsed by the World Health Organization (WHO) supports assessment tools and presents recommendations on which tools to use and how to use them. The framework is divided into: (1) Functioning and Disability, which is subdivided in body function and body structures, and (2) Contextual Factors. The first one considers the individual and the societal perspective, and his/her ability to perform. The second one considers personal, attitudinal, environmental, physical and social factors. 4
Range of Procedures and Settings:
The practice of PM&R includes in-patient and outpatient settings. The setting where the evaluation is taking place will impact the extent and format followed to assess our patients. Traditionally, the inpatient scenario includes an inter-professional team that allows for a comprehensive evaluation and treatment recommendations. The family takes a huge role in this setting, particularly with the purpose of understanding the psychosocial context of the patient as well as the overall residual function and impairment. This setting is highly influenced by third party medical insurers who will dictate costs and the limit/length of stay. 3
The specialty of PM&R makes use of a series of procedures that allows the diagnosis and treatment of patients with functional disability. Electromyography has complemented the physical exam impression by allowing the study of muscles and nerves through electrophysiology principles. This study uses a combination of superficial and intramuscular electrodes to study the nerve and muscle physiologic behavior, allowing the qualification and quantification of pathology, its localization, and the establishment of prognosis. Electrodiagnostic studies are not a substitute for radiologic imaging or physical exam, but a complement to understanding anatomic and clinical findings. Specialized training is required to be able to provide a comprehensive interpretation of the pathology identified by the study. 5
Procedures in PM&R include an array of interventions ranging from peripheral joint and trigger point injections to interventional pain management of spine and deeper joints under fluoroscopy and ultrasound guidance. Although interventional procedures in pain management can be done by other medical subspecialties, the physiatrist’s intervention incorporates not only the expertise of pain management, but the component of function and rehabilitation after the procedure is completed. This creates an impact in wellness and overall quality of life. 6 ,7
Diagnostic ultrasound is another tool that has taken an important role in musculoskeletal medicine. This technology allows for quick, real-time portability, low cost and safe application in the clinical practice, allowing for a functional evaluation, diagnosis and treatment of musculoskeletal complaints and conditions. At the care site, the physiatrist can make immediate decisions about therapeutic interventions, particularly when applied to guided injections.8
Assessment tools allow measuring and comparing clinical outcomes based on expected milestones. Ongoing observations allow for determining if functional progress goes along with the expected prognosis.
Specific features of clinical applications of the assessment /treatment procedures:
In rehabilitation medicine, a detailed history is initially obtained by the physiatrist, complemented by a comprehensive approach with inter-professional contribution of collaborative disciplines like the speech pathologist, the occupational therapist, the physical therapist, and the rehabilitation nurse, among others. The history includes the present illness, past medical history, and functional limitations. Although this information is obtained from the patient, the caregiver and family play a key role in understanding the contextual dimension. A functional history allows for an understanding of the resulting disability, the remaining capabilities, and the compensatory techniques used by the patient. There are several activities of daily living evaluated; some of these are communication, transfers/mobility, self-care ability, and household chores. Functional limitations in each area may vary; therefore, treatment goals are specific and adapted to improve them.3
Specific diagnostic criteria that justify use of the assessment/treatment procedure:9,10,11
Once a subjective evaluation is completed, the physiatrist will establish a diagnosis and rehabilitation goals. He/she will use objective instruments to quantify the disability and later compare the functional changes obtained after therapeutic interventions. These instruments are called assessment tools, which can be generic or specific. Specific tools can either be disease-specific or region specific. Generic tools are designed to measure and improve quality of life; thus, they are considered broad-ranged and generic and very sensitive to any health change. It can include concepts like physical health, psychological state, and level of independence, social relationships, and the relation to the patient’s environment. They are applicable to different disease and cultural groups.
In response to the Affordable Care ACT (ACA) and the reporting requirements identified in the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) of 2014, the Inpatient Rehabilitation Facilities (IRF) Quality Reporting Program (QRP) was established in fiscal year (FY) 2014.
The Centers for Medicare and Medicaid services (CMS) and their post-acute settings (PACS) which include skilled nursing facilities, long term care hospitals, inpatient rehabilitation facilities, and home health services utilize the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual; specifically, Section GG to evaluate functional abilities and goals. Self-care and mobility are measured using the GG codes on admission and discharge.
Assessment tools to be used will be based on the diagnosis established and the specific treatment goals that are aspired to attain and measure. Other scales are used for classification of health conditions, re-assessment and reimbursement purposes. Some examples of assessment tools include:
|Scale||What it assesses?||Disability target or function||Where it is used?|
|FIM (Functional independence measure)*||Functional Status, Self care, mobility, cognition||18 items in a 7-level scale that is used to uniformly to assess the severity of patient disability and medical rehabilitation functional outcomes.||IRF|
|RUGS (Resource Utilization Groups)*||Level of the patients care requirement; 8 major categories divided in different subcategories||Activities of daily living, special care, clinically complex, behavioral, cognitive and function||Skilled Nursing Facilities|
|OASIS (Outcome and Assessment Information Set)**||Comprehensive assessment related to individuals clinical and functional status, demographic and service needs||Can be used for quality improvement for skilled services rendered. Allows for a systematic comparative measurement of home health care outcomes||Home health agencies|
|ICD(International classification of Disease)**||Classification of diseases and health conditions||Disease classification tool that it is also used for quality, epidemiological and reimbursement purposes||All agencies|
|ICF (International Classification of Functioning, Disability and Health)*||“Provides a standard language and framework for describing health and health related conditions”||Overall function and disability including contextual factors such as environmental, personal and societal factors||All agencies|
|LCDS(local coverage determination)*||Determination of whether a service is covered||Coverage criteria is defined within each LCD||Long term care hospitals|
|MDS (Minimum Data Set) *||Self- care and mobility needs||Current needs for self-care of individuals; specific GG codes capture current ability or performance||All PACs|
|Arthritis impact measurement scale||multidimensional health status index used in arthritis patients||It consists of 9 areas of evaluation: mobility, physical activity, dexterity, household activities, activities of daily living, social activities, anxiety, depression, and pain.||All users|
|Fibromyalgia Impact Questionnaire||assessment and outcome instrument developed to assess health components affected by this condition||Items evaluated include physical function, pain and fatigue, among others.||All users|
|Oswestry disability questionnaire||Measurement of disability and quality of life||Measures disability especially in low back pain||All users|
|Barthel Index||it allows measuring activities of daily living with chronically disabled patients;||Ten items, among those, bowel and bladder assessment scores.||All users|
|Katz Index of Independence||evaluates results of treatment and prognosis in the elderly and in chronic illness||This tool includes activities of self-care.|
Other factors that may influence clinical decision making when applying the assessment/treatment procedures:
A comprehensive rehabilitation treatment plan takes into account the environment and social support system to which the individual will be exposed. Consideration of structural and social barriers is crucial, especially when the individual presents with impairments that might restrict him/her (wheelchair accessible, elevators, ramps). Prior to making certain treatment decisions, it is imperative to explore the involvement of support systems, evaluate for a safe environment, the need for assistance with ADL/mobility, need of supervision, home modifications and the cost that these challenges involve.
Formal guidelines for using the assessment / treatment procedures: translation into practice: clinical pearls or potential performance improvement in practice
Evidence-based medicine (EBM) has been considered the backbone of high-quality medical practice. It is the process of systematically reviewing, appraising, and using clinical research findings to aid in the delivery of optimum clinical care to patients. 12 It is estimated that less than 20% of medicine is based on scientific evidence. However, upon the integration of EBM with clinical expertise and patient values, clinical practice guidelines are developed to assist practitioners and patient decisions about appropriate health care for specific circumstances. 13 These guidelines are meant to provide a tool which complements the clinician’s evaluation, assessment and treatment plan, always acknowledging that the individual needs of patients must be considered.
The American Academy of Physical Medicine & Rehabilitation (AAPM&R) has established the Clinical Practice Guideline Committee (CPGC) through which practice guidelines critical for the field of PM&R are developed and endorsed. Guidelines endorsed by the Academy require peer-reviewed evidence, classification of the evidence based on quality of study design, systematic review of the literature and recommendations based on the strength of the supporting evidence. The Committee also evaluates the quality guidelines established by other organizations that may benefit the practice of PM&R. The quality of the process through which each guideline is developed is key to the final decision of the Committee. Proposed guidelines are either endorsed (fully complying with the AAPM&R standards), accepted (information beneficial for members but recommendations endorsed only partially), affirmed (considered as educational tool but not endorsed) or denied.14
AAPM&R is one of the multiple worldwide organizations active in the Physician Consortium for Performance Improvement (PCPI), identifying within established guidelines aspects of care from which evidence-based, statistically valid, and reliable performance measures are developed.15
Cutting Edge/ Unique Concepts/ Emerging Issues
The field of Physiatry has been expanding with emerging diagnostic and treatment technologies. Among them is the growing use of ultrasonography as a diagnostic tool as well as treatment modality. As a diagnostic tool ultrasonography has led to increased efficiency regarding timeliness and decreased cost, substituting other forms of diagnostic imaging such as CT and MRI for the diagnosis of multiple musculoskeletal conditions. Ultrasound guided injections have also improved the efficacy in the treatment of these conditions. The use of Proliferative Therapy including PRP (Platelet-Rich Plasma) and Prolotherapy; continue to be promising. There continues to be ongoing research for prolotherapy in chronic pain and specific musculoskeletal conditions, but it has yet provided sufficient evidence to conclude its effectiveness of treatment. Prosthetic rehabilitation has expanded with the use of high technology, including Microprocessor Knees and the inclusion of Artificial Intelligence in lower extremity prosthesis substituting the function of human muscle. Targeted nerve regeneration has also expanded the possibilities in the rehabilitation of both upper and lower extremity amputations. Newer technologies are emerging and still in research phase, such as Osseointegration, a technique which incorporates a pylon in the amputated lower extremity residual bone, eliminating the need of a socket. Treatment incorporating higher technology such as the use of robotics, is rapidly growing, and although few, upper extremity transplants are examples of cutting-edge technologies which research needs to address. Other cutting-edge advancements are the incorporation of virtual reality in the rehabilitation of central lesions contributing to an enhanced recruitment of neural pathway that can lead to an improved recovery on the rehabilitation of sub-acute and chronic conditions. 16 17 18
The Model Disability Survey (MDS) is a general population survey that provides detailed and nuanced information about how people with and without disabilities conduct their lives and the difficulties they encounter, regardless of any underlying health condition or impairment. The MDS helps Member States identify the barriers that contribute to the problems people encounter, which, in turn, helps guide policy and service development. The MDS can also contribute to monitoring the Sustainable Development Goals (SDGs). Reference: (https://www.who.int/disabilities/data/mds/en/)
Another emerging challenge that the World Health Organization has undertaken a very active role is in the development of a long-term framework for establishing care to individuals with disabling conditions. According to the Global Burden disease study from 2019, it has been estimated that approximately one third of the world population may benefit from rehabilitation in some manner.
Gaps in Knowledge/ Evidence Base
Outcome measures are key to the establishment of performance improvement measures and health care. However, are we measuring the correct outcomes? Do the outcomes measure all consequences related to disease, including parameters related to quality of life? The World Health Organization’s developed the Family of International Classifications (FIC) which is a set of integrated classifications that provide a common language for health information across the world. These include the International Classification of Health Interventions (ICHI), International Statistical Classification of Diseases and Related Health Problems (ICD) , and the International Classification of Functioning, Disability and Health (ICF) which provides a classification method that includes consequences at the organ, person, and society level as well as the influence of environment.19 The most recent revision is the ICD-11 that has been adopted by the Seventy-second World Health Assembly since May 2019 and comes into effect on January 1, 2022.
While ICD classifies health conditions that include illness/diagnosis or health, ICF classifies the extent to which those conditions impact or affect the function of an individual. The ICD 10/ICD 11(last version) is not only used as a tool for disease classification but it is also used for quality, epidemiological and reimbursement purposes.
Relevant outcomes in PM&R deal with multiple health conditions across several specialty boundaries, and as such, it assimilates practice guidelines non-specific for PM&R, gap which must be addressed in order to identify and develop the best practice standards.
Even when functional assessments are key to rehabilitation medicine, clinicians are challenged with incorporating them in their day-to-day clinical practice. On one hand, the patients may not understand the importance of measuring functional milestones; on the other hand, medical insurers may not pay for services if the need for care is not demonstrated through objective measures. Using outcome tools can be time consuming for the provider and the patient, and this may interfere with its regular use.
Even when outcomes measures can allow following up on the clinical course of a disorder, its ability will depend on the instrument used, specificity to the pathology being observed, sensitivity to clinical changes, population studied, and by the coinciding co-morbidities suffered by the patient. Clinical improvement can be subtle enough as to not allow a significant measurable improvement by the tool. Medical documentation will play a role in justifying therapeutic interventions. Third party payers more and more exert an immense influence on the care offered to patients based on the established outcome measures. Clinicians will have to assess the benefits of care, costs, and the patient’s and the family’s desires and preferences.
Another area that can be affected by not having the right outcome measure for a specific intervention is clinical research. New expensive instruments and/or technology could be developed by the industry seeking to enhance sensitive identification of clinical changes. 20
- Am Acad of Physical Medicine & Rehabilitation. https://www.aapmr.org/patients/aboutpmr/Pages/default.aspx 2015.
- Barat M, Franchiognoni F. Advances in Rehabilitation: Aggiornamenti in Medicina Reabilitativa. Assessment in Physical Medicine & Rehabilitation: Views and Perspectives. Maugeri Foundation Books and PI-ME, Via Vigentina, Italy, 2004; Vol 16: Chapter2.
- Ganter BK, Erickson RP, Butters MA, Takata JH, Noll SF. Delisa’s Physical Medicine & Rehabilitation, Principles and Practice. Chapter 1: Clinical Evaluation. Wolters Kluwer, Lippincott Williams @ Wilkins, Philadelphia, PA, 4th Edition.
- Peterson DB. International Classification of Functioning, Disability, and Health: An Introduction for Rehabilitation Psychologists. Rehabilitation Psychology. 2005 (50) 2; 105-112.
- Cole JL, Goldberg G. Delisa’s Physical Medicine & Rehabilitation, Principles and Practice. 4th Edition. Chapter 4: Central nervous system electrophysiology.
- Mukai A, Kancherla V. Interventional procedures for cervical pain. Phy Med Rehabil Clin N Am. 2011 Aug;22 (3):539-49.
- Pauza KJ. Educational Guidelines for Interventional Spinal Procedures. AAPMR. 2001.
- Patil P, Dasgupta B. Role of diagnostic ultrasound in the assessment of musculoskeletal disease. Ther Adv Musculoskelet Dis. 2012 Oct 4(5); 341-355.
- Franchiognoni F. Assessment in Physical Medicine & Rehabilitation: Views and Perspectives. Chapter 3: Generic and Specific Measures for outcome assessment in orthopedic and rheumatologic rehabilitation. 2004 (16).
- Christiansen CH. Delisa’s Physical Medicine & Rehabilitation, Principles and Practice. Chapter 43: Functional evaluation and management of self-care and other activities of daily living. 4th Edition.
- Hamilton BB, Laughlin JA, Fiedler RC, Granger CV. Interrater reliability of the 7-level functional independence measure. Scandinavian Journal of Rehabilitation Medicine. 1994. 26 (3): 115-119.
- Rosenberg W, Donald A. Evidence based medicine: an approach to clinical problem-solving. BMJ 1995; 310: 1122–1126.
- Institute of Medicine 1990.
- AAPM&R: “The Physiatrist”- October, 2008; Vol 24, #8 – www.aapmr.org
- Cruz-Jimenez M, Rivera A, Santos-Correa L. Incorporation of upper extremity robotics in sub-acute rehabilitation stages: a case report. 2020 ISPRM Annual Meeting Poster Presentation.
- Colomer C, Baldovi A, Torrome S et al. Efficacy of Armeo® spring during the chronic phase of stroke. Study in mild to moderate cases of hemiparesis. 2013 Jun;28(5):261-7. doi: 10.1016/j.nrl.2012.04.017.
- Desiderio Cano Porras, Petra Siemonsma, Rivka Inzelberg, Gabriel Zeilig, Meir Plotnik. Advantages of virtual reality in the rehabilitation of balance and gait: a systematic review. Neurology May 2018, 90 (22) 1017-1025; DOI: 10.1212/WNL.0000000000005603
- Tenant, A. in Barat, M, Franchignoni, F. Advances in Rehabilitation: Assessment in Physical Medicine & Rehabilitation. Maugeri Foundation Books and PI-ME Press. Vol. 16, 2004
- Carl V Granger, MD; Chief Editor: Rene Cailliet, MD. Quality and Outcome Measures for Rehabilitation Programs. August 2013. http://emedicine.medscape.com/article/317865-overview#a30
Original Version of the Topic
Maricarmen Cruz, MD, Isabel Borras-Fernandez MD, Ana V. Cintron, MD. Essentials of Physiatric Assessment and Management Strategies. 9/14/2015
Isabel Borras-Fernandez, MD
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Maricarmen Cruz-Jimenez, MD
Nothing to Disclose
Raul Rodriguez-Ramos, MD
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