Author(s): Raul Rodriguez-Ramos, MD, Isabel Borras-Fernandez MD, Maricarmen Cruz-Jimenez, MD, Edgar Perez-Curet, MD, MPH
Originally published: September 14, 2015 Last updated: June 27, 2024
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Overview and Description

Definition of the assessment/treatment procedure

Physical Medicine & Rehabilitation (PM&R) aims to enhance and restore functional ability and quality of life by prevention, diagnosis, and treatment of conditions and syndromes that result in impairment. Disorders may include pathology of the nerves, muscles, bones, joints, ligaments, tendons, blood vessels, heart, lungs, and brain.1 The specialty of PM&R moves from a general disease-oriented approach to a comprehensive, detailed functional approach, incorporating medical factors, physical impairments, socio-economic factors, environmental barriers, and individual goals. This overall approach leads to maximizing planning and achievement of functional goals and improved quality of life.

The development of subspecialty training in PM&R is evolving and includes the following ACGME-accredited fellowships: Brain Injury Medicine, Sports Medicine, Neuromuscular Medicine, Hospice & Palliative Medicine, Pediatric Rehabilitation Medicine, Pain Medicine, Neuromuscular Medicine and Spinal Cord Injury Medicine. Other subspecialty fellowships which are non-ACGME accredited fellowships include Cancer Rehabilitation, Amputation Rehabilitation, Women’s Health, Cardiopulmonary Rehabilitation, Interventional Spine, and Musculoskeletal Medicine, some of which are actively working to achieve ACGME recognition.

To objectively understand the functional changes achieved by rehabilitation treatment interventions, the rehabilitation team uses assessment instruments that provide objective systematic evaluation and comparison of clinical changes. The use of standardized instruments and outcome measures contributes to improved clinical decision-making and evidence-based-practice.2

Ideally, the clinical assessment instruments selected are standardized, are reliable and valid instruments relevant to the population being treated. Importantly, the physiatrist and the rehabilitation team must acknowledge that clinical assessment tools serve to enhance and improve therapeutic care and should not be valued above clinical care and recommendations.

Conceptual Model 

In Physiatry the biopsychosocial model of patient care is fundamental. As Physical Medicine & Rehabilitation physician specialists, our practice is not limited to diagnosing and treating patient’s pathology (biomedical model) but includes understanding and integrating the secondary effects of injury and illness into the treatment plan. Secondary effects include, but are not limited to, how pathology impacts the patient’s family and social environment, occupational responsibilities, hobbies, and more.

We successfully address this by assessing the whole patient, incorporating motor, cognitive, and emotional dimensions to the assessment so that a complete picture of goals and barriers can be identified early in the planning of the rehabilitation program.

The biopsychosocial model of patient care is fundamental to Physiatry. Consequently, as Rehabilitation Medicine specialists do not limit their practice to diagnosing and treating patient’s pathology (biomedical model) but includes understanding and integrating the secondary effects of injury and illness into the treatment plan. Secondary effects include, but are not limited to, the way pathology impacts the patient’s family and social environment, occupational responsibilities, hobbies, and other aspects of the patient’s life.

In keeping with the biopsychosocial model, the physiatrist assesses the whole patient, incorporating medical, motor, cognitive, social, functional and emotional dimensions of the patient and their social setting. This ongoing assessment provides a picture of the patient needs and resources. This assessment defines the individualized medical and rehabilitation goals and barriers to success.3 These components and dimensions are incorporated into patient assessment tools, which document data regarding the ongoing patient progress. These assessments aid the patient’s and the team’s decisions as to whether to continue the current treatment plan or reset their medical and functional goals and treatment.

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 into body function and body structures, and (2) Contextual Factors. The first one considers the individual and the societal perspective, as well as 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 takes place impacts the extent and format followed to assess 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 helping the physician and team understand the psychosocial context of the patient and the implications on overall residual function and impairment. This setting is highly influenced by third-party medical insurers, who dictate costs and the limit/length of stay.3

The specialty of PM&R utilizes various procedures to diagnose and treat patients with impairments that lead to disability. Electrodiagnostic studies complement the physical exam diagnostic 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 provide a comprehensive interpretation of the pathology identified by the study.5

Other procedures in PM&R include an array of treatment interventions ranging from peripheral joint and trigger point injections, including but not limited to emerging options such as platelet-rich plasma infiltration, 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 and skills of pain management but also the component of function and rehabilitation after the procedure is completed. This impacts wellness and overall quality of life.6,7,8

Diagnostic ultrasound (US) technology has emerged as a valuable tool in musculoskeletal medicine as a low cost, portable, safe and effective option for real-time clinic evaluation and treatment of musculoskeletal conditions. This technology facilitates functional evaluation, and treatment, such as targeted injections.

Moreover, physiatrists can make immediate decisions about therapeutic interventions, especially US guided injections at the care site.9 Additionally, in sports medicine scenarios, diagnostic ultrasound aids in identifying and assessing athlete’s acute and chronic musculoskeletal injuries as well as non-musculoskeletal pathology on-site, potentially avoiding prolonged hospitalization for the athlete.10

Determining Prognosis

Assessment tools measure and compare clinical outcomes based on expected milestones. Ongoing observations allow on to determine if functional progress aligns with the expected prognosis.

Specific features of clinical applications of the assessment /treatment procedures

Rehabilitation medicine employs a comprehensive approach to obtain a detailed patient history complemented by collaborative efforts of inter-professional disciplines, including speech pathologists, occupational therapists, physical therapists, and rehabilitation nurses, among others. A functional history, including present illness, past medical history, and functional limitations is taken to understand the resulting impairment, disability, remaining capabilities, and compensatory techniques used by the patient. Additionally, functional assessments can be conducted to measure an individual’s ability to perform specific tasks safely and reliably. Assessments must be valid, reliable, and can be self-administered or conducted by a clinician. Functional assessments allow for objective testing of treatment outcomes. For further details, refer to the PM&R KnowledgeNOW® topic, Functional Assessment. Caregivers and family play a key role in understanding contextual dimensions and are valuable resources of information when a patient has communication disorders and cognitive impairments.  Activities of daily living are evaluated, and specific treatment goals are developed to improve functional limitations. This approach provides a nuanced understanding of the patient’s condition, facilitating effective treatment and rehabilitation.3

Specific diagnostic criteria that justify use of the assessment/treatment procedure:11,12,13 

Once a subjective evaluation is completed, the physiatrist will incorporate physical examination, studies, and tests to establish a diagnosis and rehabilitation goals. After therapeutic interventions are initiated and completed, objective instruments are used to quantify disability and compare the functional changes. These instruments, or assessment tools, range from generic to highly specific. Specific assessment tools are either disease-specific or region specific. Generic tools re designed to measure and improve quality of life; thus, they are considered broad-ranged, generic, and sensitive to any health change. These instruments measure concepts like physical health, psychological state, level of independence, social relationships, and the relation to the patient’s environment. They are applicable to different diseases 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 used are based on the diagnosis established and the specific treatment goals. Other scales are used for classification of health conditions, re-assessment and reimbursement purposes. Some examples of assessment tools include:

ScaleWhat is assessed?Disability target or functionWhere is it used?
AM-PAC (Activity Measure for Post Acute Care)Activities of daily living Cognition
Functional mobility		5-8 items per domain.
Inpatient short: 6 domains
Outpatient short: 15-18 domain

In each domain, AM-PAC scores have a mean of 50 and a standard deviation of 10		Acute Care & All PACS
IRF-PAI (Inpatient rehab facility patient assessment instrument) – Section GGFunctional Abilities and Goals, Prior Level of Function (PLOF), Assistive Devices28 functional items using a 6-level rating scale which includes admission and discharge goals, and mobility performance elements.IRF
ICD (International classification of Disease)**Classification of diseases and health conditionsDisease 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 coveredCoverage criteria is defined within each LCD Long term care hospitals
MDS (Minimum Data Set) *Self- care and mobility needsCurrent needs for self-care of individuals; specific GG codes capture current ability or performanceAll PACs
    
Arthritis Impact Measurement ScaleMultidimensional health status index used in arthritis patientsConsists 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 QuestionnaireAssessment and outcome instrument developed to assess health components affected by this conditionItems evaluated include physical function, pain, and fatigue, among others. All users
Oswestry Disability QuestionnaireMeasurement of disability and quality of lifeMeasures disability, especially in low back pain All users
Barthel IndexIt allows measuring activities of daily living with chronically disabled patients;Ten items, among those, bowel and bladder assessment scores. All users
Katz Index of IndependenceEvaluates results of treatment and prognosis in the elderly and chronic illnessThis tool includes activities of self- care of all users. 

*CMS.gov
**www.ncbi.nlm.nih.gov>pmc>articles>PMC4529994

Retired Functional Assessment Tools

FIM (Functional independence measure) *Functional Status, Self-care, mobility, cognition18 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 functionSkilled 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 outcomesHome health agencies

Other factors that may influence clinical decision making when applying the assessment/treatment procedures

A comprehensive rehabilitation treatment plan incorporates the evaluation of an individual’s impairments, social determinants of health and other barriers that influence on disability. Evaluation and consideration of structural and social barriers is crucial, especially when the individual presents with impairments that might restrict him/her (e.g., wheelchair accessibility elevators, ramps). Prior to making treatment decisions, it is imperative to assess the patient’s support systems and extent of involvement, evaluate the environment for safety, determine the level of assistance with ADL/mobility required, supervision needs, home modifications needed and the costs involved.  

Formal guidelines for using the assessment/treatment procedures: translation into practice: clinical pearls or potential performance improvement in practice

Evidence-Based Medicine (EBM) is 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.14 It is estimated that less than 20% of medicine is based on scientific evidence. Unfortunately, available relevant research addressing many areas of clinical care is limited impacting the use of EBM. 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.15 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) Clinical Practice Guideline Committee (CPGC), the American College of Sports Medicine (ACSM), American Heart Association (AHA), among others develop and established practice guidelines critical for the field of PM&R. Guidelines endorsed by AAPM&R require peer-reviewed evidence, classification of the evidence based on quality of study design, systematic review of the literature and recommendations are 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.16

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.17

Cutting Edge/Unique Concepts/Emerging Issues

The field of Physiatry is expanding with emerging diagnostic and treatment technologies. For example, the use of ultrasonography as a diagnostic tool as well as treatment modality, is growing. As a diagnostic tool ultrasonography increases timeliness and decreases cost by substituting other forms of diagnostic imaging such as CT and MRI for the diagnosis of multiple musculoskeletal conditions. Ultrasound guided injections also improve the efficacy in the treatment of these conditions.

Regenerative medicine, which includes treatments like stem cells, viscosupplementation, and Proliferative Therapy (such as PRP and Prolotherapy), continues to show promise. Research on Prolotherapy for chronic pain and specific musculoskeletal conditions is ongoing, but as of now, there isn’t enough evidence to definitively prove its effectiveness as a treatment.

There have also been significant breakthroughs in the rehabilitation of prosthetics, robotics, brain computer interface, wearable sensors, virtual reality, artificial intelligence, and all forms of interactive media. 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.18 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 robotics, is rapidly growing. Upper extremity transplants are examples of cutting-edge surgical technologies which requires further research. 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.19,20,21

In response to the recent pandemic, patient care has expanded to include the use of telerehabilitation in addition to in person patient care visit. Smart phone applications have also been incorporated to assist in delivery and monitoring of rehabilitation interventions. For example, exercise applications, brain/memory games, mindfulness coach, wearable devices, among others.

Artificial intelligence (AI) is another area that is revolutionizing the medical field. Its impact in rehabilitation medicine is evolving. Current applications include its use/application in imaging (interpretation, identification and monitoring of abnormalities, etc.), wearable sensors (for inertia measurement, electromyography, movement sensors, etc.) and electronic health records. Further research and implementation are warrant so that effective AI implementation in rehabilitation.22

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/news-room/questions-and-answers/item/model-disability-survey)

Another emerging challenge that the World Health Organization (WHO) 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. Additionally, the WHO has also issued guidelines for the design and use of AI in Rehabilitation.23 In response to the effects of COVID 19, recent advancements in the field of PM&R include evolving treatment of long COVID which will continue to expand as evidenced based medicine develops. Current guidelines are published in the AAPM&R website long COVID page and the PM&R KnowledgeNOW topic, Post-Acute Sequelae of SARS-CoV-2 Infection (PASC)/Long COVID.

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.24 The most recent revision is the ICD-11 that has been adopted by the Seventy-second World Health Assembly since May 2019 and came 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 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 provide data on the clinical course of a disorder, the ability to detect meaningful change depends on the instrument used, specificity to the pathology being observed, sensitivity to clinical changes, population studied, and by the coinciding patient co-morbidities. Clinical improvement may be too subtle or the tool not sensitive enough to detect and measure meaningful improvement. Consequently, medical documentation plays a role in justifying therapeutic interventions above and beyond outcome measurements. Third party payers are increasingly exerting immense influence on the care provided to patients by determining what patient care and interventions are paid. Utilizing outcome measures helps demonstrate the clinical/functional impact that rehabilitation interventions provide, from a scientific/evidence-based point of view. Furthermore, it provides evidence that assist in justifying the need of these interventions to third party payers. Additionally, clinicians must continuously 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.25

References

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  19. 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.
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  25. 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

Previous Revision(s) of the Topic

Isabel Borras-Fernandez MD, Maricarmen Cruz, MD, Raul Rodriguez-Ramos, MD. Essentials of Physiatric Assessment and Management Strategies. 4/29/2021

Author Disclosures

Raul Rodriguez-Ramos, MD
Nothing to Disclose

Isabel Borras-Fernandez, MD
Nothing to Disclose

Maricarmen Cruz-Jimenez, MD
Nothing to Disclose

Edgar Perez-Curet, MD, MPH
Nothing to Disclose