--- module: 072-02 language: en chapter: 72 title: "Rehabilitation Medicine, Disability, Function, and Participation" module_title: "History, examination, diagnostic strategy, differential diagnosis, and common disease" source_sha256: 019006ec26148db83aac351fbdaeaf2573d21979444c4ebd63390a88010b9d0c --- # Rehabilitation assessment and diagnosis ## Functional history in real environments ### Functional diagnosis supplements disease diagnosis #### Same lesion, very different lives ### Pre-morbid function, trajectory, assistance ### Type of help #### Supervision, prompting, setup #### Physical assistance or complete performance ### Fatigue and variability #### Once, but not repeatedly or safely #### Good and bad days, near falls ### Owning equipment is not correct use ### Home layout, steps, bathroom, egress ### Caregiver assessed separately #### Assumed unlimited family help is unsafe ## Impairment and activity examination ### Neurological and musculoskeletal examination ### Manual muscle testing is ordinal #### Misses endurance and small changes ### Tone scales conflate neural and mechanical #### Compare velocities, assess fixed range ### Electrodiagnosis localises peripheral disease #### Velocity and amplitude: myelin and axon #### Denervation evolves, so timing matters #### Normal study misses small fibre, central ### Cardiopulmonary exercise testing #### Cardiac, pulmonary, peripheral, deconditioning #### Field tests depend on pacing, motivation ### Observe transfers, turning, gait, stairs #### Gait label should lead to mechanism ### Standardised measures #### Floor, ceiling, learning, rater effects #### Detectable change: measurement error #### Important difference: perceived relevance ### Participation beyond physical capacity #### Occupational analysis of valued roles ## Falls as a systems failure ### Balance, vision, cognition, pressure, medication ### Circumstances, prodrome, witness, getting up ### Mechanical fall, syncope, seizure, drop attack ### Orthostatic pressure, rhythm, feet, cognition ### Review sedatives and antihypertensives ### Multifactorial beats be careful ### Fracture risk and bone protection ## Localising gait disorders ### Hemiparetic: circumduction, equinovarus ### Steppage: dorsiflexor weakness ### Sensory ataxia worsens without vision ### Cerebellar broad; parkinsonian freezing ### Antalgic: short stance on painful side ### Trendelenburg: hip-abductor weakness ### Frontal: initiation failure, short steps ### Devices #### Cane opposite the painful or weak leg #### Poorly sized frame risks tripping ## Cognition, communication, swallowing ### Screening, then domain-specific testing ### Capacity is decision-specific ### Aphasia: fluency, comprehension, naming #### Speaking loudly does not help ### Dysarthria: respiration to prosody ### Swallowing #### Cough, wet voice, weight loss, pneumonia #### Bedside cannot exclude silent aspiration #### Videofluoroscopy or endoscopy tests strategy ## Pressure, skin, seating ### Load, duration, shear, moisture, perfusion ### Dark skin: warmth, firmness, texture ### Risk scales support, not replace ### Do not massage damaged tissue ### Wheelchair is a mobility system #### Poor fit: pain, deformity, pressure ## Autonomic, bowel, bladder, sexual function ### Neurogenic bladder #### High-pressure storage, reflux, renal damage #### Symptoms do not show bladder pressure ### Neurogenic bowel programme ### Sexual function: ask directly ## Rehabilitation complications ### New decline has medical causes #### Infection, thrombosis, occult fracture #### Not simply poor motivation ### Painful swollen limb differential ### Impaired communication hides acute disease ## Prioritised problem list ### Links impairment to participation and risk ### Reversible, compensable, preventable, uncertain