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BRADDOM’S
REHABILITATION
CARE
A Clinical Handbook
This page intentionally left blank

BRADDOM’S
REHABILITATION
CARE
A Clinical Handbook
David X. Cifu, MD
Chairman
Department of Physical Medicine and Rehabilitation
Herman J. Flax, MD Professor
Virginia Commonwealth University School of Medicine
Principal Investigator
Veterans Affairs/Department of Defense Chronic Effects of Neurotrauma Consortium
Richmond, Virginia
Henry L. Lew, MD, PhD

Tenured Professor, University of Hawaii School of Medicine
Chair, Department of Communication Sciences and Disorders
Honolulu, Hawaii
Adjunct Professor, Department of Physical Medicine and Rehabilitation
Richmond, Virginia
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
BRADDOM’S REHABILITATION CARE:

A CLINICAL HANDBOOK ISBN: 978-0-323-47904-2
Copyright © 2018 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means,
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This book and the individual contributions contained in it are protected under copyright by
the Publisher (other than as may be noted herein).
Notices
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vidual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors,
or editors, assume any liability for any injury and/or damage to persons or property as a
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methods, products, instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data

Names: Cifu, David X., editor. | Lew, Henry L., editor.
Title: Braddom’s rehabilitation care : a clinical handbook / [edited by]
David X. Cifu, Henry L. Lew.
Other titles: Rehabilitation care | Supplement to (expression): Braddom’s
physical medicine & rehabilitation. Fifth edition.
Description: Philadelphia, PA : Elsevier, [2018] | Includes bibliographical
references and index.
Identifiers: LCCN 2017021675 | ISBN 9780323479042 (pbk. : alk. paper)
Subjects: | MESH: Rehabilitation—methods | Handbooks
Classification: LCC RM700 | NLM WB 39 | DDC 617.03—dc23 LC record available at
https://lccn.loc.gov/2017021675
Senior Acquisition Editor: Kristine Jones

Content Development Specialist: Meghan Andress
Publishing Services Manager: Patricia Tannian
Senior Project Manager: Claire Kramer
Design Direction: Amy Buxton
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contributors
Mohd Izmi Bin Ahmad, MBBS, MRehabMed, CIME (USA)
Rehabilitation Physician
Head, Department of Rehabilitation Medicine
Hospital Pulau Pinang
George Town, Penang, Malaysia
Eleftheria Antoniadou, MD, FEBPMR, PhDc

Consultant
Rehabilitation Clinic for Spinal Cord Injury
Patras University Hospital
University of Patras
Patras, Greece
Joseph Burris, MD
Associate Professor of Clinical Physical Medicine and Rehabilitation
University of Missouri
Columbia, Missouri
Maria Gabriella Ceravolo, MD, PhD

Professor of Physical and Rehabilitation Medicine
Department of Experimental and Clinical Medicine
Politecnica delle Marche University
Director of Neurorehabilitation Clinic
University Hospital of Ancona
Ancona, Italy
Chein-Wei Chang, MD
Professor
National Taiwan University
Taipei, Taiwan
Shih-Chung Chang, MD, MS

Chung Shan Medical University
Chung Shan Medical University Hospital
Taichung, Taiwan
Carl Chen, MD, PhD

Director
Chang Gung Memorial Hospital
Taipei, Taiwan
v
vi Contributors
Chih-Kuang Chen, MD
Assistant Professor
Chang Gung Memorial Hospital
Taoyuan, Taiwan
Shih-Ching Chen, MD, PhD

Deputy Dean and Professor
School of Medicine
College of Medicine
Taipei Medical University
Professor and Attending Physician
Taipei Medical University Hospital
Taipei, Taiwan
Chen-Liang Chou, MD
Director and Clinical Professor
National Yang-Ming University
Taipei Veterans General Hospital
Taipei, Taiwan
Willy Chou, MD, HRMS

General Secretary, Superintendent Office
Chief Director, Physical Medicine and Rehabilitation
Chi Mei Medical Center
Associate Professor
Recreation and Health Care Management
Chia Nan University of Pharmacy
Tainan, Taiwan
Tze Yang Chung, MBBS, MRehabMed

Senior Lecturer, Department of Rehabilitation Medicine
University of Malaya
Department of Rehabilitation Medicine
University of Malaya Medical Centre
Kuala Lumpur, Malaysia
David X. Cifu, MD
Chairman
Herman J. Flax, MD Professor
Principal Investigator
Veterans Affairs/Department of Defense Chronic Effects of Neurotrauma
Consortium
Richmond, Virginia
Contributors vii
Andrew Malcolm Dermot Cole, MBBS (Hons), FACRM, FAFRM

Chief Medical Officer
HammondCare
Sydney, Australia
Associate Professor (Conjoint)
Faculty of Medicine
University of New South Wales
Kensington, Australia
Senior Consultant Rehabilitation Medicine
Greenwich Hospital
Greenwich, Australia
Rochelle Coleen Tan Dy, MD

Assistant Professor
Baylor College of Medicine
Houston, Texas
Blessen C. Eapen, MD
Section Chief, Polytrauma Rehabilitation Center
TBI/Polytrauma Fellowship Program Director
South Texas Veterans Health Care System
Associate Professor
UT Health San Antonio
San Antonio, Texas
Julia Patrick Engkasan, MBBS (Mal), MRehabMed (Mal)

Associate Professor
Gerard E. Francisco, MD
University of Texas Health Science Center (UTHealth)
McGovern Medical School
NeuroRecovery Research Center
TIRR Memorial Hermann
Houston, Texas
Francesca Gimigliano, MD, PhD

Associate Professor of Physical and Rehabilitation Medicine
Department of Mental and Physical Health and Preventive Medicine
University of Campania “Luigi Vanvitelli”
Naples, Italy
viii Contributors
Elizabeth J. Halmai, DO
Medical Director, Section Chief
Division of Polytrauma
South Texas Veterans Health Care System
Assistant Professor
University of Texas Health Science Center San Antonio
San Antonio, Texas
Nazirah Hasnan, MBBS, MRehabMed, PhD

Deputy Director (Clinical)
Associate Professor and Rehabilitation Consultant
Ziad M. Hawamdeh, MD
Senior Fellowship of the European Board of Physical Medicine and
Rehabilitation
Jordanian Board of Physical Medicine and Rehabilitation
Professor of Physical Medicine and Rehabilitation
Faculty of Medicine
University of Jordan
Amman, Jordan
Joseph E. Herrera, DO, FAAPMR

Chairman and Lucy G Moses Professor
Mount Sinai Health System
Icahn School of Medicine at Mount Sinai
New York, New York
Ming-Yen Hsiao, MD
Lecturer
National Taiwan University Hospital
College of Medicine
National Taiwan University
Taipei, Taiwan
Lin-Fen Hsieh, MD
Professor
School of Medicine
Fu Jen Catholic University
New Taipei City, Taiwan
Director
Shin Kong Wo Ho-Su Memorial Hospital
Taipei, Taiwan
Contributors ix
Rashidah Ismail Ohnmar Htwe, MBBS, M MED Sc (Rehab Med), CMIA

Associate Professor
Rehabilitation Unit
Department of Orthopedics and Traumatology
Associate Research Fellow
Tissue Engineering Centre
Faculty of Medicine
Universiti Kebangsaan Malaysia
Consultant Rehabilitation Physician
Rehabilitation Unit
Hospital Canselor Tuanku Muhriz
Yu-Hui Huang, MD, PhD

Associate Professor
School of Medicine
Chung Shan Medical University
Director
Physical Medicine and Rehabilitation
Chung Shan Medical University Hospital
Taichung, Taiwan
Chen-Yu Hung, MD
Attending Physician
Physical Medicine and Rehabilitation
National Taiwan University Hospital, Beihu Branch
Taipei, Taiwan
Norhayati Hussein, MBBS, MRehabMed, Fellowship in Neurorehabilitation

Cheras Rehabilitation Hospital
Elena Milkova Ilieva, MD, PhD, Prof.

Head of Department
Physical and Rehabilitation Medicine
Medical Faculty
Medical University of Plovdiv
Head of Department
Physical and Rehabilitation Medicine
“Sv Georgi” University Hospital
Plovdiv, Bulgaria
Lydia Abdul Latif, MBBS, MRM

Professor and Consultant Rehabilitation Physician
Faculty of Medicine
x Contributors
Wai-Keung Lee, MD
Chief, Department of Physical Medicine and Rehabilitation
Tao Yuan General Hospital
Tao Yuan, Taiwan
Henry L. Lew, MD, PhD

Tenured Professor, University of Hawaii School of Medicine
Chair, Department of Communication Sciences and Disorders
Honolulu, Hawaii
Adjunct Professor, Department of Physical Medicine and Rehabilitation
Richmond, Virginia
Chia-Wei Lin, MD
Attending Physician
National Taiwan University Hospital, Hsin Chu Branch
Hsin Chu, Taiwan
Ding-Hao Liu, MD
Taipei Veterans General Hospital, Yuanshan Branch
Yilan, Taiwan
Mazlina Mazlan, MBBS, MRM

Associate Professor
Faculty of Medicine
Matthew J. McLaughlin, MD, MSB

Assistant Professor
Division of Pediatric Rehabilitation Medicine
Children’s Mercy Hospital
Kansas City, Missouri
Amaramalar Selvi Naicker, MBBS (Ind), MRehabMed (Mal)

Professor of Rehabilitation Medicine and Head of Rehabilitation Medicine Unit
Associate Research Fellow
Tissue Engineering Centre
Faculty of Medicine
Universiti Kebangsaan Malaysia
Contributors xi
Mooyeon Oh-Park, MD, MS

Director of Geriatric Rehabilitation
Kessler Institute for Rehabilitation
Vice Chair of Education
Research Professor
Rutgers New Jersey Medical School
Newark, New Jersey
Vishwa S. Raj, MD
Director of Oncology Rehabilitation
Carolinas Rehabilitation
Chief of Cancer Rehabilitation
Department of Supportive Care
Levine Cancer Institute
Carolinas Healthcare System
Charlotte, North Carolina
Renald Peter Ty Ramiro, MD

Dean, College of Rehabilitative Sciences
Cebu Doctors’ University
Mandaue City, Cebu, Philippines,
Head, Physical and Rehabilitation Medicine
Cebu Doctors’ University Hospital
Cebu City, Cebu, Philippines
Head, Rehabilitation Medicine
Mactan Doctors’ Hospital
Lapu-lapu City, Cebu, Philippines
Reynaldo R. Rey-Matias, PT, MD, MSHMS

Chair, Department of Physical Medicine and Rehabilitation
St. Luke’s Medical Center and College of Medicine
Quezon City, Metro Manila, Philippines
Clinical Associate Professor
University of the Philippines–College of Medicine
Manila, Philippines
Desiree L. Roge, MD
Assistant Professor
Baylor College of Medicine
Assistant Professor
Texas Children’s Hospital
Houston, Texas
xii Contributors
Shaw-Gang Shyu, MD
Taipei, Taiwan
Clarice N. Sinn, DO, MHA

Assistant Professor
UT Southwestern Medical Center/Children’s Health
Dallas, Texas
Anwar Suhaimi, MBBS, MRehabMed (Malaya)

Rehabilitation Medicine Specialist
Senior Lecturer
Yi-Chian Wang, MD, MSc

Taipei, Taiwan
Chueh-Hung Wu, MD
Taipei City, Taiwan
Yung-Tsan Wu, MD
Attending Physician and Assistant Professor
Tri-Service General Hospital and School of Medicine
National Defense Medical Center
Taipei, Taiwan
Tian-Shin Yeh, MD, MMS

Attending Physician
National Taiwan University Hospital, Yun-Lin Branch
Yun-Lin, Taiwan
Graduate Institute of Clinical Medicine
National Taiwan University College of Medicine
Taipei, Taiwan
Contributors xiii
Mauro Zampolini, MD
Chief
Department of Rehabilitation
Italian National Health Service, USL UMBRIA 2
Foligno, Perugia, Italy
Tunku Nor Taayah Tunku Zubir, MBBS

Consultant Rehabilitation Physician
Department of Rehabilitation
Gleneagles Hospital

Preface
Over the past 4 years, we have worked diligently with more than 200 authors from
across the international community to create (1) the fifth edition of the textbook
Braddom’s Physical Medicine & Rehabilitation and (2) Braddom’s Rehabilitation Care:
A Clinical Handbook. These complementary resources compile key elements of the
field of disability medicine, ranging from the basic sciences to clinical care. While
the Braddom’s textbook is the premier reference for all academicians and practitio-
ners in physical medicine and rehabilitation, this new clinical handbook represents
the first comprehensive practical guide for trainees and practitioners across all ele-
ments of health care. Any student or clinician who sees, evaluates, manages, or
refers individuals with disability should use this handbook as his or her key source
for information. Whether the patient is a young adult with an acute combat-related
musculoskeletal injury, a teen with a sports medicine injury, an elderly person with
joint or neurologic dysfunction, a child with specialized equipment needs, or a
middle-aged individual after a life-altering trauma, this text can serve as a guide
for each patient’s clinical care. In addition to practical information and clinical
pearls, this handbook also features accompanying online slides and training mate-
rials to enhance understanding, to serve as part of core educational modules, and
to expand on the key points of the text. We are indebted to the authors of Brad-
dom’s Physical Medicine & Rehabilitation for providing the comprehensive materials
from which this clinical handbook was abstracted, the more than 50 authors who
worked meticulously to develop this special edition, and the editorial support staff
at Elsevier. We are hopeful that this handbook will be used throughout the world
to support the training of health care professionals working with individuals with
disabilities and to enhance the clinical care of those individuals with disabilities. It
is a resource that we would see in any health care and training setting and used by
the full range of trainees and practitioners. We also welcome feedback from readers
and users of it to improve the quality and usability of future iterations and editions.
David X. Cifu, MD, and Henry L. Lew, MD, PhD
xv

Foreword
There are more than 1 billion individuals with some degree of disability, physical or
mental, in the world, and there are a growing number of practicing clinicians and
trainees to assist them in achieving and maintaining their independence. However,
there has not been a single, easy-to-use clinical guide to specifically assist these
practitioners to optimize their care. This handbook brings together all the key ele-
ments of practical clinical care in physical and rehabilitation medicine found in the
fifth edition of Braddom’s Physical Medicine & Rehabilitation into a single, convenient
source. The compact size, clinical focus, and state-of-the-art online resources make
it the must-have guide. It has been designed to be invaluable at the bedside, in the
clinic, in the office, and even in the patient’s home. Written in a straightforward
style, supported by online slides, and packed with clinical pearls, this handbook
is perfect for the full range of professionals, from the beginning student to the
advanced practitioner. Created by two of the leading international educators in the
field of physical medicine and rehabilitation, Drs. David Cifu and Henry Lew, this
book was carefully compiled by more than 50 professionals in physical medicine
and rehabilitation from more than 25 countries across the globe to reflect the latest
in the field, while remaining consistent with the Braddom’s reference textbook. It is
truly the must-have resource for all trainees and clinicians who see individuals with
acute and chronic disabilities.
Jianan Li, MD, Immediate Past President, International Society of Physical

and Rehabilitation Medicine (ISPRM)
Jorge Lains, MD, President, ISPRM
xvii

Contents
SECTION I EVALUATION
1 The Physiatric History and Physical Examination, 3

Shaw-Gang Shyu
2 History and Examination of the Pediatric Patient, 14

Chia-Wei Lin
3 Adult Neurogenic Communication and Swallowing Disorders, 18

Ming-Yen Hsiao
4 P sychological Assessment and Intervention in Rehabilitation, 24

Willy Chou
5 Practical Aspects of Impairment Rating and

Disability Determination, 28
Maria Gabriella Ceravolo
6 Employment of People with Disabilities, 34

Renald Peter Ty Ramiro
7 Quality and Outcome Measures for Medical Rehabilitation, 39

Elizabeth J. Halmai
8 Electrodiagnostic Medicine, 44
Chein-Wei Chang
SECTION II TREATMENT TECHNIQUES AND SPECIAL

EQUIPMENT
9 Rehabilitation and Prosthetic Restoration in Upper

Limb Amputation, 51
Joseph Burris
10 Lower Limb Amputation and Gait, 57

Matthew J. McLaughlin
11 Upper Limb Orthoses, 66
Chih-Kuang Chen
12 Lower Limb Orthoses, 75

Tze Yang Chung
13 Spinal Orthoses, 85
Wai-Keung Lee
xix
xx Contents
14 Wheelchairs and Seating Systems, 92

Nazirah Hasnan
15 Therapeutic Exercise, 102

Rochelle Coleen Tan Dy
16 Manipulation, Traction, and Massage, 111

Reynaldo R. Rey-Matias
17 P hysical Agent Modalities, 119

Chueh-Hung Wu
18 Integrative Medicine in Rehabilitation, 126

Tian-Shin Yeh
19 Computer Assistive Devices and Environmental Controls, 129

Shih-Ching Chen
SECTION III COMMON CLINICAL PROBLEMS
20 B ladder Dysfunction, 137

Shih-Chung Chang
21 Neurogenic Bowel: Dysfunction and Rehabilitation, 143

Yu-Hui Huang
22 Sexual Dysfunction and Disability, 150

Tunku Nor Taayah Tunku Zubir
23 Spasticity, 157
Gerard E. Francisco
24 Chronic Wounds, 164

Julia Patrick Engkasan
25 Vascular Diseases, 173

Blessen C. Eapen
26 B urns, 178
Amaramalar Selvi Naicker
27 Acute Medical Conditions, 183

Norhayati Hussein
28 C
hronic Medical Conditions: Pulmonary Disease, Organ
Transplantation, and Diabetes, 190
Chen-Liang Chou
29 Cancer Rehabilitation, 197

Vishwa S. Raj
Contents xxi
30 The Geriatric Patient, 204

Mooyeon Oh-Park
31 Rheumatologic Rehabilitation, 208

Lin-Fen Hsieh
SECTION IV ISSUES IN SPECIFIC DIAGNOSES
32 Common Neck Problems, 216

Carl Chen
33 Low Back Pain, 228

Anwar Suhaimi
34 Osteoporosis, 238
Francesca Gimigliano
35 Upper Limb Pain and Dysfunction, 244

Eleftheria Antoniadou
36 Musculoskeletal Disorders of the Lower Limb, 248

Elena Milkova Ilieva
37 Chronic Pain, 257

Yung-Tsan Wu
38 Pelvic Floor Disorders, 264

Clarice N. Sinn
39 Sports Medicine and Adaptive Sports, 270

Joseph E. Herrera
40 Motor Neuron Diseases, 279
Lydia Abdul Latif
41 Rehabilitation of Patients With Neuropathies, 287

Yi-Chian Wang
42 Myopathy, 299
Ziad M. Hawamdeh
43 Traumatic Brain Injury, 305

Mazlina Mazlan
44 Stroke Syndromes, 315

Mauro Zampolini
45 D
egenerative Movement Disorders of the Central
Nervous System, 319
Andrew Malcolm Dermot Cole
xxii Contents
46 Multiple Sclerosis, 324

Mohd Izmi Bin Ahmad
47 Cerebral Palsy, 331

Desiree L. Roge
48 Myelomeningocele and Other Spinal Dysraphisms, 338

Rashidah Ismail Ohnmar Htwe
49 Spinal Cord Injury, 345

Chen-Yu Hung
50 Auditory, Vestibular, and Visual Impairments, 355

Ding-Hao Liu
Video Contents
SECTION II TREATMENT TECHNIQUES AND SPECIAL
EQUIPMENT
16 Manipulation, Traction, and Massage

Video 16.1. M uscle Energy Technique
17 P hysical Agent Modalities

Video 17.1. Paraffin Bath
SECTION III COMMON CLINICAL PROBLEMS
25 Vascular Diseases
Video 25.1. M onophasic Ar terial Doppler Waveform
31 Rheumatologic Rehabilitation
Video 31.1. Feeding Training with Putty
SECTION IV ISSUES IN SPECIFIC DIAGNOSES
36 Musculoskeletal Disorders of the Lower Limb

Video 36.1. L achman Test
45 Degenerative Movement Disorders of the Central Nervous System

Video 45.1. C arbidopa- and Levodopa-Induced Dyskinesia
xxiii

BRADDOM’S
REHABILITATION
CARE
A Clinical Handbook

SECTION 1
EVALUATION
1 The Physiatric History and Physical Examination

Shaw-Gang Shyu
2 History and Examination of the Pediatric Patient

Chia-Wei Lin
3 Adult Neurogenic Communication and Swallowing Disorders

Ming-Yen Hsiao
4 Psychological Assessment and Intervention in Rehabilitation

Willy Chou
5 Practical Aspects of Impairment Rating and Disability Determination

Maria Gabriella Ceravolo
6 Employment of People with Disabilities

Renald Peter Ty Ramiro
7 Quality and Outcome Measures for Medical Rehabilitation

Elizabeth J. Halmai
8 Electrodiagnostic Medicine
Chein-Wei Chang
1

The Physiatric
History and Physical
1
Examination
Shaw-Gang Shyu
The physiatric history and physical examination are the basis for precise diagnosis
and recognition of the patient’s impairment, and they help in the development of a
comprehensive treatment plan. They also serve as a medicolegal record and a basis
for physician billing. They are documents used for communication between reha-
bilitation and nonrehabilitation health care professionals. The essential elements
of the physiatric history and physical examination are summarized in this chapter
and the accompanying eSlides.
• THE PHYSIATRIC HISTORY

The World Health Organization classification defines impairment as any loss or
abnormality of body structure or a physiologic or psychological function. Activity
is the nature and extent of functioning at the level of the person. Participation refers
to the nature and extent of a person’s involvement in life situations in relation to
impairments, activities, health conditions, and contextual factors. One of the unique
aspects of physiatry is the recognition of functional deficits caused by illness or
injury. Identifying and treating the primary impairments to maximize performance
becomes the primary thrust of physiatric evaluation and treatment. Physicians in
training tend to overassess, but with time the experienced physiatrist develops an
intuition regarding the detail needed for each patient, given a particular presenta-
tion and setting. The time spent in taking a history also allows the patient to become
familiar with the physician, establishing rapport and trust. This initial rapport is crit-
ical for a constructive and productive doctor–patient–family relationship. Patients
are the primary source of information, but if patients are not able to fully express
themselves, the history takers might also rely on the patient’s family members and
friends; other physicians, nurses, and professionals; or previous medical records.
Chief Complaint
The chief complaint is the symptom or concern that caused the patient to seek
medical treatment. Unlike the relatively objective physical examination, the chief
complaint is purely subjective, and the physician should use the patient’s own
words.
History of the Present Illness

The history of the present illness details the chief complaint(s), and it should include
some or all of these eight components related to the chief complaint: location, time
3
4 SECTION I EVALUATION
of onset, quality, context, severity, duration, modifying factors, and associated signs
and symptoms.
Functional Status and Activities of Daily Living

The patient’s functional status provides a better understanding of mobility, activi-
ties of daily living (ADL), instrumental activities of daily living (I-ADL) (eSlide
1.1), communication, cognition, work, and recreation. Assessing the potential for
functional gain or deterioration requires an understanding of the natural history,
cause, and time of onset of the functional problems.
It is sometimes helpful to assess functional status with a standardized scale.
No single scale is appropriate for all patients, but the Functional Independence
Measure (FIM) is the scoring system most commonly used in the inpatient reha-
bilitation setting. Each of 18 different activities is scored on a scale of 1 to 7 (total
score: 18 to 126) (eSlide 1.2), and FIM serves as a kind of rehabilitation shorthand
among team members to quickly and accurately describe functional deficits.
MOBILITY
Mobility is the ability to move about in one’s environment. Bed mobility includes
turning from side to side, changing from the prone to supine positions, sitting up,
and lying down. Transfer mobility includes getting in and out of bed, standing
from the sitting position, and moving between a wheelchair and another seat.
Wheelchair mobility can be assessed by asking if patients can propel the
wheelchair independently, how far or how long they can go without resting,
whether they need assistance with managing the wheelchair parts, and the extent
to which they can move about at home, in the community, and up and down
ramps. Whether the home is potentially wheelchair accessible is particularly
important in cases of new onset of severe disability.
Ambulation and stair mobility can be assessed by the patient’s walking distance
and endurance, the patient’s requirement for assistive devices and need for breaks,
the number of stairs the patient must routinely climb and descend at home or in the
community, and the presence or absence of handrails in their daily lives. Identify-
ing associated symptoms during ambulation and a history of falling or instability
are also important.
Driving (a type of community mobility) is a crucial activity for many people,
and older adults who stop driving face increased depressive symptoms. The risks of
driving are weighed against the consequences of not being able to drive.
COGNITION
Cognition is the mental process of knowing. Because persons with cognitive defi-
cits often cannot recognize their own impairments (agnosia), it is important to also
gather information from other individuals who are familiar with the patient. Cog-
nitive deficits interfere with the patient’s rehabilitation and safety.
COMMUNICATION
Communication skills are used to convey information, including thoughts, needs,
and emotions. Verbal-expression deficits can be subtle. Patients who have deficits
in verbal expression might or might not be able to communicate through other
means, known as augmentative communication strategies. These strategies include
writing and physicality (e.g., sign language, gestures, and body language) and the
use of communication aids (e.g., picture, letter, word board, and electronic devices).
CHAPTER 1 The Physiatric History and Physical Examination 5
Past Medical and Surgical History

The past medical and surgical history allows the physiatrist to understand how pre-
existing illnesses affect the patient’s current status, the precautions and limitations
that will be necessary during a rehabilitation program, and the impact on rehabili-
tation outcomes. Particularly, cardiopulmonary deficits can severely compromise
mobility, ADL, I-ADL, work, and leisure.
All medications should be documented, including prescription medications,
over-the-counter drugs, nutraceuticals, supplements, herbs, and vitamins.
Drug and food allergies should be noted. Particular attention should be paid
to commonly prescribed medications, such as nonsteroidal antiinflammatory
agents.
Social History
Understanding the patient’s home environment and living situation includes ask-
ing whether the patient lives in a house or an apartment and whether elevators,
stairs, or handrails are present. These factors, in conjunction with the level of sup-
port from the patient’s family and friends, will help determine the discharge plans.
Patients should be asked in a nonjudgmental manner about their history of
smoking, alcohol use or abuse, and drug abuse. Sexuality is particularly important
to patients in their reproductive years. Sexual orientation and safer sex practices
should be addressed when appropriate.
VOCATIONAL ACTIVITIES
Vocation is a source of financial security and provides self-confidence and even
identity. The history should include the patient’s education level, recent work his-
tory, and ability to fulfill job requirements subsequent to injury or illness.
FINANCES AND INCOME MAINTENANCE

A social worker may help patients with financial concerns. Whether a patient has
the financial resources or insurance to pay for adaptive devices can significantly
affect discharge planning.
RECREATION
Loss or limitation of the ability to engage in hobbies and recreational activities can
be stressful to most people. Recreation is also a primary outcome in sports medi-
cine. A recreational therapist can be helpful.
PSYCHOSOCIAL HISTORY, SPIRITUALITY, AND BELIEFS

Patients with impairment may feel a loss of overall health, body image, mobil-
ity, independence, or income. Providing assistance in developing coping strategies,
especially for depression and anxiety, can help accelerate the process whereby the
patient learns to adjust to a new disability.
Health care providers should be sensitive to the patient’s spiritual needs and
provide appropriate referral or counseling.
LITIGATION
Litigation (active or pending) can be a source of anxiety, depression, or guilt.
Patients should be asked in a nonjudgmental manner whether they are involved in
litigation. The answer should not change the treatment plan.
Family History
Patients should be asked about the health, or cause and age of death, of parents and
siblings. The family history will help identify genetic disorders within the family
and potential assistance that may be obtained from family members.
Review of Systems
The review of systems identifies problems or diseases that have not yet been
reviewed during the history taking.
• THE PHYSIATRIC PHYSICAL EXAMINATION

Neurologic Examination
Neurologic problems are common in rehabilitation medicine. The precise loca-
tion of the lesion should be identified from an organized neurologic examination.
An accurate and efficient neurologic examination requires that the examiner have
a thorough knowledge of both central and peripheral neuroanatomy before the
examination. Weakness may be seen in both upper motor neuron (UMN) and
lower motor neuron (LMN) disorders. UMN lesions involving the central ner-
vous system are typically characterized by hypertonia and hyperreflexia. LMN
defects are characterized by hypotonia, hyporeflexia, significant muscle atrophy,
fasciculations, and electromyographic changes. UMN and LMN lesions often
coexist, as seen in amyotrophic lateral sclerosis or traumatic brain injury with a
brachial plexus injury.
MENTAL STATUS EXAMINATION

The mental status examination (MSE) should be performed in a comfortable set-
ting where the patient is not likely to be distracted by external stimuli. Bedside
MSE might need to be supplemented by observations in therapy and evaluation by
a neuropsychologist.
The Folstein Mini-Mental Status Examination is a brief and convenient tool
to test general cognitive function. It is useful for screening patients for dementia
and brain injuries. Of a maximum of 30 points, a score of 24 or above is considered
within the normal range. The clock-drawing test is a quick and sensitive test of
cognitive impairment. This task uses memory, visual spatial skills, and executive
functioning. The use of the three-word recall test in addition to the clock-drawing
test, which is known collectively as the Mini-Cog Test, has recently gained popu-
larity in screening for dementia.
Level of consciousness. Consciousness is the state of awareness of one’s surround-

ings. A functioning pontine reticular activating system is necessary for normal con-
scious functioning.
Lethargy is the general slowing of motor processes, such as speech and move-
ment, in which the patient can easily fall asleep if not stimulated but is easily aroused.
Obtundation is a dulled or blunted sensitivity in which the patient is difficult to arouse
and is still confused after arousal. Stupor is a state of semi consciousness characterized
by arousal only by intense stimuli, such as sharp pressure over a bony prominence
(e.g., sternal rub); the patient also has few or even no voluntary motor responses.
In coma, the eyes are closed, sleep-wake cycles are absent, and there is no evi-
dence of a contingent relationship between the patient’s behavior and the environ-
ment. Vegetative state is characterized by the presence of sleep-wake cycles but still
no contingent relationship. Minimally conscious state indicates a patient who remains

severely disabled but demonstrates sleep-wake cycles and inconsistent, nonreflex-
ive, contingent behaviors in response to a specific environmental stimulus. In acute
settings, the Glasgow Coma Scale is the most commonly used objective measure to
document level of consciousness (eSlide 1.3).
Attention. Attention is the ability to address a specific stimulus for a short period
of time without being distracted by internal or external stimuli. Vigilance is the
ability to hold one’s attention over longer periods. Attention is tested by digit re-
call; repeating seven numbers in the forward direction is considered normal, with
fewer than five indicating significant attention deficits.
Orientation. Orientation is composed of four parts: person, place, time, and situ-
ation. Sense of time is usually the first to be lost, and sense of person is typically
the last. Temporary stress can account for a minor loss of orientation, but major
disorientation usually suggests an organic brain syndrome.
Memory. The components of memory include learning, retention, and recall. The
patient is typically asked to remember three or four objects or words and then
asked to repeat the items immediately to assess immediate acquisition (encoding)
of the information. Retention is assessed by recall after a delayed interval, usually
5 to 10 minutes. Normal individuals younger than 60 years should be able to recall
three of four items. Recent memory can be tested by asking questions about the
past 24 hours. Remote memory is tested by asking where the patient was born or
which school or college the patient attended.
General fundamentals of knowledge and abstract thinking. Intelligence is a

global function encompassing both basic intellect and remote memory. The ex-
aminer should note the patient’s highest level of education. Abstraction is a higher
cortical function and should always be considered in the context of intelligence and
cultural differences. It can be tested by asking the patient to interpret a common
proverb or explain a humorous phrase or situation.
Insight and judgment. Insight has been conceptualized into three components:
awareness of impairment, need for treatment, and attribution of symptoms. Recog-
nizing that one has an impairment is the initial step necessary for recovery. A lack
of insight can severely hamper a patient’s progress in rehabilitation.
Judgment is an estimate of a person’s ability to solve real-life problems, and
it is related to the patient’s capacity for independent functioning. Judgment can
be evaluated by simply observing the patient’s behavior or by noting the patient’s
responses to hypothetical situations.
Mood and affect. The examiner should document reactivity and stability of mood.
Mood can be described in terms such as being happy, sad, euphoric, blue, de-
pressed, angry, or anxious. Affect describes how a patient feels at a given moment,
which can be described by terms such as blunted, flat, inappropriate, labile, opti-
mistic, or pessimistic.
COMMUNICATION
Aphasia. Aphasia involves the loss of production or comprehension of language.
Naming, repetition, comprehension, and fluency are the key components. Testing
comprehension of spoken language should begin with single words, progress to

sentences that require only yes/no responses, and then progress to complex com-
mands. Visual naming, repetition of single words and sentences, word-finding
abilities, reading and writing from dictation, and then spontaneous reading and
writing should also be assessed. Some standardized aphasia measures include the
Boston Diagnostic Aphasia Examination and the Western Aphasia Battery (see
Chapter 3).
Dysarthria. Dysarthria refers to defective articulation but unaffected content of

speech. Key sounds include “ta ta ta,” which is made by the tongue (lingual con-
sonants); “mm mm mm,” which is made by the lips (labial consonants); and “ga ga
ga,” which is made by the larynx, pharynx, and palate.
Dysphonia. Dysphonia is a deficit in sound production, which can be secondary

to respiratory disease, fatigue, or vocal cord paralysis. Indirect laryngoscopy is the
best method to examine the vocal cords. Patients are asked to say “ah” to assess
vocal cord abduction and “e” to assess adduction. Patients with weakness of both
vocal cords will speak in a whisper and exhibit inspiratory stridor.
Verbal apraxia. Apraxia of speech involves a deficit in motor planning without

impaired strength or coordination. It is characterized by inconsistent errors when
speaking. Oromotor apraxia is seen in patients with difficulty organizing nonspeech
oral motor activity. It can adversely affect swallowing. Tests for verbal and oral mo-
tor function are listed in Chapter 3.
Cognitive linguistic deficits. Cognitive linguistic deficits involve the pragmatics

and context of communication, such as confabulation. Cognitive linguistic deficits
are distinguished from fluent aphasias (e.g., Wernicke aphasia) by the presence of
relatively normal syntax and grammar.
CRANIAL NERVE EXAMINATION

Cranial nerve I: olfactory nerve. Both perception and identification of smell
should be tested with aromatic, nonirritating materials that avoid stimulation of
the trigeminal nerve. The olfactory nerve is the most commonly injured cranial
nerve (CN) in head trauma.
Cranial nerve II: optic nerve. The optic nerve is assessed by testing visual acuity
and visual fields. Visual acuity refers to central vision. Visual field testing assesses
the integrity of the optic pathway. Testing visual fields is most commonly per-
formed by confrontation. For patients with deficits, further assessment by a neuro-
optometrist or visually trained occupational therapist can be helpful.
Cranial nerves III, IV, and VI: oculomotor, trochlear, and abducens nerves. The
oculomotor nerve innervates the medial rectus muscle (adductor of the eye), supe-
rior rectus and inferior oblique muscles (elevators of the eye), and inferior rectus
muscle (depressor of the eye). The trochlear nerve innervates the superior oblique
muscle, which is responsible for the downward gaze, especially during adduction.
The abducens nerve controls the lateral rectus muscle, which abducts the eye. The
examiner should assess the alignment of the patient’s eyes while the eyes are at rest
and when the eyes are following an object, observing the full range of horizontal
and vertical eye movements in the six cardinal directions. The optic (afferent) and
oculomotor (efferent) nerves are involved with the pupillary light reflex, which
normally results in constriction of both pupils when a light stimulus is presented to
either eye separately. A characteristic head tilt when looking downward is some-
times seen in CN IV lesions.
Cranial nerve V: trigeminal nerve. The three sensory branches of CN V can be

tested along the forehead (ophthalmic branch), cheeks (maxillary branch), and jaw
(mandibular branch) bilaterally. The motor branch of the trigeminal nerve inner-
vates the muscles of mastication, which include the masseters, pterygoids, and tem-
poralis muscles. The corneal reflex tests the ophthalmic division of the trigeminal
nerve (afferent) and the facial nerve (efferent).
Cranial nerve VII: facial nerve. The facial nerve is first examined by observing the
patient while he or she is talking, smiling, closing the eyes, flattening the nasolabial
fold, and elevating one corner of the mouth. The patient is then asked to wrinkle
the forehead (frontalis muscle function), close the eyes while the examiner attempts
to open them (orbicularis oculi function), puff out both cheeks while the examiner
presses on the cheeks (buccinator function), and show the teeth (orbicularis oris
function). A peripheral injury to the facial nerve, such as Bell palsy, affects both
the upper and lower face, whereas a central lesion typically affects mainly the lower
face.
Cranial nerve VIII: vestibulocochlear nerve. The vestibulocochlear nerve com-

prises two divisions: the cochlear nerve, which is responsible for hearing, and the
vestibular nerve, which is related to balance. The cochlear division can be tested by
checking gross hearing by rubbing the thumb and index fingers near each ear of the
patient. Patients with dizziness or vertigo associated with changes in head position
or suspected of having benign paroxysmal positional vertigo should be assessed
with the Dix-Hallpike maneuver (eSlide 1.4).
Cranial nerves IX and X: glossopharyngeal nerve and vagus nerve. Hoarseness

is usually associated with a lesion of the recurrent laryngeal nerve, a branch of the
vagus nerve. Normally, the soft palate should elevate symmetrically, and the uvula
should remain in the midline when the patient says “ah.” In UMN vagus nerve le-
sions, the uvula will deviate toward the side of the lesion, but in LMN lesions, the
uvula will deviate to the contralateral side. Gag reflex can be tested by touching the
pharyngeal wall with a cotton tip applicator until the patient gags. The examiner
should compare the sensitivity of each side (afferent: glossopharyngeal nerve) and
observe the symmetry of the palatal movement (efferent: vagus nerve). The pres-
ence of a gag reflex does not imply the ability to swallow without risk of aspiration.
Cranial nerve XI: accessory nerve. Atrophy or asymmetry of the patient’s trape-
zius and sternocleidomastoid muscles should be checked. Trapezius atrophy results
in a laterally migrated scapula (“open door” winging). To test the strength of the
sternocleidomastoid muscle, the patient should be asked to rotate the head against
resistance.
Cranial nerve XII: hypoglossal nerve. The hypoglossal nerve is tested by asking
the patient to protrude the tongue and noting evidence of atrophy, fasciculation,
or deviation. Fibrillations in the tongue are common in patients with amyotrophic

lateral sclerosis. The tongue typically points to the side of the lesion in peripheral
hypoglossal nerve lesions but away from the lesion in UMN lesions.
SENSORY EXAMINATION (eSlides 1.5 and 1.6)

Evaluation of the sensory system requires testing both superficial sensation (light
touch, pain, and temperature) and deep sensation (position and vibration).
Light touch can be assessed with a fine wisp of cotton or a cotton tip applicator.
Pain is assessed with a safety pin. Thermal sensation can be checked with two dif-
ferent cups, one filled with hot water and one filled with cold water and ice chips.
Proprioception is tested by passive vertical movement of the toes or fingers
when the patient’s eyes are closed. The patient is asked whether the digit is being
moved in an upward or downward direction. It is important to grasp the sides of the
digit rather than the nailbed to avoid the patient perceiving pressure in this area.
Vibration is tested with a 128-Hz tuning fork, which is placed on a bony promi-
nence, such as the dorsal aspect of the malleoli, olecranon, or terminal phalange of
the great toe or finger. The patient is asked to indicate when the vibration ceases.
Two-point discrimination is tested by calipers with blunt ends. The patient
(with closed eyes) is asked to indicate whether one or two stimulation points are
felt. Commonly tested two-point discrimination areas and their normal values are
as follows: lips (2–3 mm), fingertips (3–5 mm), dorsum of the hand (20–30 mm),
and palms (8–15 mm).
Testing for graphesthesia, the ability to recognize numbers, letters, or sym-
bols traced onto the palm, is performed by writing recognizable numbers on the
patient’s palm while the patient’s eyes remain closed. Stereognosis is the ability to
recognize common objects, such as keys or coins, when placed in the hand.
MOTOR CONTROL
Strength. Manual muscle testing (eSlides 1.7 and 1.8) provides an important
method of quantifying strength. Pain can result in give-way weakness. It is impor-
tant to recognize the presence of substitution when muscles are weak or movement
is uncoordinated. Patients who cannot actively control muscle tension (e.g., those
with spasticity) are not appropriate for standard manual muscle testing methods.
A muscle grade of 3 is functionally important because antigravity strength implies
that a limb can be used for activity. Females’ strength typically increases up to 20
years, plateaus through the twenties, and then gradually declines after age 30 years.
Males increase strength up to age 20 years and then plateau until older than 30
years before declining.
Tables 1.13 and 1.14 in Braddom’s Physical Medicine and Rehabilitation, Fifth Edi-
tion (ISBN: 978-0-323-28046-4), summarize joint movements, innervation, and
manual strength testing techniques for all major muscle groups of the extremities.
Examples of tests for shoulder abduction are shown in eSlide 1.9.
Coordination. Ataxia or coordination deficits can be secondary to deficits of sen-

sory, motor, or cerebellar connections. Dysdiadochokinesia describes an inability
to perform rapidly alternating movements.
Lesions affecting the midline cerebellum usually produce truncal ataxia, whereas
lesions that affect the anterior lobe of the cerebellum usually result in gait ataxia.
Lateral cerebellar hemisphere lesions produce limb ataxia, which can be tested by
the finger-to-nose test and heel-to-shin test.
The Romberg test can be used to differentiate a cerebellar deficit from a pro-
prioceptive deficit. If loss of balance is present when the eyes are open or closed,
it is indicative of cerebellar ataxia. If loss of balance occurs only when the eyes are
closed, it is a positive Romberg sign, which indicates a proprioceptive (sensory)
deficit.
Apraxia. Apraxia is the loss of the ability to carry out programmed or planned
movements despite adequate understanding of the task and no weakness or sensory
loss. Ideomotor apraxia occurs when a patient cannot carry out motor commands
but can perform the required movements under different circumstances. Ideational
apraxia refers to the inability to carry out sequences of acts, although each compo-
nent can be performed separately. Dressing apraxia and constructional apraxia are
the result of neglect rather than actual deficits in motor planning.
Involuntary movements. Tremor, the most common type of involuntary move-

ment, is a rhythmic movement of a body part. Myoclonus is a quick jerking move-
ment of a muscle or body part. Chorea constitutes movements that consist of
brief, random, nonrepetitive movements in a fidgety patient who is unable to
sit still. Athetosis consists of twisting and writhing movements and is commonly
seen in cerebral palsy. Dystonia is a sustained posturing that can affect small
or large muscle groups. Hemiballismus occurs when there are repetitive violent
flailing movements.
Tone. Tone is the resistance of a muscle to stretch or passively elongate (see Chap-
ter 23). Spasticity is a velocity-dependent increase in the stretch reflex, whereas
rigidity is the resistance of the limb to passive movement in the relaxed state (non–
velocity-dependent).
Tone can be quantified by the Modified Ashworth Scale (MAS). A pendulum
test can also be used to quantify spasticity. The Tardieu Scale has been suggested
as a more appropriate clinical measure of spasticity than the MAS. Measurements
are usually taken at three velocities (V1, V2, and V3). V1 is measured as slow as
possible, V2 is measured at the speed of the limb falling under gravity, and V3 is
measured when the limb is moving as fast as possible. Responses are recorded at
each velocity and at the angles (in degrees) at which the muscle response occurs.
REFLEXES
Superficial reflexes (eSlide 1.10). The normal plantar reflex consists of flexion
of the great toe or no response. With dysfunction of the corticospinal tract, there
is a positive Babinski sign, which consists of dorsiflexion of the great toe with an
associated fanning of the other toes. A positive Chaddock sign refers to dorsiflex-
ion of the great toe after stroking from the lateral ankle to the lateral dorsal foot.
A positive Stransky sign refers to an upgoing great toe after flipping the little toe
outward.
Muscle stretch reflexes (eSlide 1.11). Muscle stretch reflexes, which were called
deep tendon reflexes in the past, are assessed by tapping the skin overlying the
muscle tendon with a reflex hammer. The response is assessed as 0, no response;
1+, diminished but present and might require facilitation; 2+, usual response; 3+,
brisker than usual; and 4+, hyperactive with clonus. Reinforcement maneuvers,
such as the Jendrassik maneuver, assist examination.
Primitive reflexes. Primitive reflexes are abnormal reflexes that represent devel-
opmental regression, indicating significant neurologic abnormalities in adults. Ex-
amples of primitive reflexes include the sucking reflex, rooting reflex, grasp reflex,
snout reflex, and palmomental response.
GAIT
Gait is a series of rhythmic, alternating movements of the limbs and trunk that
result in the forward progression of the center of gravity. Gait is dependent on
input from several systems, including the visual, vestibular, cerebellar, motor, and
sensory systems. Gait disorders have stereotypical patterns that reflect injury to
various aspects of the neurologic system (eSlide 1.12).
Musculoskeletal Examination
The musculoskeletal (MSK) examination incorporates inspection, palpation, pas-
sive and active range of movement (ROM), assessment of joint stability, manual
muscle testing, joint-specific provocative maneuvers, and special tests. Readers may
view Table 1.9 in Braddom’s Physical Medicine and Rehabilitation, Fifth Edition, for
details and reliability of joint-specific provocative maneuvers.
INSPECTION
Inspection includes observing mood, signs of pain or discomfort, functional
impairments, or evidence of malingering (e.g., Waddell signs). The spine should
be inspected for scoliosis, kyphosis, and lordosis, whereas limbs should be exam-
ined for symmetry, circumference, and contour. Muscle atrophy, masses, edema,
scars, skin breakdown, and fasciculations should also be checked. Joints should be
inspected for deformity, visible swelling, and erythema.
Kinetic chain refers to the summation of individual joint movements linked in
a series, leading to the production of a larger functional goal. A change in move-
ment of a single joint may affect the motion of adjacent, as well as distant, joints
in the chain. This may result in asymmetric patterns causing disease at seemingly
unrelated sites.
PALPATION
Palpation is used to identify tender areas and localize trigger points, muscle guard-
ing, or spasticity. Joints and soft tissues should be assessed for effusion, warmth,
masses, tight muscle bands, tone, and crepitus.
Assessment of joint stability. Bilateral examination is critical because assessment

of the “normal” side establishes a patient’s unique biomechanics. Joint play or cap-
sular patterns assess the integrity of the capsule in positions of minimal bony con-
tact, sometimes referred to as an open-packed position.
Assessment of range of movement general principles. ROM testing is used to

assess the integrity of a joint, monitor the efficacy of treatment regimens, and deter
mine the mechanical cause of impairment. Normal ROM varies according to age,
gender, conditioning, body habitus, and genetics. Passive ROM should be performed
through all planes of motion. Active ROM is performed by the patient through all
planes of motion, without assistance from the examiner. Range is measured with
a universal goniometer (eSlide 1.13). Correct patient positioning and planes of
motion for testing shoulder and hip joint ROM are shown in eSlides 1.14 and 1.15.
For more comprehensive and detailed information regarding measurements of

each joint, the reader may refer to Chapter 1 in Braddom’s Physical Medicine and
Rehabilitation, Fifth Edition.
• ASSESSMENT, SUMMARY, AND PLAN

Only after completing a thorough physiatric history and physical examination is
the physiatrist able to develop a comprehensive treatment plan. The organization
of the initial treatment plan and goals should clearly state the impairments, perfor-
mance deficits (activity limitations), community or role dysfunction (participation
level), medical conditions that can affect achieving both short-term and long-term
functional goals, and goals for the interdisciplinary rehabilitation team. Follow-up
treatment plans and notes are likely to be shorter and less detailed, but they must
address important interval changes since the last documentation and any significant
changes in treatment or goals.
Clinical Pearls
A comprehensive rehabilitation physiatric history and physical examination help
develop a treatment plan with proper goals.
The physiatric history and physical examination begin with the standard medical
format but go beyond that to assess impairment, activity limitation (disability), and
participation (handicap).
Identifying and treating the primary impairments to maximize performance is the
primary thrust of physiatric evaluation and treatment.
Physiatrists’ understanding of the MSK principles and MSK examination distin-
guishes them from neurologists and neurosurgeons. Bilateral examination is critical.
Physiatrists’ understanding of neurology and the neurologic examination distin-
guishes them from orthopedists and rheumatologists.

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BOILED LOIN OF VEAL.
If dressed with care and served with good sauces, this, when the
meat is small and white is an excellent dish, and often more
acceptable to persons of delicate habit than roast veal. Take from
eight to ten pounds of the best end of the loin, leave the kidney in
with all its fat, skewer or bind down the flap, lay the meat into cold
water, and boil it as gently as possible from two hours and a quarter
to two and a half, clearing off the scum perfectly, as in dressing the
fillet. Send it to table with well-made oyster sauce, or béchamel, or
with white sauce well flavoured with lemon-juice, and with parsley,
boiled, pressed dry, and finely chopped.
2-1/4 to 2-1/2 hours.
STEWED LOIN OF VEAL.
Take part of a loin of veal, the chump end will do; put into a large,
thick, well-tinned iron saucepan, or into a stewpan, about a couple of
ounces of butter, and shake it over a moderate fire until it begins to
brown; flour the veal well all over, lay it into the saucepan, and when
it is of a fine, equal, light brown, pour gradually in veal broth, gravy,
or boiling water to nearly half its depth; add a little sauce, one or two
sliced carrots, a small onion, or more when the flavour is much liked,
and a bunch of parsley; stew the veal very softly for an hour or rather
more; then turn it, and let it stew for nearly or quite another hour, or
longer should it not be perfectly tender. As none of our receipts have
been tried with large, coarse veal, the cooking must be regulated by
that circumstance, and longer time allowed should the meat be of
more than moderate size. Dish the joint, skim all the fat from the
gravy, and strain it over the meat; or keep the joint hot while it is
rapidly reduced to a richer consistency. This is merely a plain family
stew.
BOILED BREAST OF VEAL.
Let both the veal and the sweetbread be washed with exceeding
nicety, cover them with cold water, clear off the scum as it rises,
throw in a little salt, add a bunch of parsley, a large blade of mace,
and twenty white peppercorns; simmer the meat from an hour to an
hour and a quarter, and serve it covered with rich onion sauce. Send
it to table very hot. The sweetbread may be taken up when half
done, and curried, or made into cutlets, or stewed in brown gravy.
When onions are objected to, substitute white sauce and a cheek of
bacon for them, or parsley and butter, if preferred to it.
1 to 1-1/4 hour.
TO ROAST A BREAST OF VEAL.
Let the caul remain skewered over the joint till with within half an
hour of its being ready for table: place it at a moderate distance from
a brisk fire, baste it constantly, and in about an hour and a half
remove the caul, flour the joint, and let it brown. Dish and pour
melted butter over it, and serve it with a cut lemon, and any other of
the usual accompaniments to veal. It may be garnished with fried
balls of the forcemeat (No. 1, Chapter VIII.) about the size of a
walnut.
2 to 2-1/2 hours.
TO BONE A SHOULDER OF VEAL, MUTTON, OR LAMB.
Spread a clean cloth upon a table or

dresser, and lay the joint flat upon it, with
the skin downwards; with a sharp knife cut
off the flesh from the inner side nearly down
to the blade bone, of which detach the
edges first, then work the knife under it,
keeping it always close to the bone, and
Shoulder of Veal
using all possible precaution not to pierce
boned.
the outer skin; when it is in every part
separated from the flesh, loosen it from the
socket with the point of the knife, and remove it; or, without dividing
the two bones, cut round the joint until it is freed entirely from the
meat, and proceed to detach the second bone. That of the knuckle is
frequently left in, but for some dishes it is necessary to take it out; in
doing this, be careful not to tear the skin. A most excellent grill may
be made by leaving sufficient meat for it upon the bones of a
shoulder of mutton, when they are removed from the joint: it will be
found very superior to the broiled blade-bone of a roast shoulder,
which is so much liked by many people.
STEWED SHOULDER OF VEAL.
(English Receipt.)
Bone a shoulder of veal, and strew the inside thickly with savoury
herbs minced small; season it well with salt, cayenne, and pounded
mace; and place on these a layer of ham cut in thin slices and freed
from rind and rust. Roll up the veal, and bind it tightly with a fillet;
roast it for an hour and a half, then simmer it gently in good brown
gravy for five hours; add forcemeat balls before it is dished; skim the
fat from the gravy, and serve it with the meat. This receipt, for which
we are indebted to a correspondent on whom we can depend, and
which we have not therefore considered it necessary to test
ourselves, is for a joint which weighs ten pounds before it is boned.
ROAST NECK OF VEAL.
The best end of the neck will make an excellent roast. A forcemeat
may be inserted between the skin and the flesh, by first separating
them with a sharp knife; or the dish may be garnished with the
forcemeat in balls. From an hour and a half to two hours will roast it.
Pour melted butter over it when it is dished, and serve it like other
joints. Let it be floured when first laid to the fire, kept constantly
basted, and always at a sufficient distance to prevent its being
scorched.
1-1/2 to 2 hours.
For the forcemeat, see No. 1, Chapter VIII. From 8 to 10 minutes
will fry the balls.
NECK OF VEAL À LA CRÊME.
(Or Au Béchamel.)
Take the best end of a neck of white and well-fed veal, detach the
flesh from the ends of the bones, cut them sufficiently short to give
the joint a good square form, fold and skewer the skin over them,
wrap a buttered paper round the meat, lay it at a moderate distance
from a clear fire, and keep it well basted with butter for an hour and a
quarter; then remove the paper and continue the basting with a pint,
or more, of béchamel or of rich white sauce, until the veal is
sufficiently roasted, and well encrusted with it. Serve some béchamel
under it in the dish, and send it very hot to table. For variety, give the
béchamel in making it a high flavour of mushrooms, and add some
small buttons stewed very white and tender, to the portion reserved
for saucing the joint.
2 to 2-1/4 hours.
VEAL GOOSE.
(City of London receipt.)

“This is made with the upper part of the flank of a loin of veal (or
sometimes that of the fillet) covered with a stuffing of sage and
onions, then rolled, and roasted or broiled. It is served with brown
gravy and apple sauce, is extremely savoury, and has many
admirers.” We transcribe the exact receipt for this dish, which was
procured for us from a house in the city, which is famed for it. We
had it tested with the skin of the best end of a fine neck of veal, from
which it was pared with something more than an inch depth of the
flesh adhering to it. It was roasted one hour, and answered
extremely well. It is a convenient mode of dressing the flank of the
veal for eaters who do not object to the somewhat coarse savour of
the preparation. When the tendrons or gristles of a breast, or part of
a breast of veal, are required for a separate dish, the remaining
portion of the joint may be dressed in this way after the bones have
been taken out; or, without removing them, the stuffing may be
inserted under the skin.
KNUCKLE OF VEAL EN RAGOUT.
Cut in small thick slices the flesh of a knuckle of veal, season it

with a little fine salt and white pepper, flour it lightly, and fry it in
butter to a pale brown, lay it into a very clean stewpan or saucepan,
and just cover it with boiling water; skim it clean, and add to it a
faggot of thyme and parsley, the white part of a head of celery, a
small quantity of cayenne, and a blade or two of mace. Stew it very
softly from an hour and three quarters to two hours and a half.
Thicken and enrich the gravy if needful with rice-flour and mushroom
catsup or Harvey’s sauce, or with a large teaspoonful of flour, mixed
with a slice of butter, a little good store-sauce and a glass of sherry
or Madeira. Fried forcemeat balls of No. 1, Chapter VIII. may be
added at pleasure. With an additional quantity of water, or of broth
(made with the bones of the joint), a pint and a half of young green
peas stewed with the veal for an hour will give an agreeable variety
of this dish.
BOILED KNUCKLE OF VEAL.
After the joint has been trimmed and well washed, put it into a
vessel well adapted to it in size, for if it be very large, so much water
will be required that the veal will be deprived of its flavour; it should
be well covered with it, and very gently boiled until it is perfectly
tender in every part, but not so much done as to separate from the
bone. Clear off the scum with scrupulous care when the simmering
first commences, and throw in a small portion of salt; as this, if
sparingly used, will not redden the meat, and will otherwise much
improve it. Parsley and butter is usually both poured over, and sent
to table with a knuckle of veal, and boiled bacon also should
accompany it. From the sinewy nature of this joint, it requires more
than the usual time of cooking, a quarter of an hour to the pound not
being sufficient for it.
Veal 6 to 7 lbs.: 2 hours or more.
KNUCKLE OF VEAL WITH RICE.
Pour over a small knuckle of veal rather more than sufficient water
to cover it; bring it slowly to a boil; take off all the scum with great
care, throw in a teaspoonful of salt, and when the joint has simmered
for about half an hour, throw in from eight to twelve ounces of well
washed rice, and stew the veal gently for an hour and a half longer,
or until both the meat and rice are perfectly tender. A seasoning of
cayenne and mace in fine powder with more salt, should it be
required, must be added twenty or thirty minutes before they are
served. For a superior stew good veal broth may be substituted for
the water.
Veal, 6 lbs.; water, 3 to 4 pints; salt, 1 teaspoonful: 30 to 40
minutes. Rice, 8 to 12 oz.: 1-1/2 hour.
Obs.—A quart or even more of full grown green peas added to the
veal as soon as the scum has been cleared off will make a most
excellent stew. It should be well seasoned with white pepper, and the
mace should be omitted. Two or three cucumbers, pared and freed
from the seeds, may be sliced into it when it boils, or four or five
young lettuces shred small may be added instead. Green onions
also, when they are liked, may be used to give it flavour.
SMALL PAIN DE VEAU, OR, VEAL CAKE.
Chop separately and very fine, a pound and a quarter of veal quite
free from fat and skin, and six ounces of beef kidney-suet; add a
teaspoonful of salt, a full third as much of white pepper and of mace
or nutmeg, with the grated rind of half a lemon, and turn the whole
well together with the chopping-knife until it is thoroughly mixed; then
press it smoothly into a small round baking dish, and send it to a
moderate oven for an hour and a quarter. Lift it into a clean hot dish,
and serve it plain, or with a little brown gravy in a tureen. Three
ounces of the lean of a boiled ham minced small, will very much
improve this cake, of which the size can be increased at will, and
proportionate time allowed for dressing it. If baked in a hot oven, the
meat will shrink to half its proper size, and be very dry. When done, it
should be of a fine light brown, and like a cake in appearance.
Veal, 1-1/4 lb.; beef-suet, 6 oz.; salt, 1 teaspoonful; pepper and
mace, or nutmeg, 3/4 teaspoonful each; rind of 1/2 lemon; ham
(when added) 3 oz.; baked 1-1/4 hour.
BORDYKE VEAL CAKE.
(Good.)
Take a pound and a half of veal perfectly clear of fat and skin, and
eight ounces of the nicest striped bacon; chop them separately, then
mix them well together with the grated rind of a small lemon, half a
teaspoonful of salt, a fourth as much of cayenne, the third part of a
nutmeg grated, and a half-teaspoonful of freshly pounded mace
When it is pressed into the dish, let it be somewhat higher in the
centre than at the edge; and whether to be served hot or cold, lift it
out as soon as it comes from the oven, and place it on a strainer that
the fat may drain from it; it will keep many days if the under side be
dry. The bacon should be weighed after the rind, and any rust it may
exhibit, have been trimmed from it. This cake is excellent cold, better
indeed than the preceding one; but slices of either, if preferred hot,
may be warmed through in a Dutch oven, or on the gridiron, or in a
few spoonsful of gravy. The same ingredients made into small cakes,
well floured, and slowly fried from twelve to fifteen minutes, then
served with gravy made in the pan as for cutlets, will be found
extremely good.
Veal, 1-1/2 lb.; striped bacon, 8 oz.; salt and mace, 1 teaspoonful
each; rind of lemon, 1; third of 1 nutmeg; cayenne, 4 grains; baked
1-1/4 to 1-1/2 hour.
FRICANDEAU OF VEAL. (ENTRÉE).
French cooks always prefer for this dish, which is a common one
in their own country, that part of the fillet to which the fat or udder is
attached;[76] but the flesh of the finer part of the neck or loin, raised
clear from the bones, may be made to answer the purpose nearly or
quite as well, and often much more conveniently, as the meat with us
is not divided for sale as in France; and to purchase the entire fillet
for the sake of the fricandeau would render it exceedingly expensive.
Lay the veal flat upon a table or dresser, with the skin uppermost,
and endeavour, with one stroke of an exceedingly sharp knife, to
clear this off, and to leave the surface of the meat extremely smooth;
next lard it thickly with small lardoons, as directed for a pheasant
(page 181), and make one or two incisions in the underside with the
point of a knife, that it may the better imbibe the flavour of the
seasonings. Take a stewpan, of sufficient size to hold the fricandeau,
and the proper quantity of vegetables compactly arranged, without
much room being left round the meat. Put into it a couple of large
carrots, cut in thick slices, two onions of moderate size, two or three
roots of parsley, three bay leaves, two small blades of mace, a
branch or two of lemon thyme, and a little cayenne, or a saltspoonful
of white peppercorns. Raise these high in the centre of the stewpan,
so as to support the meat, and prevent its touching the gravy. Cover
them with slices of very fat bacon, and place the fricandeau gently
on them; then pour in as much good veal broth, or stock, as will
nearly cover the vegetables without reaching to the veal. A calf’s
foot, split in two, may with advantage be laid under them in the first
instance. Stew the fricandeau very gently for upwards of three hours,
or until it is found to be extremely tender when probed with a fine
skewer or a larding-pin. Plenty of live embers must then be put on
the lid of the stewpan for ten minutes or a quarter of an hour, to
render the lardoons firm. Lift out the fricandeau and keep it hot;
strain and reduce the gravy very quickly, after having skimmed off
every particle of fat; glaze the veal, and serve it on a ragout of sorrel,
cucumbers, or spinach. This, though rather an elaborate receipt, is
the best we can offer to the reader for a dish, which is now almost as
fashionable with us as it is common on the Continent. Some English
cooks have a very summary method of preparing it; they merely lard
and boil the veal until they can “cut it with a spoon.” then glaze and
serve it with “brown gravy in the dish.” This may be very tolerable
eating, but it will bear small resemblance to the French fricandeau.
76. Called by them the noix.
3-1/2 to 4 hours.
SPRING-STEW OF VEAL.
Cut two pound of veal, free from fat, into small half-inch thick
cutlets; flour them well, and fry them in butter with two small
cucumbers sliced, sprinkled with pepper, and floured, one moderate
sized lettuce, and twenty-four green gooseberries cut open
lengthwise and seeded. When the whole is nicely browned, lift it into
a thick saucepan, and pour gradually into the pan half a pint, or
rather more, of boiling water, broth, or gravy. Add as much salt and
pepper as it requires. Give it a minute’s simmer, and pour it over the
meat, shaking it well round the pan as this is done. Let the veal stew
gently from three quarters of an hour to an hour. A bunch of green
onions cut small may be added to the other vegetables if liked; and
the veal will eat better, if slightly seasoned with salt and pepper
before it is floured; a portion of fat can be left on it if preferred.
Veal 2 lbs.; cucumbers, 2; lettuce, 1; green gooseberries, 24;
water or broth, 1/2 pint or more: 3/4 to 1 hour.
NORMAN HARRICO.
Brown in a stewpan or fry lightly, after having sprinkled them with

pepper, salt, and flour, from two to three pounds of veal cutlets. If
taken from the neck or loin, chop the bones very short, and trim
away the greater portion of the fat. Arrange them as flat as they can
be in a saucepan; give a pint of water a boil in the pan in which they
have been browned, and pour it on them; add a small faggot of
parsley, and, should the flavour be liked, one of green onions also.
Let the meat simmer softly for half an hour; then cover it with small
new potatoes which have had a single boil in water, give the
saucepan a shake, and let the harrico stew very gently for another
half hour, or until the potatoes are quite done, and the veal is tender.
When the cutlets are thick and the potatoes approaching their full
size, more time will be required for the meat, and the vegetables
may be at once divided: if extremely young they will need the
previous boil. Before the harrico is served, skim the fat from it, and
add salt and pepper should it not be sufficiently seasoned. A few bits
of lean ham, or shoulder of bacon browned with the veal, will much
improve this dish, and for some tastes, a little acid will render it more
agreeable. Very delicate pork chops may be dressed in the same
way. A cutlet taken from the fillet and freed from fat and skin,
answers best for this dish. Additional vegetables, cooked apart, can
be added to it after it is dished. Peas boiled very green and well
drained, or young carrots sliced and stewed tender in butter, are both
well suited to it.
Veal, 2 to 3 lbs.; water (or gravy), 1 pint; new potatoes 1-1/2 to 2
lbs.; faggot, parsley, and green onions: 1 hour or more.
PLAIN VEAL CUTLETS.
Take them if possible free from bone, and after having trimmed
them into proper shape, beat them with a cutlet-bat or paste-roller
until the fibre of the meat is thoroughly broken; flour them well to
prevent the escape of the gravy, and fry them from twelve to fifteen
minutes over a fire which is not sufficiently fierce to burn them before
they are quite cooked through: they should be of a fine amber brown,
and perfectly done. Lift them into a hot dish, pour the fat from the
pan, throw in a slice of fresh butter, and when it is melted, stir or
dredge in a dessertspoonful of flour; keep these shaken until they
are well-coloured, then pour gradually to them a cup of gravy or of
boiling water; add pepper, salt, a little lemon-pickle or juice, give the
whole a boil, and pour it over the cutlets: a few forcemeat balls fried
and served with them, is usually a very acceptable addition to this
dish, even when it is garnished or accompanied with rashers of ham
or bacon. A morsel of glaze, or of the jelly of roast meat, should
when at hand be added to the sauce, which a little mushroom
powder would further improve: mushroom sauce, indeed, is
considered by many epicures, as indispensable with veal cutlets. We
have recommended in this one instance that the meat should be
thoroughly beaten, because we find that the veal is wonderfully
improved by the process, which, however, we still deprecate for
other meat.
12 to 15 minutes.
VEAL CUTLETS A L’INDIENNE, OR INDIAN FASHION. (ENTRÉE.)
Mix well together four ounces of very fine stale bread-crumbs, a

teaspoonful of salt, and a tablespoonful of the best currie powder.
Cut down into small well-shaped cutlets or collops, two pounds of
veal free from fat, skin, or bone; beat the slices flat, and dip them
first into some beaten egg-yolks, and then into the seasoned
crumbs; moisten them again with egg, and pass them a second time
through bread-crumbs. When all are ready, fry them in three or four
ounces of butter over a moderate fire, from twelve to fourteen
minutes. For sauce, mix smoothly with a knife, a teaspoonful of flour
and an equal quantity of currie-powder, with a small slice of butter;
shake these in the pan for about five minutes, pour to them a cup of
gravy or boiling water, add salt and cayenne if required and the
strained juice of half a lemon; simmer the whole till well flavoured,
and pour it round the cutlets. A better plan is, to have some good
currie sauce ready prepared to send to table with this dish; which
may likewise be served with only well-made common cutlet gravy,
from the pan, when much of the pungent flavour of the currie-powder
is not desired.
Bread-crumbs, 4 oz.; salt, 1 teaspoonful; currie powder, 1
tablespoonful; veal, 2 lbs.: 12 to 14 minutes.
Obs.—These cutlets may be broiled; they should then be well
beaten first, and dipped into clarified butter instead of egg before
they are passed through the curried seasoning.

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BRADDOM’S REHABILITATION CARE:

Copyright © 2018 by Elsevier, Inc. All rights reserved.

Library of Congress Cataloging-in-Publication Data

Senior Acquisition Editor: Kristine Jones

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Eleftheria Antoniadou, MD, FEBPMR, PhDc

Maria Gabriella Ceravolo, MD, PhD

Shih-Chung Chang, MD, MS

Carl Chen, MD, PhD

Shih-Ching Chen, MD, PhD

Willy Chou, MD, HRMS

Tze Yang Chung, MBBS, MRehabMed

Andrew Malcolm Dermot Cole, MBBS (Hons), FACRM, FAFRM

Rochelle Coleen Tan Dy, MD

Julia Patrick Engkasan, MBBS (Mal), MRehabMed (Mal)

Francesca Gimigliano, MD, PhD

Nazirah Hasnan, MBBS, MRehabMed, PhD

Joseph E. Herrera, DO, FAAPMR

Rashidah Ismail Ohnmar Htwe, MBBS, M MED Sc (Rehab Med), CMIA

Yu-Hui Huang, MD, PhD

Norhayati Hussein, MBBS, MRehabMed, Fellowship in Neurorehabilitation

Elena Milkova Ilieva, MD, PhD, Prof.

Lydia Abdul Latif, MBBS, MRM

Henry L. Lew, MD, PhD

Mazlina Mazlan, MBBS, MRM

Matthew J. McLaughlin, MD, MSB

Amaramalar Selvi Naicker, MBBS (Ind), MRehabMed (Mal)

Mooyeon Oh-Park, MD, MS

Renald Peter Ty Ramiro, MD

Reynaldo R. Rey-Matias, PT, MD, MSHMS

Clarice N. Sinn, DO, MHA

Anwar Suhaimi, MBBS, MRehabMed (Malaya)

Yi-Chian Wang, MD, MSc

Tian-Shin Yeh, MD, MMS

Tunku Nor Taayah Tunku Zubir, MBBS

David X. Cifu, MD, and Henry L. Lew, MD, PhD

Jianan Li, MD, Immediate Past President, International Society of Physical

1 The Physiatric History and Physical Examination, 3

2 History and Examination of the Pediatric Patient, 14

3 Adult Neurogenic Communication and Swallowing Disorders, 18

4 P sychological Assessment and Intervention in Rehabilitation, 24

5 Practical Aspects of Impairment Rating and

6 Employment of People with Disabilities, 34

7 Quality and Outcome Measures for Medical Rehabilitation, 39

SECTION II TREATMENT TECHNIQUES AND SPECIAL

9 Rehabilitation and Prosthetic Restoration in Upper

10 Lower Limb Amputation and Gait, 57

1 The Physiatric History and Physical Examination, 3

2 History and Examination of the Pediatric Patient, 14

3 Adult Neurogenic Communication and Swallowing Disorders, 18

4 P sychological Assessment and Intervention in Rehabilitation, 24

6 Employment of People with Disabilities, 34

7 Quality and Outcome Measures for Medical Rehabilitation, 39

SECTION II TREATMENT TECHNIQUES AND SPECIAL

10 Lower Limb Amputation and Gait, 57

12 Lower Limb Orthoses, 75

14 Wheelchairs and Seating Systems, 92

15 Therapeutic Exercise, 102

16 Manipulation, Traction, and Massage, 111

17 P hysical Agent Modalities, 119

18 Integrative Medicine in Rehabilitation, 126

19 Computer Assistive Devices and Environmental Controls, 129

SECTION III COMMON CLINICAL PROBLEMS

20 B ladder Dysfunction, 137

21 Neurogenic Bowel: Dysfunction and Rehabilitation, 143

22 Sexual Dysfunction and Disability, 150

24 Chronic Wounds, 164

25 Vascular Diseases, 173

27 Acute Medical Conditions, 183

29 Cancer Rehabilitation, 197

30 The Geriatric Patient, 204

31 Rheumatologic Rehabilitation, 208

SECTION IV ISSUES IN SPECIFIC DIAGNOSES

32 Common Neck Problems, 216

33 Low Back Pain, 228

35 Upper Limb Pain and Dysfunction, 244

36 Musculoskeletal Disorders of the Lower Limb, 248

37 Chronic Pain, 257

38 Pelvic Floor Disorders, 264

39 Sports Medicine and Adaptive Sports, 270

41 Rehabilitation of Patients With Neuropathies, 287

43 Traumatic Brain Injury, 305

44 Stroke Syndromes, 315

46 Multiple Sclerosis, 324

47 Cerebral Palsy, 331

48 Myelomeningocele and Other Spinal Dysraphisms, 338

49 Spinal Cord Injury, 345

50 Auditory, Vestibular, and Visual Impairments, 355

16 Manipulation, Traction, and Massage

17 P hysical Agent Modalities

SECTION III COMMON CLINICAL PROBLEMS

SECTION IV ISSUES IN SPECIFIC DIAGNOSES

36 Musculoskeletal Disorders of the Lower Limb

45 Degenerative Movement Disorders of the Central Nervous System