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Braddom’s Physical Medicine
and Rehabilitation
SIXTH EDITION
Editor-in-Chief
David X. Cifu, MD
Associate Dean of Innovation and System Integration
Herman J. Flax, MD Professor and Chair, Department of Physical Medicine and Rehabilitation
Virginia Commonwealth University School of Medicine
Richmond, Virginia;
Senior TBI Specialist, U.S. Department of Veterans Affairs
Washington, DC;
Principal Investigator
Long-term Impact of Military-relevant Brain Injury Consortium - Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC)
Central Virginia VA Health Care System/Virginia Commonwealth University
Richmond, Virginia
Associate Editors
Blessen C. Eapen, MD Henry L. Lew, MD, PhD, ABPMR, CCC-A

Chief, Physical Medicine and Rehabilitation Professor and Chair
VA Greater Los Angeles Health Care System; Department of Communication Sciences and Disorders
Associate Clinical Professor John A. Burns School of Medicine
Department of Medicine University of Hawai’i at Mānoa
Division of Physical Medicine and Rehabilitation Honolulu, Hawaii;
David Geffen School of Medicine at UCLA Adjunct Professor
Los Angeles, California Department of Physical Medicine and Rehabilitation
Virginia Commonwealth University School of Medicine
Richmond, Virginia
Jeffery S. Johns, MD
Associate Professor Michelle A. Miller, MD
Physical Medicine and Rehabilitation
Vanderbilt University Medical Center; Assistant Clinical Professor
Medical Director Physical Medicine and Rehabilitation
Vanderbilt Stallworth Rehabilitation Hospital The Ohio State University;
Nashville, Tennessee Section Chief
Pediatric Physical Medicine
Nationwide Children’s Hospital
Karen Kowalske, MD Columbus, Ohio
Professor
Physical Medicine and Rehabilitation Gregory Worsowicz, MD, MBA
University of Texas Southwestern Medical Center
Dallas, Texas Professor of Clinical Physical Medicine and Rehabilitation
Department of Physical Medicine and Rehabilitation
University of Missouri
Columbia, Missouri
Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
BRADDOM’S PHYSICAL MEDICINE AND REHABILITATION,

SIXTH EDITION ISBN: 978-0-323-62539-5
Copyright © 2021 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verification of diagnoses and drug dosages should
be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or
contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Previous editions copyrighted 2016, 2011, 2007, 2000, and 1996.
International Standard Book Number: 978-0-323-62539-5
Content Strategist: Humayra R. Khan

Senior Content Development Specialist: Ann Ruzycka Anderson
Publishing Services Manager: Catherine Jackson
Health Content Management Specialist: Kristine Feeherty
Design Direction: Ryan Cook
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

This book is dedicated to my parents, John and Rosa,
who made me all that I am; my children, Brie and Belle,
who remind me to look to the horizon;
and to my love, Hilary, who makes it all worthwhile.
A special thank you to Randy Braddom for the legacy that

started this textbook and for his ongoing support.
Thank you to my amazingly supportive colleagues, staff,

and trainees all across Virginia Commonwealth University,
including in the School of Medicine and the Department of Physical
Medicine and Rehabilitation, for their mentorship,
their friendship, and the time to complete this project.
Thank you to the wonderful members of the Office of Rehabilitation

and Prosthetic Services in the U.S Department of Veterans Affairs
for all they do for America’s Veterans and Service Members
and for allowing me the time to complete this project.
Thank you to the thousands of patients and their family members

who allowed me to participate in their care over the years;
you have taught me so much.
Thank you to my family, friends, and other loved ones

for your ongoing support that allows me to pursue my work and career.
v
Contributors
Denise M. Ambrosi, MS, CCC-SLP W. David Arnold, MD

Director of Accreditation Associate Professor
Quality and Compliance Physical Medicine and Rehabilitation
Spaulding Rehabilitation Hospital; Neuromuscular Division
Assistant Professor Department of Neurology
Communication Sciences and Disorders Physiology and Cell Biology
MGH Institute of Health Professions Neuroscience
Charlestown, Massachusetts The Ohio State University
3 Rehabilitation of Swallowing Disorders Columbus, Ohio
40 Motor Neuron Diseases
Michael Andary, MD, MS
Professor Arash Asher, MD
Physical Medicine and Rehabilitation Director, Cancer Survivorship and Rehabilitation
Michigan State University College of Osteopathic Medicine; Samuel Oschin Comprehensive Cancer Institute
Residency Director, Physical Medicine and Rehabilitation Cedars-Sinai Medical Center
Sparrow Hospital Los Angeles, California
East Lansing, Michigan 29 Cancer Rehabilitation
8 Electrodiagnostic Medicine
James W. Atchison, DO
Karen L. Andrews, MD Chair
Physical Medicine and Rehabilitation Department of Physical Medicine and Rehabilitation
Mayo Clinic Mayo Clinic Florida
Rochester, Minnesota Jacksonville, Florida
24 Prevention and Management of Chronic Wounds 16 Manipulation, Traction, and Massage
25 Vascular Diseases
Rita Ayyangar, MBBS
Thiru M. Annaswamy, MD, MA Associate Professor
Professor Department of Physical Medicine and Rehabilitation
Department of Physical Medicine and Rehabilitation University of Michigan
University of Texas Southwestern Medical Center; Ann Arbor, Michigan
Section Chief, Spine and Electrodiagnostic Sections 48 Myelomeningocele and Other Spinal Dysraphisms
Physical Medicine and Rehabilitation Service
VA North Texas Health Care System Kim D.D. Barker, MD
Dallas, Texas Associate Professor
7 Quality and Outcome Measures for Medical Rehabilitation Physical Medicine and Rehabilitation
17 Physical Agent Modalities University of Texas Southwestern Medical Center
Dallas, Texas
Dixie Aragaki, MD 1 The Physiatric History and Physical Examination
Professor
Department of Medicine Touré Barksdale, MD
Division of Physical Medicine and Rehabilitation Mayo Clinic/Mayo Clinic Health System
David Geffen School of Medicine at UCLA; Physical Medicine and Rehabilitation
Program Director Mayo Clinic
Physical Medicine and Rehabilitation Residency Mankato, Minnesota
VA Greater Los Angeles Healthcare System 29 Cancer Rehabilitation
Los Angeles, California
6 Occupational Medicine and Vocational Rehabilitation
vi
Contributors vii
Karen P. Barr, MD Mary Caldwell, DO

Associate Professor Assistant Professor
Chief, Division of Physical Medicine and Rehabilitation Sports Medicine/Physical Medicine and Rehabilitation
Department of Orthopaedics VCU Health
West Virginia University Richmond, Virginia
Morgantown, West Virginia 36 Lower Limb Pain and Dysfunction
33 Low Back Disorders
William Carne, PhD
Matthew N. Bartels, MD, MPH Associate Professor
Professor and Chairman of Rehabilitation Medicine Physical Medicine and Rehabilitation
Albert Einstein College of Medicine; Virginia Commonwealth University
Chairman, Department of Rehabilitation Medicine Richmond, Virginia
Montefiore Medical Center 45 Degenerative Movement Disorders of the Central Nervous System
The Bronx, New York
27 Acute Medical Conditions: Cardiopulmonary Disease, Priya Chandan, MD, MPH
Medical Frailty, and Renal Failure Assistant Professor
Division of Physical Medicine and Rehabilitation
Stacey A. Bennis, MD University of Louisville
Assistant Professor Louisville, Kentucky
Orthopaedics and Rehabilitation 45 Degenerative Movement Disorders of the Central Nervous System
Obstetrics and Gynecology
Loyola University Medical Center Shih-Ching Chen, MD, PhD
Maywood, Illinois Professor
38 Pelvic Floor Disorders Physical Medicine and Rehabilitation
Director
Theresa F. Berner, OTR/L, ATP Research Center of Rehabilitation Engineering and Assistive
Rehabilitation Clinical Manager Technology
Occupational Therapist Taipei Medical University
The Ohio State University Wexner Medical Center Taipei, Taiwan
Columbus, Ohio 19 Assistive Technology and Environmental Control Devices
14 Wheelchairs and Seating Systems
Wen-Shiang Chen, MD, PhD
Cathy Bodine, PhD, CCC-SLP Professor
Associate Professor Physical Medicine and Rehabilitation
Bioengineering College of Medicine
University of Colorado National Taiwan University;
Denver, Colorado Director
19 Assistive Technology and Environmental Control Devices Physical Medicine and Rehabilitation
National Taiwan University Hospital
Jaclyn Bonder, MD Taipei, Taiwan
Assistant Professor 17 Physical Agent Modalities
Rehabilitation Medicine
Weill Cornell Medical College Andrea Cheville, MD, MDCE
New York, New York Professor
38 Pelvic Floor Disorders Department of Physical Medicine and Rehabilitation
Director of Lymphedema and Cancer Rehabilitation Services
Angeline Bowman, MD Mayo Clinic
Assistant Professor Rochester, Minnesota
Department of Physical Medicine and Rehabilitation 29 Cancer Rehabilitation
University of Michigan
Ann Arbor, Michigan Li-Wei Chou, MD, PhD
48 Myelomeningocele and Other Spinal Dysraphisms Director and Professor
Physical Therapy and Graduate Institute of Rehabilitation Science
Thomas N. Bryce, MD China Medical University;
Professor Chairman
Rehabilitation and Human Performance Physical Medicine and Rehabilitation
Icahn School of Medicine at Mount Sinai Asia University Hospital;
New York, New York Attending Physician
49 Spinal Cord Injury Physical Medicine and Rehabilitation
China Medical University Hospital
Taichung, Taiwan
17 Physical Agent Modalities
viii Contributors
Jeffrey M. Cohen, MD Katherine Louise Dec, MD

Clinical Professor Professor
Rehabilitation Medicine Physical Medicine and Rehabilitation
NYU School of Medicine; Virginia Commonwealth University School of Medicine;
Medical Director, Medically Complex Rehabilitation Professor
Rusk Rehabilitation Orthopaedic Surgery
NYU Langone Health Virginia Commonwealth University School of Medicine;
New York, New York Past President
28 Chronic Medical Conditions: Pulmonary Disease, Organ American Medical Society for Sports Medicine;
Transplantation, and Diabetes Director, Sports Medicine and Performance
Rory A. Cooper, PhD Virginia Commonwealth University Health Systems
Director Richmond, Virginia
Human Engineering Research Laboratories 36 Lower Limb Pain and Dysfunction
VA Pittsburgh Healthcare System;
Associate Dean for Inclusion Andrew Cullen Dennison, Sr., MD
SHRS and FISA/Paralyzed Veterans of America Distinguished Adjunct Assistant Professor
Professor Rehabilitation Medicine
School of Health and Rehabilitation Sciences Emory University;
University of Pittsburgh Medical Director of Acquired Brain Injury Rehabilitation
Pittsburgh, Pennsylvania Shepherd Center
14 Wheelchairs and Seating Systems Atlanta, Georgia
44 Stroke Rehabilitation
Rosemarie Cooper, MPT/ATP
Assistant Professor Michael J. DePalma, MD
Department of Rehabilitation Science and Technology President and Medical Director
University of Pittsburgh; Virginia iSpine Physicians, PC;
Director, Center for Assistive Technology Director
University of Pittsburgh Medical Center Interventional Spine Care Fellowship Program
Pittsburgh, Pennsylvania Virginia iSpine Physicians, PC;
14 Wheelchairs and Seating Systems Director of Research
Virginia Spine Research Institute, Inc.
Anita Craig, DO Richmond, Virginia
Assistant Professor 32 Common Neck Problems
University of Michigan Kelly M. Derby, MS, APRN, CNS
Ann Arbor, Michigan Clinical Nurse Specialist
41 Neuropathies Department of Nursing
Mayo Clinic
Edan A. Critchfield, PsyD, ABPP Rochester, Minnesota
Clinical Neuropsychologist 24 Prevention and Management of Chronic Wounds
Psychology
South Texas Veterans Healthcare System Carmen P. DiGiovine, PhD, ATP/SMS, RET
San Antonio, Texas Clinical Associate Professor
4 Psychological Assessment and Intervention in Rehabilitation Director of Rehabilitation Science and Technology
Assistive Technology Center
Deepthi S. Cull, MD, CPE, FAAPM&R The Ohio State University
Encompass Health Deaconess Rehabilitation Hospital Columbus, Ohio
Newburgh, Indiana 14 Wheelchairs and Seating Systems
7 Quality and Outcome Measures for Medical Rehabilitation
Timothy Dillingham, MD, MS
Aaron Danison, DO Professor and Chairman
Physician Physical Medicine and Rehabilitation
Neurosurgery The University of Pennsylvania
Vidant Medical Center Philadelphia, Pennsylvania
Greenville, North Carolina 8 Electrodiagnostic Medicine
13 Spinal Orthoses
Carole Dodge, OTRL, CHT
Arthur J. De Luigi, DO, MHSA Allied Health Supervisor
Chair Occupational Therapy
Department of Physical Medicine and Rehabilitation Michigan Medicine
Mayo Clinic Arizona University of Michigan
Scottsdale, Arizona Ann Arbor, Michigan
39 Sports Medicine and Adaptive Sports 11 Upper Limb Orthotic Devices
Contributors ix
David F. Drake, MD Jonathan Finnoff, DO, FACSM, FAMSSM

Associate Professor Professor
Department of Physical Medicine and Rehabilitation Department of Physical Medicine and Rehabilitation
Virginia Commonwealth University; Mayo Clinic
Director, Interventional and Integrative Pain Medicine Rochester, Minnesota;
Physical Medicine and Rehabilitation Service Chief Medical Officer
Central Virginia VA Healthcare System United States Olympic and Paralympic Committee
Richmond, Virginia Colorado Springs, Colorado
18 Integrative Medicine in Rehabilitation 35 Upper Limb Pain and Dysfunction
Daniel Dumitru, MD, PhD Gerard E. Francisco, MD

Professor Professor and Chair
Rehabilitation Medicine Department of Physical Medicine and Rehabilitation
University of Texas Health Science Center University of Texas Health Science (UTHealth) McGovern
San Antonio, Texas Medical School
8 Electrodiagnostic Medicine Houston, Texas
23 Spasticity
Jason Edinger, DO
Assistant Professor Kevin Franzese, DO
Physical Medicine and Rehabilitation Assistant Professor
University of Pittsburgh Medical Center Physical Medicine and Rehabilitation
Pittsburgh, Pennsylvania University of Pittsburgh
43 Traumatic Brain Injury University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Miguel X. Escalon, MD, MPH 43 Traumatic Brain Injury
Associate Professor
Department of Rehabilitation Medicine Vincent Gabriel, MSc, MD, FRCPC
Icahn School of Medicine Clinical Associate Professor
New York, New York Clinical Neurosciences, Pediatrics, and Surgery
49 Spinal Cord Injury University of Calgary
Calgary, Alberta, Canada
Reuben Escorpizo, PT, DPT, MSc 26 Burns
Clinical Associate Professor
Doctor of Physical Therapy Program Gary N. Galang, MD
Department of Rehabilitation and Movement Science Director of TBI Services
The University of Vermont Physical Medicine and Rehabilitation
Burlington, Vermont; University of Pittsburgh Medical Center
Adjunct Research Scientist Pittsburgh, Pennsylvania
Swiss Paraplegic Research 43 Traumatic Brain Injury
Nottwil, Switzerland
6 Occupational Medicine and Vocational Rehabilitation Justin J. Gasper, DO
St. Louis, Missouri
James E. Eubanks, MD, DC, MS 32 Common Neck Problems
Resident Physician
Physical Medicine and Rehabilitation Lance L. Goetz, MD
University of Pittsburgh Medical Center Associate Professor
Pittsburgh, Pennsylvania Physical Medicine and Rehabilitation
16 Manipulation, Traction, and Massage Virginia Commonwealth University;
Staff Physician
Gabriel Sunn Felsen, MD, FAAPMR Spinal Cord Injury and Disorders
Associate Professor of Rehabilitation Medicine Hunter Holmes McGuire VA Medical Center
University of Miami; Richmond, Virginia
Spinal Cord Injury and Wound Rehabilitation Physician 20 Neurogenic Lower Urinary Tract Dysfunction
Miami VA Healthcare System
Miami, Florida James W. Hall III, PhD
13 Spinal Orthoses Professor
Department of Communication Sciences and Disorders
University of Hawaii
Honolulu, Hawaii;
Professor
Osborne College of Audiology
Salus University
Elkins Park, Pennsylvania
50 Auditory, Vestibular, and Visual Impairments
x Contributors
R. Norman Harden, MD Lin-Fen Hsieh, Doctor of Medicine

Senior Associate Editor, Pain Medicine Adjunct Professor
Addison Chair in Pain Studies School of Medicine
Professor Fu Jen Catholic University
Department of Physical Medicine and Rehabilitation New Taipei City, Taiwan;
Department of Physical Therapy and Human Movements Attending Physician (Former Director)
Sciences Department of Physical Medicine and Rehabilitation
Northwestern University Shin Kong Wo Ho-Su Memorial Hospital
Chicago, Illinois Taipei, Taiwan
37 Chronic Pain 31 Rheumatologic Rehabilitation
Mark A. Harrast, MD Wei-Li Hsu, PT, PhD

Clinical Professor Associate Professor
Departments of Rehabilitation Medicine, Orthopaedics, and School and Graduate Institute of Physical Therapy
Sports Medicine National Taiwan University;
University of Washington School of Medicine; Physical Therapist
Medical Director Physical Therapy Center
Sports Medicine Center at Husky Stadium; National Taiwan University Hospital
Program Director Taipei, Taiwan
Sports Medicine Fellowship 31 Rheumatologic Rehabilitation
University of Washington School of Medicine;
Medical Director Vincent Huang, MD
Seattle Marathon Assistant Professor
Seattle, Washington Department of Rehabilitation and Human Performance
39 Sports Medicine and Adaptive Sports Icahn School of Medicine at Mount Sinai
New York, New York
Julie A. Hastings, MD 49 Spinal Cord Injury
Assistant Professor
Physical Medicine and Rehabilitation Elizabeth Huntoon, MS, MD
Creighton University School of Medicine - Phoenix Campus; Associate Professor
Assistant Clinical Professor Program Director Pain Medicine Fellowship
Physical Medicine and Rehabilitation Physical Medicine and Rehabilitation
University of Arizona College of Medicine Virginia Commonwealth University
Phoenix, Arizona Richmond, Virginia
22 Sexual Dysfunction and Disability 36 Lower Limb Pain and Dysfunction
Radha Holavanahalli, PhD Sarah K. Hwang, MD

Professor Assistant Professor
Physical Medicine and Rehabilitation Physical Medicine and Rehabilitation
University of Texas Southwestern Medical Center Shirley Ryan AbilityLab;
Dallas, Texas Assistant Professor
26 Burns Obstetrics and Gynecology
Northwestern University
Amy Houtrow, MD, PhD, MPH Chicago, Illinois
Professor of Physical Medicine and Rehabilitation and Pediatrics 38 Pelvic Floor Disorders
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania Shoji Ishigami, MD, PhD
7 Quality and Outcome Measures for Medical Rehabilitation Assistant Professor
Interventional Spine Clinic
David Hryvniak, DO Department of Neurosurgery
Assistant Professor West Virginia University School of Medicine
Physical Medicine and Rehabilitation WVU Rockefeller Neuroscience Institute
University of Virginia; Martinsburg, West Virginia
Team Physician 32 Common Neck Problems
University of Virginia Athletics
Charlottesville, Virginia; Therese M. Jacobson, DNP, APRN, CNS, CWOCN
Team Physician Nursing Quality Specialist
James Madison University Athletics Nursing
Harrisonburg, Virginia Mayo Clinic
15 Therapeutic Exercise Rochester, Minnesota
24 Prevention and Management of Chronic Wounds
Contributors xi
Carlos Anthony Jaramillo, MD, PhD Lester J. Kiemele, PA-C, MPAS

Staff Physician Physician Assistant
Polytrauma Rehabilitation Center Vascular Medicine
Clinical and Research Faculty Mayo Clinic
Geriatric Research, Education and Clinical Center (GRECC) Rochester, Minnesota
South Texas Veterans Health Care System; 24 Prevention and Management of Chronic Wounds
Assistant Professor
Department of Rehabilitation Medicine Daniel J. Kim, MD
University of Texas Health Science Center The Ohio State University Wexner Medical Center
San Antonio, Texas Columbus, Ohio
30 Geriatrics 14 Wheelchairs and Seating Systems
Jeffrey Jenkins, MD Adam P. Klausner, MD

Associate Professor Professor and Director of Neurourology and Voiding
Physical Medicine and Rehabilitation Dysfunction
University of Virginia Warren Koontz Professor of Urologic Research
Charlottesville, Virginia Surgery/Urology
15 Therapeutic Exercise Virginia Commonwealth University
Midlothian, Virginia;
Mariana M. Johnson, MD Staff Urologist
Assistant Professor Surgery/Urology
Physical Medicine and Rehabilitation Hunter Holmes McGuire VA Medical Center
University of Texas Southwestern Medical Center Richmond, Virginia
Dallas, Texas 20 Neurogenic Lower Urinary Tract Dysfunction
1 The Physiatric History and Physical Examination
Amy L. Kolarova, DO
Stephen C. Johnson, MD, MS ABI Physician
Clinical Assistant Professor Rehabilitation Medicine
Sports and Spine Division Shepherd Center
Department of Rehabilitation Medicine Atlanta, Georgia
University of Washington 44 Stroke Rehabilitation
Seattle, Washington
33 Low Back Disorders Alicia M. Koontz, PhD, RET, ATP
Professor
Wade Johnson, DO Department of Rehabilitation Science and Technology
Senior Associate Consultant University of Pittsburgh;
Physical Medicine and Rehabilitation Associate Director for Research
Mayo Clinic Health System Human Engineering Research Laboratories
Mankato, Minnesota VA Pittsburgh Healthcare System
35 Upper Limb Pain and Dysfunction Pittsburgh, Pennsylvania
14 Wheelchairs and Seating Systems
Shawn Jorgensen, MD
Clinical Professor Karen Kowalske, MD
Physical Medicine and Rehabilitation Professor
Albany Medical Center Physical Medicine and Rehabilitation
Albany, New York; University of Texas Southwestern Medical Center
Adjunct Professor Dallas, Texas
Family Medicine 26 Burns
Larner Medical College at the University of Vermont
Burlington, Vermont Christina Kwasnica, MD
40 Motor Neuron Diseases Medical Director, Neurorehabilitation
Brian M. Kelly, DO Barrow Neurological Institute
Professor and Medical Director Phoenix, Arizona
Division of Orthotics and Prosthetics 43 Traumatic Brain Injury
Michigan Medicine Dong Rak Kwon, MD, PhD
University of Michigan Professor
Ann Arbor, Michigan Rehabilitation Medicine
11 Upper Limb Orthotic Devices School of Medicine
Catholic University of Daegu
Daegu, Republic of Korea
17 Physical Agent Modalities
xii Contributors
Scott R. Laker, MD Chuan-Chin Lu, MD

Associate Professor Attending Physician
Department of Physical Medicine and Rehabilitation Department of Rheumatology
University of Colorado School of Medicine Department of Physical Medicine and Rehabilitation
Denver, Colorado Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation;
39 Sports Medicine and Adaptive Sports Assistant Professor
Department of Physical Therapy
Erek W. Latzka, MD, RMSK Hungkuang University
Clinical Assistant Professor Taichung, Taiwan
Department of Rehabilitation Medicine 31 Rheumatologic Rehabilitation
University of Washington School of Medicine
Seattle, Washington Hui-Fen Mao, MS, OT
39 Sports Medicine and Adaptive Sports Associate Professor
School of Occupational Therapy
Melissa Lau, MD College of Medicine
Resident National Taiwan University;
Physical Medicine and Rehabilitation Occupational Therapist
The Ohio State University Department of Physical Medicine and Rehabilitation
Columbus, Ohio National Taiwan University Hospital
40 Motor Neuron Diseases Taipei, Taiwan
31 Rheumatologic Rehabilitation
Yong-Tae Lee, MD
Assistant Professor of Physical Medicine and Rehabilitation Craig M. McDonald, MD
Harvard Medical School; Professor and Chair
Chief Medical Information Officer Department of Physical Medicine and Rehabilitation
Staff Physiatrist Professor
Spaulding Rehabilitation Hospital Department of Pediatrics
Charlestown, Massachusetts University of California Davis Health
3 Rehabilitation of Swallowing Disorders Sacramento, California
42 Myopathic Disorders
Henry L. Lew, MD, PhD, ABPMR, CCC-A
Professor and Chair Christopher W. McMullen, MD, CAQSM
Department of Communication Sciences and Disorders Clinical Assistant Professor
John A. Burns School of Medicine Department of Rehabilitation Medicine
University of Hawai’i at Mānoa University of Washington School of Medicine
Honolulu, Hawaii; Seattle, Washington
Adjunct Professor 39 Sports Medicine and Adaptive Sports
Virginia Commonwealth University School of Medicine Sudeep K. Mehta, MD
Richmond, Virginia Chief Resident
19 Assistive Technology and Environmental Control Devices Department of Physical Medicine and Rehabilitation
50 Auditory, Vestibular, and Visual Impairments East Carolina University/Vidant Medical Center
Greenville, North Carolina
Sheng Li, MD, PhD 13 Spinal Orthoses
Professor
Physical Medicine and Rehabilitation Michelle A. Miller, MD
University of Texas Health Science Center Assistant Clinical Professor
Houston, Texas Physical Medicine and Rehabilitation
23 Spasticity The Ohio State University;
Section Chief
Mark Linsenmeyer, MD Pediatric Physical Medicine
Brain Injury Medicine and Rehabilitation Nationwide Children’s Hospital
Physical Medicine and Rehabilitation Columbus, Ohio
Sunnyview Rehabilitation Hospital 2 Examination of the Pediatric Patient
Schenectady, New York
43 Traumatic Brain Injury Douglas P. Murphy, MD
Associate Professor
William Lovegreen, MS, CPO Department of Physical Medicine and Rehabilitation
Prosthetist-Orthotist Regional Clinical Director School of Medicine at Virginia Commonwealth University;
Physical Medicine and Rehabilitation Staff Physician, Physical Medicine and Rehabilitation
Veterans Administration Central Virginia Veterans Healthcare System
Richmond, Virginia Richmond, Virginia
10 Lower Limb Amputation and Gait 10 Lower Limb Amputation and Gait
12 Lower Limb Orthoses 12 Lower Limb Orthoses
Contributors xiii
Ram N. Narayan, MBBS, CRND Sofiya Prilik, MD

Assistant Professor Clinical Director of Cardiac and Pulmonary Rehabilitation
Department of Neurology Rusk Rehabilitation
Barrow Neurological Institute NYU Langone Medical Center
Phoenix, Arizona New York, New York
46 Multiple Sclerosis 28 Chronic Medical Conditions: Pulmonary Disease, Organ
Transplantation, and Diabetes
Christian M. Niedzwecki, DO, MS
Assistant Professor David Z. Prince, MD, FAAPMR
Physical Medicine and Rehabilitation Assistant Professor of Rehabilitation Medicine
Baylor College of Medicine Albert Einstein College of Medicine;
Houston, Texas Director, Cardiopulmonary Rehabilitation
47 Cerebral Palsy Department of Rehabilitation Medicine
Montefiore Medical Center
John W. Norbury, MD The Bronx, New York
Assistant Professor 27 Acute Medical Conditions: Cardiopulmonary Disease,
Department of Physical Medicine and Rehabilitation Medical Frailty, and Renal Failure
Brody School of Medicine at East Carolina
University Abu A. Qutubuddin, MD, MBBS
Greenville, North Carolina Assistant Professor
13 Spinal Orthoses Director of Rehabilitation
Associate Director of Rehabilitation
Justin J.F. O’Rourke, PhD, ABPP Parkinson’s Disease Research Education and Clinical Center
Neuropsychologist Physical Medicine and Rehabilitation and Neurology
Polytrauma Rehabilitation Center Virginia Commonwealth University;
Veterans Affairs; Hunter Holmes McGuire VA Medical Center
Neuropsychologist Richmond, Virginia
Clinical Neuropsychology of Texas; 45 Degenerative Movement Disorders of the Central Nervous
Site Primary Investigator System
TBI Model Systems
San Antonio, Texas Mohammed I. Ranavaya, MD, JD, MS, FRCPI, CIME
4 Psychological Assessment and Intervention in Professor and Chief
Rehabilitation Division of Occupational Medicine
Joan C. Edwards School of Medicine at Marshall University;
Ajit B. Pai, MD President
Assistant Professor American Board of Independent Medical Examiners;
Department of Physical Medicine and Rehabilitation Medical Director
Virginia Commonwealth University; Appalachian Institute of Occupational and Environmental
Solutions Expert Medicine
Office of Electronic Health Record Modernization Huntington, West Virginia
Veterans Health Administration 5 Practical Aspects of Impairment Rating and Disability
Richmond, Virginia Determination
18 Integrative Medicine in Rehabilitation
Zachary J. Resch, MS
Atul T. Patel, MD, MHSA Doctoral Candidate
Vice President Psychology
Physical Medicine and Rehabilitation Rosalind Franklin University
Kansas City Bone and Joint Clinic Chicago, Illinois
Overland Park, Kansas 4 Psychological Assessment and Intervention in Rehabilitation
11 Upper Limb Orthotic Devices
Gianna M. Rodriguez, MD
Terri K. Pogoda, PhD Associate Professor
Research Health Scientist Physical Medicine and Rehabilitation
Center for Healthcare Organization and Implementation University of Michigan
Research Ann Arbor, Michigan
VA Boston Healthcare System; 21 Neurogenic Bowel: Dysfunction and Rehabilitation
Research Assistant Professor
Health Law, Policy, and Management Robert D. Rondinelli, MD, PhD
Boston University School of Public Health Staff Physiatrist
Boston, Massachusetts UnityPoint Health Des Moines
50 Auditory, Vestibular, and Visual Impairments Des Moines, Iowa
5 Practical Aspects of Impairment Rating and Disability
Determination
xiv Contributors
Brendon Scott Ross, DO, MS Anjali Shah, MD

Assistant Professor Associate Professor
Primary Care Sports Medicine Physical Medicine and Rehabilitation
Department of Orthopedic Surgery and Rehabilitation University of Texas Southwestern Medical Center
Medicine Dallas, Texas
University of Chicago 46 Multiple Sclerosis
Chicago, Illinois
16 Manipulation, Traction, and Massage Terrence P. Sheehan, MD
Chief Medical Officer
Adam Saby, MD Adventist Healthcare, Rehabilitation
Assistant Medical Director Rockville, Maryland;
Division of Occupational Health Medical Director
Department of Emergency Medicine Amputee Coalition of America
University of California, Los Angeles Washington, DC
Los Angeles, California 9 Rehabilitation and Prosthetic Restoration in Upper Limb
6 Occupational Medicine and Vocational Rehabilitation Amputation
Neelwant S. Sandhu, MD Lori V. Shuart, MS, RKT

Clinical Assistant Professor Supervisory Kinesiotherapist
Department of Rehabilitation Medicine Physical Medicine and Rehabilitation Service
University of Washington Central Virginia VA Healthcare System
Seattle, Washington Richmond, Virginia
33 Low Back Disorders 18 Integrative Medicine in Rehabilitation
Mark Schmeler, PhD, OTR/L, ATP Beth A. Sievers, MS, APRN, CNS, CWCN
Vice Chair for Education and Training Nursing
Associate Professor Mayo Clinic
Department of Rehabilitation Science and Technology Rochester, Minnesota
University of Pittsburgh 24 Prevention and Management of Chronic Wounds
14 Wheelchairs and Seating Systems Andrew Simoncini, MD
Staff Physician
Evan T. Schulze, PhD Physical Medicine and Rehabilitation
Instructor Southeast Louisiana Veterans Health Care System
Neurology New Orleans, Louisiana
Saint Louis University 12 Lower Limb Orthoses
St. Louis, Missouri
4 Psychological Assessment and Intervention in Mehrsheed Sinaki, MD, MS
Rehabilitation Consultant
Aloysia L. Schwabe, MD Mayo Clinic;
Associate Professor Professor of Physical Medicine and Rehabilitation
Physical Medicine and Rehabilitation Mayo Clinic College of Medicine and Science
Baylor College of Medicine Rochester, Minnesota
Houston, Texas 34 Osteoporosis
47 Cerebral Palsy
Curtis W. Slipman, MD
Kelly M. Scott, MD 32 Common Neck Problems
Professor
Physical Medicine and Rehabilitation Sean Smith, MD
University of Texas Southwestern Medical Center Assistant Professor
Dallas, Texas Department of Physical Medicine and Rehabilitation
22 Sexual Dysfunction and Disability University of Michigan
38 Pelvic Floor Disorders Ann Arbor, Michigan
29 Cancer Rehabilitation
Young Il Seo, MD
Fellow
Hunter Holmes McGuire VA Medical Center
Richmond, Virginia
10 Lower Limb Amputation and Gait
Contributors xv
Fantley Clay Smither, MD Chiemi Tanaka, PhD

Mayo Scholar Adjunct Assistant Professor
Physical Medicine and Rehabilitation Department of Communication Sciences and
Mayo Clinic; Disorders
Amputee Fellow University of Hawai’i at Manoa
Physical Medicine and Rehabilitation Honolulu, Hawaii;
Hunter Homes McGuire VA Medical Center Director
Richmond, Virginia Advanced Audiology Center
25 Vascular Diseases Audmet K.K., Kawasak-shi
Kanagawa, Japan
Jason R. Soble, PhD, ABPP 50 Auditory, Vestibular, and Visual Impairments
Assistant Professor of Clinical Psychiatry and Neurology
Psychiatry Kate E. Temme, MD
University of Illinois College of Medicine Assistant Professor
Chicago, Illinois Department of Physical Medicine and
4 Psychological Assessment and Intervention in Rehabilitation Rehabilitation
Department of Orthopaedic Surgery
Christopher J. Standaert, MD University of Pennsylvania
Visiting Associate Professor Philadelphia, Pennsylvania
Department of Physical Medicine and Rehabilitation 22 Sexual Dysfunction and Disability
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania Sruthi P. Thomas, MD, PhD
33 Low Back Disorders Assistant Professor
Physical Medicine & Rehabilitation and Neurosurgery
Steven P. Stanos, DO Baylor College of Medicine
Medical Director, Pain Medicine and Services Houston, Texas
Swedish Pain Services 47 Cerebral Palsy
Swedish Health System
Seattle, Washington Ronald B. Tolchin, DO
37 Chronic Pain Medical Director
Miami Neuroscience Institute Spine Center
Siobhan M. Statuta, MD, CAQSM Baptist Health South Florida
Associate Professor Miami, Florida;
Family Medicine and Physical Medicine & Rehabilitation; Voluntary Clinical Associate Professor
Director, Primary Care Sports Medicine Fellowship Department of Neuroscience
Family Medicine FIU Herbert Wertheim School of Medicine
University of Virginia Miami, Florida;
Charlottesville, Virginia Voluntary Clinical Associate Professor
15 Therapeutic Exercise Department of Medicine
Kiran C. Patel College of Osteopathic
Phillip M. Stevens, Med, CPO Medicine
Director Nova Southeastern University
Department of Clinical and Scientific Affairs Fort Lauderdale, Florida
Hanger Clinic; 16 Manipulation, Traction, and Massage
Adjunct Professor
Physical Medicine and Rehabilitation Mark D. Tyburski, MD
University of Utah Chief, Comprehensive Pain Management Department
Salt Lake City, Utah Department of Physical Medicine and Rehabilitation
10 Lower Limb Amputation and Gait The Permanente Medical Group, Inc.
Sacramento/Roseville, California
Steven A. Stiens, MD, MS 37 Chronic Pain
Curator of Education
Adjunct Clinical Professor
Geisinger Commonwealth School of Medicine
Seattle, Washington
21 Neurogenic Bowel: Dysfunction and Rehabilitation
Olaf Stüve, MD, PhD

Professor
Department of Neurology
University of Texas Southwestern Medical Center
Dallas, Texas
46 Multiple Sclerosis
xvi Contributors
Amy K. Wagner, MD Robert P. Wilder, MD

Professor Professor and Chair
Physical Medicine and Rehabilitation, Neuroscience, and Medical Director, The Runner’s Clinic at UVA
Clinical and the Translational Science Institute Physical Medicine and Rehabilitation
University of Pittsburgh; The University of Virginia
Director, Translational Research Charlottesville, Virginia
Director, Brain Injury Medicine Fellowship 15 Therapeutic Exercise
University of Pittsburgh Medical Center; Lisa M. Williams, MD
Associate Director, Rehabilitation Research Assistant Clinical Professor
Safar Center for Resuscitation Research Department of Physical Medicine and Rehabilitation
Training Faculty University of California, Davis
Center for Neuroscience Sacramento, California
University of Pittsburgh 42 Myopathic Disorders
43 Traumatic Brain Injury Laurie L. Wolf, MD, FAAPM+R
Chair
Tyng-Guey Wang, MD Physical Medicine and Rehabilitation
Professor Acuity Neurology
Physical Medicine and Rehabilitation Wausau, Wisconsin
College of Medicine 25 Vascular Diseases
National Taiwan University;
Attending Physician Weibin Yang, MD, MBA
Physical Medicine and Rehabilitation Associate Professor
National Taiwan University Hospital Physical Medicine and Rehabilitation
Taipei, Taiwan UT Southwestern School of Medicine;
17 Physical Agent Modalities Chief
Physical Medicine and Rehabilitation Service
Joseph B. Webster, MD VA North Texas Health Care System
Associate Professor Dallas, Texas
Department of Physical Medicine and Rehabilitation 7 Quality and Outcome Measures for Medical Rehabilitation
School of Medicine at Virginia Commonwealth University; 17 Physical Agent Modalities
Staff Physician, Physical Medicine and Rehabilitation
Central Virginia Veterans Healthcare System Michael R. Yochelson, MD, MBA
Richmond, Virginia Chief Medical Officer
10 Lower Limb Amputation and Gait Medical Affairs
12 Lower Limb Orthoses Shepherd Center;
Adjunct Professor
Justin L. Weppner, DO Rehabilitation Medicine
Assistant Professor Emory University
Physical Medicine and Rehabilitation; Atlanta, Georgia
Director, Neurorehabilitation 44 Stroke Rehabilitation
University of Virginia
Charlottesville, Virginia Mauro Zappaterra, MD, PhD
43 Traumatic Brain Injury Director of Multidisciplinary Care and Clinical Research
Synovation Medical Group
Jonathan H. Whiteson, MBBS Pasadena, California;
Associate Professor VA Staff Physician Physical Medicine and Rehabilitation
Rehabilitation Medicine and Medicine Residency Program
NYU School of Medicine; Greater Los Angeles VA Healthcare System
Vice Chair, Clinical Operations; Los Angeles, California
Medical Director, Cardiac and Pulmonary Rehabilitation 6 Occupational Medicine and Vocational Rehabilitation
Rehabilitation Medicine
Rusk Rehabilitation, NYU Langone Health
New York, New York
28 Chronic Medical Conditions: Pulmonary Disease, Organ
Transplantation, and Diabetes
Preface
This 6th Edition of Braddom’s Physical Medicine and Rehabilitation approach with cutting edge technology, to combine modern sci-
supports the field’s ongoing transition into the future of health- ence with old-world beliefs and practices, and to heal the mind,
care, while also securely tethering learners to the more than seven body, and soul. This textbook has met all of these manifold chal-
decades of formal specialty recognition and centuries of rehabili- lenges by bringing together an internationally renowned team of
tative practice. Stem cells, genetic engineering, brain-computer authors and associate editors from the full range of physical and
interface, osseointegration, wearable diagnostics, and implantable rehabilitation medicine practices and systems who have created
stimulators are no longer simply within the realm of researchers informative and practical chapters covering the breadth of the
and inventors but are now a part of the modern-day practice of field of PM&R. The best of academic medicine, private practice,
physiatrists and other physical rehabilitation practitioners. At veterans and military health, all aspects of rehabilitative services,
the same time, there is a blossoming of acceptance and applica- integrative practitioners, and a wide range of specialty areas have
tion of integrative medicine, or whole-health, approach to care, been brought together to provide the most up-to-date and useful
which has always been an overarching tenet of the field of physi- resource for the field. This 6th Edition of Braddom’s Physical Medicine
cal medicine and rehabilitation (PM&R) for decades, across all of and Rehabilitation is the foundational textbook of PM&R, serves
medicine, along with an increasing appreciation of the importance as a key reference across all of the rehabilitation disciplines, and
and necessity of the interdisciplinary team. Similarly, a renewed now offers both the traditional core written materials as well
focus on physical activity, nutrition, emotional health, mind- as state-of-the art virtual teaching and training materials from
body interactions, and other vital elements of wellness across the the internet. As with the field itself, it has been reinvented and
lifespan have burgeoned in popularity, acceptance, and key com- improved to meet the ever-demanding needs of the practitioner
ponents of physiatric care. Finally, the field and this 6th Edition caring for the individual with disability.
have a continuing and growing emphasis on unique populations
of individuals at risk for or with disability, including servicemem- David X. Cifu, MD
bers and veterans, women, children, elders, athletes, and workers. Editor in Chief
People are living longer, demanding more from their bodies and Braddom’s Physical Medicine and Rehabilitation;
minds, seeking more from healthcare providers and having higher Associate Dean for Innovation and Systems Integration
expectations for their recovery and functioning than ever before. Herman J. Flax, MD Professor and Chairman, Department of
While earlier research or clinical successes revolved around lifesav- PM&R
ing or life-lengthening discoveries, approaches, and interventions, Virginia Commonwealth University School of Medicine;
today’s individuals with disabilities and their caregivers are not Senior TBI Specialist
only expecting to survive their acute incident or injury but also U.S. Department of Veterans Affairs;
to thrive and return to an even higher level of living, working, Principal Investigator
and playing. The physiatrist is being asked to balance the holistic Chronic Effects of NeuroTrauma Consortium (CENC-LIMBIC)
xvii
Acknowledgments
This 6th Edition of Braddom’s Physical Medicine and Rehabili- led tirelessly by our Content Specialist, Humayra R. Khan; Senior
tation has been made possible by the efforts of more than 200 Content Development Specialist, Ann Ruzycka Anderson; and
authors—physiatrists and other rehabilitation professionals from Health Content Management Specialist, Kristine Feeherty,
a wide range of practice settings, backgrounds, and specialty areas have been the consummate professionals and have again proven
who have given of their time, effort, and knowledge because of themselves to be the best of the best. Finally, a special thanks
their commitment and dedication to the field and to the individu- goes out to the mentors, professors, teachers, and practitioners
als with disability that they continually strive to partner with to who have helped to educate, shape, and train all of the indi-
enhance their lives. These colleagues and friends have my deepest viduals who contributed to this foundational textbook, for it is
gratitude and respect for their contributions. The individuals who through their efforts over the past several decades that there exist
have helped, guided, persuaded, cajoled, and at times “strongly so many skilled and dedicated professionals who could bring this
encouraged” all of these brilliant authors are the six associate book together. Just as with the best physical and rehabilitation
editors—Karen Kowalske, Michelle Miller, Blessen Eapen, Jeffery medicine practices across the globe, it takes a dedicated team of
Johns, Gregory Worsowicz, and Henry Lew—who truly have been professionals working in harmony to achieve the best outcomes.
the force driving the process forward and getting the very best for This textbook is what happens when those people work together
each of the chapters and topic areas. I am thankful for their dili- for the advancement of the field—a great outcome. My warmest
gence, oversight, and persistence. The editorial team at Elsevier, thanks.
xviii
SE C T I ON 1 Evaluation
1
The Physiatric History and
Physical Examination
KIM D.D. BARKER AND MARIANA M. JOHNSON
The physiatric history and physical examination (H&P) serves findings as they become available and that lines of verbal or writ-
several purposes. It serves as a written record that communi- ten communication be directed through the medical leadership
cates to other rehabilitation and nonrehabilitation health care of the team.
professionals. It is the data platform from which a treatment The exact structure of the physiatric assessment is deter-
plan is developed. Finally, the H&P provides the basis for physi- mined in part by personal preference, training background, and
cian billing17 and serves as a medicolegal document. Physician institutional requirements (e.g., physician billing compliance
documentation has become the critical component in inpatient expectations, proper linkage to resident documentation, forms
rehabilitation reimbursement under prospective payment (e.g., committees, and regulatory oversight). The use of templates can
interdisciplinary plan of care, admission screening), as well as be invaluable in maximizing the thoroughness of data collection
documentation for coverage by private insurers.18 The scope of and minimizing documentation time. Pertinent radiologic and
the physiatric H&P varies enormously, depending on the set- laboratory findings should be clearly documented. The essen-
ting, from the focused assessment of an isolated knee injury tial elements of the physiatric H&P are summarized in Box 1.1.
in an outpatient setting to the comprehensive evaluation of a Assessment of some or all of these elements is required for a
patient with traumatic brain or spinal cord injury admitted for complete understanding of the patient’s state of health and the
inpatient rehabilitation. An initial evaluation is almost always illness for which he or she is being seen. These elements also
more detailed and comprehensive than subsequent or follow- form the basis for a treatment plan.
up evaluations. An exception would be when a patient is seen Electronic medical records (EMRs) have significantly altered
for a follow-up visit with substantial new signs or symptoms. the landscape for documentation of the physiatric H&P in both
While initially physicians in training and new physiatrists tend the inpatient and outpatients settings.23 The tracking of a variety
to over-assess, with time, the experienced physiatrist develops an of quality measures to justify “meaningful use” of the EMR and
intuition for how much detail is needed for each patient, given a grade the physician encounter is commonplace.37 Among the
particular presentation and setting. advantages of the EMRs are increased legibility, a certain degree
The physiatric H&P resembles the traditional format taught of efficiency afforded by the use of templates and “smart phrases”
in medical school but with an additional emphasis on history, that can be tailored to individual practitioners or clinical presen-
signs, and symptoms that affect function or performance. The tations, automated warnings regarding medication interactions
physiatric H&P also identifies those systems not affected that or errors, and faster and more accurate billing. Disadvantages
might be used for compensation.22 Familiarity with the 1997 include the unacceptable use of the “copy and paste” function,
World Health Organization classification is invaluable in grasp- leading to redundancy among consecutive notes and the per-
ing the philosophic framework for viewing the evaluation of petuation of potentially inaccurate information, automated
persons with physical and cognitive disabilities (Table 1.1).73 importation of data not necessarily reviewed by the practitioner
Identifying and treating the primary impairments to maximize at the time of service, and “alarm fatigue.” As regulation of hos-
performance becomes the primary thrust of physiatric evaluation pital and physician practice and billing increases, the EMR will
and treatment. become more important in ensuring the proper, and sometimes
Patients cared for in rehabilitation medicine can be extremely convoluted, documentation required for safety initiatives28 and
complicated and this should be reflected in the H&P. Confirma- physician payment.17
tion of historical and functional items by other team members,
health care professionals, and family members can take several days The Physiatric History
and is often reflected in addendums or subsequent notes. Many of
the functional items discussed in this chapter will be assessed and History-taking skills are part of the art of medicine and are required
explored more fully by other interdisciplinary team members dur- to fully assess a patient’s presentation. One of the unique aspects of
ing the course of inpatient or outpatient treatment. It is impera- physiatry is the recognition of functional deficits caused by illness
tive that the physiatrist stays abreast of additional information and or injury. Identification of these deficits allows for the design of a
1
2 SE C T I O N 1 Evaluation
treatment program to restore performance. In a person with stroke, The time spent in taking a history also allows the patient to
for example, the most important questions for the physiatrist are become familiar with the physician, establishing rapport and
not only the etiology or location of the lesion but also “What func- trust. This initial rapport is critical for a constructive and pro-
tional deficits are present as a result of the stroke?” The answer could ductive doctor–patient–family relationship and can also help the
include deficits in swallowing, communication, mobility, cognition, physician learn about sensitive areas, such as sexual history and
activities of daily living (ADL), or a combination of these. substance abuse. It can also have an impact on outcome because
a trusting patient tends to be a more compliant patient.60 Assess-
ment of the tone of the patient or family (e.g., anger, frustration,
resolve, and determination), an understanding of the illness,
TABLE World Health Organization Definitions insight into disability, and coping skills are also gleaned during
1.1
history taking. In most cases, the patient leads the physician to a
Term Definition diagnosis and conclusion. In other cases, such as when the patient
Impairment Any loss or abnormality of body structure or of a is rambling and disorganized, frequent redirection and gentle refo-
physiologic or psychological function (essentially cus are required.
unchanged from the 1980 definition) Patients are generally the primary source of information.
However, patients with cognitive, mood (denial or decreased
Activity The nature and extent of functioning at the level of
the person
insight), or communication deficits, as well as small children,
might not be able to fully express themselves. In these cases,
Participation The nature and extent of a person’s involvement in life the history taker might rely on other sources, such as family
situations in relationship to impairments, activities, members; friends; other physicians, nurses, and medical pro-
health conditions, and contextual factors fessionals; or previous medical records. When these sources
From World Health Organization: International classification of impairments, activities, and
are used, the documentation should reflect this. This can also
participation, Geneva, 1997, World Health Organization, with permission of the World Health have an impact on physician billing. Caution must be exer-
Organization. cised in using previous medical records because inaccuracies
are sometimes repeated from provider to provider, sometimes
Essential Elements of the Physiatric History and Physical Examination

• BOX 1.1
History Review of Systems
Chief Complaint
History of Present Illness Physical Examination
Onset General Examination
Location General appearance
Duration Head, eyes, ears, nose, throat
Character/quality Cardiac
Aggravating and alleviating maneuvers or activities Pulmonary
Radiation Abdominal
Timing Psychiatric
Severity Other pertinent systems
Associated signs and symptoms Neurologic Physical Examination
Previous treatments tried Mental status
Functional History • Level of consciousness
Bed mobility, transfers, wheelchair mobility, ambulation, devices used • Attention
Activities of daily living: eating, bathing, toileting, dressing, hygiene, • Orientation
grooming • Memory
Instrumental activities of daily living: meal preparation, laundry, home • General fund of knowledge
maintenance, pet care • Abstract thinking
Driving Communication
Persons who provide assistance, if any Cranial nerve examination
Sensation
Medical and Surgical History Motor control
Medications • Strength
Allergies • Coordination
Social History • Apraxia
Substance abuse • Involuntary movements
Home environment • Tone
Social support system
Vocational activities Reflexes
Recreational activities Musculoskeletal Physical Examination
Sexual history Inspection: appearance, symmetry, deformities
Palpation: pain, stability, range of motion, strength testing
Family History Joint-specific provocative maneuvers
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LIBRO SÉPTIMO
NIGROMANCIA
Están prontos los caballos para la fuga en el rancho de Ticomaipú

El Coronelito de la Gándara cena con Niño Filomeno. Sobre los
términos de la colación, manda llamar a sus hijos el ranchero. Niña
Laurita, con reservada tristeza, sale a buscarlos, y acude, brincante, la
muchachada, sin atender a la madre, que asombra el gesto con un
dedo en los labios. El patrón también sentía cubierta su fortaleza con
una nube de duelo: Tenía los ojos en los manteles: No miraba ni a la
mujer ni a los hijos: Recobrándose, levantó la frente con austera
entereza.
II
Los chamacos, en el círculo de la lámpara, repentinamente mudos

sentían el aura de una adivinación telepática:
—Hijos, he trabajado para dejaros alguna hacienda y quitaros de los
caminos de la pobreza: Yo los he caminado, y no los quisiera para
ustedes. Hasta hoy esta ha sido la directriz de mi vida, y vean cómo
hoy he mudado de pensamiento. Mi padre no me dejó riqueza, pero me
dejó un nombre tan honrado como el primero, y esta herencia quiero yo
dejarles. Espero que ustedes la tendrán en mayor aprecio que todo e
oro del mundo, y si así no fuese, me ocasionarían un gran sonrojo.
Se oyó el gemido de la niña ranchera:
—¡Siempre nos dejas, Filomeno!
El patrón, con el gesto apagó la pregunta. La rueda de sus hijos en
torno de la mesa tenía un brillo emocionado en los ojos, pero no
lloraba:
—A vuestra mamasita pido que tenga ánimo para escuchar lo que
me falta. He creído hasta hoy que podía ser un buen ciudadano
trabajando por acrecentarles la hacienda, sin sacrificar cosa ninguna a
servicio de la Patria. Pero hoy me acusa mi conciencia, y no quiero
avergonzarme mañana, ni que ustedes se avergüencen de su padre.
Sollozó la niña ranchera:
—¡Desde ya te pasas a la bola revolucionaria!
—Con este compañero.
El Coronelito de la Gándara se levantó, alardoso, tendiéndole los
brazos:
—¡Eres un patricio espartano, y no me rajo!
Suspiraba la ranchera:
—¿Y si hallas la muerte, Filomeno?
—Tú cuidarás de educar a los chamacos y de recordarles que su
padre murió por la Patria.
La mujer presentía imágenes tumultuosas de la revolución. Muertes
incendios, suplicios y, remota, como una divinidad implacable, la momia
del Tirano.
III
Ante la reja nocturna, fragante de albahacón, refrenaba su parejeño

Zacarías el Cruzado: Apareciose en súbita galopada, sobresaltando la
nocharniega cadencia campañera:
—¡Vuelo, vuelo, mi Coronelito! La chinita fue delatada. Ya la pagó e
fregado gachupín. ¡Vuelo, vuelo!
Zacarías refrenaba el caballo, y la oscura expresión del semblante y
el sofoco de la voz metía, afanoso, por los hierros. En la sala, todas las
figuras se movieron unánimes hacia la reja. Interrogó el Coronelito:
—¿Pues qué se pasó?
—La tormentona más negra de mi vida. ¡De estrella pendeja fueron
los brillos de la tumbaguita! ¡Vuelo, vuelo, que traigo perro sobre los
rastros, mi Coronelito!
IV
La niña ranchera abraza al marido, en el fondo de la sala, y lloriquea

la tropa de chamacos encandillándose a la falda de la madre. Hipando
su grito, irrumpe por una puerta la abuela carcamana:
—¿Perché questa follia? Se il Filomeno trova fortuna nella
rivoluzione potrá diventar un Garibaldi. ¡Non mi spaventar i bambini!
El Cruzado miraba por los hierros, la figura toda en sombra. El ojo
enorme del caballo recibía por veces una luz en el juego de las siluetas
que accionaban cortando el círculo del candil. Zacarías aún terciaba
sobre la silla el saco con el niño muerto. En la sala, el grupo familia
rodeaba al patrón. La madre, uno por uno, levantaba a los hijos
pasándoles a los brazos del padre. Consideró Zacarías, con dejo
apagado:
—¡Son pidazos del corazón!
Chino Viejo acercó los caballos, y los ecos de la galopada rodaron

por la nocturna campaña. Zacarías en el primer sofreno, al meterse po
un vado, apareó su montura con la del Coronelito:
—¡Se chinga Banderitas! Tenemos un auxiliar muy grande. ¡Aquí va
conmigo!
El Coronelito le miró, sospechándole borracho:
—¿Qué dices, manís?
—La reliquia de mi chamaco. Una carnicería que los chanchos me
han dejado. Va en este alforjín.
El Coronel le tendió la mano:
—-Me ocasiona un verdadero sentimiento, Zacarías. ¿Y cómo no
has dado sepultura a esos restos?
—A su hora.
—No me parece bien.
—Esta reliquia nos sirve de salvoconducto.
—¡Es una creencia rutinaria!
—¡Mi jefecito, que lo cuente el chingado gachupín!
—¿Qué has hecho?
—Guindarlo. No pedía menos satisfacción esta carnicería de m
chamaco.
—Hay que darle sepultura.
—Cuando estemos a salvo.
—¡Y parecía muy vivo, el cabroncito!
—¡Cuanti menos, para su padre!
Q U I N TA PA R T E
S A NTA MÓ NI C A
LIBRO PRIMERO
BOLETO DE SOMBRA
El Fuerte de Santa Mónica, que en las luchas revolucionarias sirvió

tantas veces como prisión de reos políticos, tenía una pavorosa
leyenda de aguas empozoñadas, mazmorras con reptiles, cadenas
garfios y cepos de tormento. Estas fábulas, que databan de la
dominación española, habían ganado mucho valimiento en la tiranía
del General Santos Banderas. Todas las tardes en el foso del baluarte
cuando las cornetas tocaban fajina, era pasada por las armas alguna
cuerda de revolucionarios. Se fusilaba sin otro proceso que una orden
secreta del Tirano.
II
Nachito y el estudiante traspasaron la poterna, entre la escolta de

soldados. El Alcaide los acogió sin otro trámite que el parte verba
depuesto por un sargento, y enviado desde la cantina por el Mayor de
Valle. Al cruzar la poterna, los dos esposados alzaron la cabeza para
hundir una larga mirada en el azul remoto y luminoso del cielo. E
Alcaide de Santa Mónica, Coronel Irineo Castañón, aparece en las
relaciones de aquel tiempo como uno de los más crueles sicarios de la
Tiranía: Era un viejo sanguinario y potroso que fumaba en cachimba y
arrastraba una pata de palo. Con la bragueta desabrochada, jocoso y
cruel, dio entrada a los dos prisioneros:
—¡Me felicito de recibir a una gente tan seleccionada!
Nachito acogió el sarcasmo con falsa risa de dientes y quiso
explicarse:
—Se padece una ofuscación, mi Coronelito.
El Coronel Irineo Castañón vaciaba la cachimba golpeando sobre la
pata de palo:
—A mí en eso ninguna cosa me va. Los procesos, si hay lugar, los
instruye el Licenciadito Carballeda. Ahora, como aún se trata de una
simple detención, van a tener por suyo todo el recinto murado.
Agradeció Nachito con otra sonrisa cumplimentera y acabó
moqueando:
—¡Es un puro sonambulismo este fregado!
El Cabo de Vara, en el sombrizo de la puerta, hacía sonar la pretina
de sus llaves: Era mulato, muy escueto, con automatismo de fantoche
Se cubría con un chafado kepis francés, llevaba pantalones colorados
de uniforme, y guayabera rabona muy sudada: Los zapatos de charol
viejos y tilingos, traía picados en los juanetes. El Alcaide le advirtió
jovial:
—Don Trini, a estos dos flautistas vea de suministrarles boleto de
preferencia.
—No habrá queja. Si vienen provisorios se les dará luneta de
muralla.
Don Trini, cumplida la fórmula del cacheo, condujo a los presos po
un bovedizo con fusiles en armario: Al final, abrió una reja y los soltó
entre murallas:
—Pueden pasearse a su gusto.
Nachito, siempre cumplimentero y servil, rasgó la boca:
—¡Muchísimas gracias, Don Trini!
Don Trini, con absoluta indiferencia, batió la reja, haciendo rechina
cerrojos y llaves: Gritó alejándose:
—Hay cantina, si algo desean y quieren pagarlo.
III
Nachito, suspirando, leía en el muro los grafitos carcelarios

decorados con fálicos trofeos. Tras de Nachito, el taciturno estudiante
liaba el cigarro: Tenía en los ojos una chispa burlona, y en la boca
prieta, color de moras, un rictus de compasión altanera. Esparcidos y
solitarios paseaban algunos presos. Se oía el hervidero de las olas
como si estuviesen socavando el cimiento. Las ortigas lozaneaban en
los rincones sombríos, y en la azul transparencia aleteaba una
bandada de zopilotes, pájaros negros. Nachito, finchándose en e
pando compás de las zancas, miró con reproche al estudiante:
—Ese mutismo es impropio para dar ánimos al compañero, y hasta
puede ser una falta de generosidad. ¿Cómo es su gracia, amigo?
—Marco Aurelio.
—¡Marquito, qué será de nosotros!
—¡Pues, y quién sabe!
—¡Esto impone! ¡Se oye el farollón de las olas!... Parece que
estamos en un barco.
El Fuerte de Santa Mónica, castillote teatral con defensas del tiempo
de los virreyes, erguíase sobre los arrecifes de la costa, frente al vasto
mar ecuatorial, caliginoso, de ciclones y calmas. En la barbacana
algunos morteros antiguos, roídos de lepra por el salitre, se alineaban
moteados con las camisas de los presos tendidas a secar: Un viejo
sentado sobre el cantil frente al mar inmenso, ponía remiendos a la
frazada de su camastro. En el más erguido baluarte cazaba lagartijas
un gato, y pelotones de soldados hacían ejercicios en Punta Serpiente.
IV
Hilo de la muralla, la curva espumosa de las olas balanceaba una

ringla de cadáveres. Vientres inflados, livideces tumefactas. Algunos
prisioneros, con grito de motín, trepaban al baluarte. Las olas mecían
los cadáveres ciñéndolos al costado de la muralla, y el cielo alto
llameante, cobijaba un astroso vuelo de zopilotes, en la crue
indiferencia de su turquesa. El preso que ponía remiendos en la
frazada de su camastro quebró el hilo, y con la hebra en el bezo
murmuró leperón y sarcástico:
—¡Los chingados tiburones ya se aburren de tanta carne
revolucionaria, y todavía no se satisface el cabrón Banderas! ¡Puta
madre!
El rostro de cordobán, burilado de arrugas, tenía un gesto estoico
La rasura de la barba, crecida y cenicienta, daba a su natural adusto un
cierto aire funerario. Nachito y Marco Aurelio caminaron inciertos, como
viajeros extraviados: Nachito, si algún preso cruzaba por su vera
apartábase solícito y abría paso con una sonrisa amistosa. Llegaron a
baluarte y se asomaron a mirar el mar alegre de luces mañaneras
nigromántico con la fúnebre ringla balanceándose en las verdosas
espumas de la resaca. Entre los presos que coronaban el baluarte
acrecía la zaloma de motín con airados gestos y erguir de brazos
Nachito se aleló de espanto:
—¿Son náufragos?
El viejo de la frazada le miró despreciándole:
—Son los compañeros recién ultimados en Foso-Palmitos.
Interrogó el estudiante:
—¿No se les enterraba?
—¡Qué va! Se les tiraba al mar. Pero visto cómo a los tiburones ya
les estomaga la carne revolucionaria, tendrán que darnos tierra a los
que estamos esperando vez.
Tenía una risa rabiosa y amarga. Nachito cerró los ojos:
—¿Es de muerte su sentencia, mi viejo?
—¿Pues conoce otra penalidad más clemente el Tigre de
Zamalpoa? ¡De muerte! ¡Y no me arrugo ni me rajo! ¡Abajo el Tirano!
Los prisioneros encaramados en el baluarte, hundían las miradas en
los disipados verdes que formaba la resaca entre los contrafuertes de
la muralla. El grupo tenía una frenética palpitación, una brama, un
clamoreo de denuestos. El Doctor Alfredo Sánchez Ocaña, poeta y
libelista, famoso tribuno revolucionario, se encrespó con el brazo
tendido en arenga, bajo la mirada retinta del centinela que paseaba en
la poterna con el fusil terciado:
—¡Héroes de la libertad! ¡Mártires de la más noble causa! ¡Vuestros
nombres escritos con letras de oro, fulgirán en las páginas de nuestra
Historia! ¡Hermanos, los que van a morir os rinden un saludo, y os
presentan armas!
Se arrancó el jipi con un gran gesto, y todos le imitaron. El centinela
amartilló el fusil:
—¡Atrás! No hay orden para demorar en el baluarte.
Le apostrofó el Doctor Sánchez Ocaña:
—¡Vil esclavo!
Una barca tripulada por carabineros de mar, arriando vela
maniobraba para recoger los cadáveres. Embarcó siete. Y como los
prisioneros en creciente motín no desalojaban el baluarte, salió la
guardia y sonaron cornetas.
V
Nachito, tomado de alferecía, se agarraba al brazo del estudiante:
—¡Nos hemos fregado!
El viejo de la manta le miró despacio, el belfo mecido por una risa de
cabrío:
—No merita tanto atribulo esta vida pendeja.
Nachito ahiló la voz en el hipo de un sollozo:
—¡Muy triste morir inocente! ¡Me condenan las apariencias!
Y el viejo, con burlona mueca de escarnio, seguía martillando:
—¿No sos revolucionario? Pues sin merecerlo vas vos a tener el fin
de los hombres honrados.
Nachito, relajándose en una congoja, tendía los ojos suplicantes a
preso, que, con el ceño fruncido y la manta tendida sobre las piernas
se había puesto a estudiar la geometría de un remiendo. Nachito
intentó congraciarse la voluntad de aquel viejo de cordobán: El azar los
reunía bajo la higuera, en un rincón del patio:
—Nunca he sido simpatizante con el ideario de la revolución y lo
deploro, comprendo que son ustedes héroes con un puesto en la
Historia: Mártires de la Idea. ¡Sabe, amigo, que habla muy lindo e
Doctor Sánchez Ocaña!
Hízole coro el estudiante, con sombrío apasionamiento:
—En el campo revolucionario militan las mejores cabezas de la
República.
Aduló Nachito:
—¡Las mejores!
Y el viejo de la frazada, lentamente, mientras enhebra, desdeñoso y
arisco comentaba:
—Pues, manifiestamente, para enterarse no hay cosa como visita
Santa Mónica. A lo que se colige, el chamaco tampoco es
revolucionario.
Declaró Marco Aurelio con firmeza:
—Y me arrepiento de no haberlo sido, y lo seré, si alguna vez me
veo fuera de estos muros.
El viejo, anudando la hebra, reía con su risa de cabra:
—De buenos propósitos está empedrado el Infierno.
Marco Aurelio miró al viejo conspirador y juzgó tan cuerdas sus
palabras, que no sintió el ultraje: Le sonaban como algo lógico e
irremediable en aquella cárcel de reos políticos, orgullosos de morir.
VI
El tumbo del mar batía la muralla, y el oboe de las olas cantaba e

triunfo de la muerte. Los pájaros negros hacían círculos en el remoto
azul, y sobre el losado del patio se pintaba la sombra fugitiva de
aleteo. Marco Aurelio sentía la humillación de su vivir, arremansado en
la falda materna, absurdo, inconsciente como las actitudes de esos
muñecos olvidados tras de los juegos: Como un oprobio remordíale su
indiferencia política. Aquellos muros, cárcel de exaltados
revolucionarios, le atribulaban y acrecían el sentimiento mezquino de
su vida, infantilizada entre ternuras familiares y estudios pedantes, con
premios en las aulas. Confuso atendía al viejo que entraba y sacaba la
aguja de lezna:
—¿Venís vos a la sombra por incidencia justificada, o por espiar lo
que se conversa? Eso, amigo, es bueno ponerlo en claro. Recorra las
cuadras y vea si encuentra algún fiador. ¿No dice que es estudiante?
Pues aquí no faltan universitarios. Si quiere tener amigos en esta
mazmorra, busque modo de justificarse. Los revolucionarios platónicos
merecen poca confianza.
El estudiante había palidecido intensamente. Nachito, con ojos de
perro, imploraba clemencia:
—A mí también me tenía horrorizado Tirano Banderas: ¡Muy po
demás sanguinario! Pero no era fácil romper la cadena. Yo para volinas
no valgo, y ¿adónde iba que me recibiesen si soy inútil para ganarme
los fríjoles? El Generalito me daba un hueso que roer y se divertía
choteándome. En el fondo parecía apreciarme. ¿Qué está mal, que soy
un pendejo, que aquello era por demás, que tiene sus fueros la
dignidad humana? Corriente. Pero hay que reflexionar lo que es un
hombre privado del albedrío por ley de herencia. ¡Mi papá, un
alcohólico! ¡Mi mamá, con desvarío histérico! El Generalito, a pesar de
sus escarnios, se divertía oyéndome decir jangadas. No me faltaban
envidiosos. ¡Y ahora caer de tan alto!
Marco Aurelio y el viejo conspirador oían callados y por veces se
miraban. Concluyó el viejo:
—¡Hay sujetos más ruines que putas!
Se ahogaba Nachito.
—¡Todo acabó! El último escarnio supera la raya. Nunca llegó a
tanto. Divertirse fusilando a un desgraciado huérfano, es propio de
Nerón. Marquito, y usted amigo, yo les agradecería que luego me
ultimasen. Sufro demasiado. ¡Qué me vale vivir unas horas, si todo e
gusto me lo mata este chingado sobresalto! Conozco mi fin, tuve un
aviso de las ánimas. Porque en este fregado ilusorio andan las
Benditas. Marquito, dame cachete, indúltame de este suplicio nervioso
Hago renuncia de la vida por anticipado. Vos, mi viejo, ¿qué hacés que
no me sangrás con esa lezna remendona? Mero mero, pasame las
entretelas. Amigos, ¿qué dicen? Si temen complicaciones, háganme e
servicio de consolarme de alguna manera.
VII
El planto pusilánime y versátil de aquel badulaque aparejaba un

gesto ambiguo de compasión y desdén en la cara funeraria del viejo
conspirador y en la insomne palidez del estudiante. La mengua de
aquel bufón en desgracia tenía cierta solemnidad grotesca como los
entierros de mojiganga con que fina el antruejo. Los zopilotes abatían
sus alas tiñosas sobre la higuera.
LIBRO SEGUNDO
EL NÚMERO TRES
El calabozo número tres era una cuadra con altas luces enrejadas
mal oliente de alcohol, sudor y tabaco. Colgaban en calle, a uno y otro
lateral, las hamacas de los presos, reos políticos en su mayor cuento
sin que faltasen en aquel rancho el ladrón encanecido, ni el idiota
sanguinario, ni el rufo valiente, ni el hipócrita desalmado. Por hacerles
a los políticos más atribulada la cárcel, les befaba con estas compañías
el de la pata de palo, Coronel Irineo Castañón. La luz polvorienta y alta
de las rejas resbalaba por la cal sucia de los muros, y la expresión
macilenta de los encarcelados hallaba una suprema valoración en
aquella luz árida y desolada. El Doctor Sánchez Ocaña, declamatorio
verboso, con el puño de la camisa fuera de la manga, el brazo siempre
en tribuno arrebato, engolaba elocuentes apóstrofes contra la tiranía:
—El funesto fénix del absolutismo colonial, renace de sus cenizas
aventadas a los cuatro vientos, concitando las sombras y los manes de
los augustos libertadores. Augustos, sí, y el ejemplo de sus vidas debe
servirnos de luminar en estas horas, que acaso son las últimas que nos
resta vivir. El mar devuelve a la tierra sus héroes, los voraces
monstruos de las azules minas se muestran más piadosos que e
general Santos Banderas... Nuestros ojos...
Se interrumpía. Llegaba por el corredor la pata de palo. El alcaide
cruzó fumando en cachimba, y poco a poco extinguiose el alerta de su
paso cojitranco.
II
Un preso, que leía tendido en su hamaca, sacó a luz, de nuevo, e

libro que había ocultado. De la hamaca vecina le interrogó la sombra
de Don Roque Cepeda:
—¿Siempre con las Evasiones Célebres?
—Hay que estudiar los clásicos.
—¡Mucho le intriga esa lectura! ¿Sueña usted con evadirse?
—Pues quién sabe.
—¡Ya estaría bueno, podérsela jugar al Coronelito Pata de Palo!
Cerró el libro con un suspiro el que leía:
—No hay que pensarlo. Posiblemente a usted y a mí nos fusilan
esta tarde.
Denegó con ardiente convicción Don Roque:
—A usted, no sé... Pero yo estoy seguro de ver el triunfo de la
Revolución. Acaso más tarde me cueste la vida. Acaso. Se cumple
siempre el Destino.
—Indudablemente. ¿Pero usted conoce su Destino?
—Mi fin no está en Santa Mónica. Tengo encima el medio siglo, aún
no hice nada, he sido un soñador y forzosamente debo regenerarme
actuando en la vida del pueblo, y moriré después de haberle
regenerado.
Hablaba con esa luz fervorosa de los agonizantes, confortados po
la fe de una vida futura, cuando reciben la Eucaristía. Su cabeza
tostada de santo campesino erguíase sobre la almohada como en una
resurrección, y todo el bulto de su figura exprimíase bajo el sabani
como bajo un sudario. El otro prisionero le miró con amistosa expresión
de burla y duda:
—¡Quisiera tener su fe, Don Roque! Pero me temo que nos fusilen
juntos en Foso-Palmitos.
—Mi destino es otro. Y usted déjese de cavilaciones lúgubres y siga
soñando con evadirse.
—Somos muy opuestos. Usted, pasivamente, espera que una fuerza
desconocida le abra las rejas. Yo hago planes para fugarme y trabajo
en ello sin echar de la imaginación el presentimiento de mi fin próximo
A lo más hondo esta idea me trabaja, y solamente, por no capitular
sigo el acecho de una ocasión que no espero.
—El Destino se vence si para combatirle sabemos reunir nuestras
fuerzas espirituales. En nosotros existen fuerzas latentes
potencialidades que desconocemos. Para el estado de conciencia en
que usted se halla, yo le recomendaría otra lectura más espiritual que
esas Evasiones Célebres. Voy a procurarle El Sendero Teosófico: Le
abrirá horizontes desconocidos.
—Recién le platicaba que somos muy opuestos. Las complejidades
de sus autores me dejan frío. Será que no tengo espíritu religioso. Eso
debe ser. Para mí todo acaba en Foso-Palmitos.
—Pues reconociéndose tan carente de espíritu religioso, usted será
siempre un revolucionario muy mediocre. Hay que considerar la vida
como una simiente sagrada que se nos da para que la hagamos
fructificar en beneficio de todos los hombres. El revolucionario es un
vidente.
—Hasta ahí llego.
—¿Y de quién recibimos esta existencia que tiene un sentido
determinado? ¿Quién la sella con esa obligación? ¿Podemos
impunemente traicionarla? ¿Concibe usted que no haya una sanción?
—¿Después de la muerte?
—Después de la muerte.
—Esas preguntas, yo me abstengo de resolverlas.
—Acaso porque no se las formula con bastante ahínco.
—Acaso.
—¿Y el enigma, tampoco le anonada?
—Procuro olvidarlo.
—¿Y puede?
—He podido.
—¿Y al presente?
—La cárcel siempre es contagiosa... Y si continúa usted
platicándome como lo hace, acabará por hacerme rezar un Credo.
—Si le enoja dejaré el tema.
—Don Roque, sus enseñanzas no pueden serme sino muy gratas
Pero entre flores tan doctas me ha puesto usted un rejón que aún me
escuece. ¿Por qué juzga que mi actuación revolucionaria será siempre
mediocre? ¿Qué relaciones establece usted entre la conciencia
religiosa y los ideales políticos?
—¡Mi viejo, son la misma cosa!
—¿La misma cosa? Podrá ser. Yo no lo veo.
—Hágase usted más meditativo y comprenderá muchas verdades
que solo así le serán reveladas.
—Cada persona es un mundo, y nosotros dos somos muy diversos
Don Roque, usted vuela muy remontado, y yo camino por los suelos
pero el calificativo que me ha puesto de mediocre revolucionario es una
ofuscación que usted padece. La religión es ajena a nuestras luchas
políticas.
—A ninguno de nuestros actos puede ser ajena la intuición de
eternidad. Solamente los hombres que alumbran todos sus pasos con
esa antorcha logran el culto de la Historia. La intuición de eternidad
trascendida es la conciencia religiosa: Y en nuestro ideario, la piedra
angular, la redención del indio, es un sentimiento fundamentalmente
cristiano.
—Libertad, Igualdad, Fraternidad, me parece que fueron los tópicos
de la Revolución Francesa. Don Roque, somos muy buenos amigos
pero sin poder entendernos. ¿No predicó el ateísmo la Revolución
Francesa? Marat, Danton, Robespierre...
—Espíritus profundamente religiosos, aun cuando lo ignorasen
algunas veces.
—¡Santa ignorancia! Don Roque, concédame usted esa categoría
para sacarme el rejón que me ha puesto.
—No me guarde rencor, se la concedo.
Se dieron la mano, y par a par en las hamacas, quedaron un buen
espacio silenciosos. En el fondo de la cuadra, entre un grupo de
prisioneros, seguía perorando el Doctor Sánchez Ocaña. El gárrulo flui
de tropos y metáforas resaltaba su frío amaneramiento en el ambiente
pesado de sudor, aguardiente y tabaco del calabozo número tres.
III
Don Roque Cepeda convocaba en torno de su hamaca un grupo

atento a las lecciones de ilusionada esperanza que vertía con apagado
murmullo y clara sonrisa seráfica. Don Roque era profundamente
religioso, con una religión forjada de intuiciones místicas y máximas
indostánicas: Vivía en un pasmo ardiente, y su peregrinación por los
caminos del mundo se le aparecía colmada de obligaciones arcanas
ineludibles como las órbitas estelares: Adepto de las doctrinas
teosóficas, buscaba en la íntima hondura de su conciencia un enlace
con la conciencia del Universo: La responsabilidad eterna de las
acciones humanas le asombraba con el vasto soplo de un aliento
divino. Para Don Roque los hombres eran ángeles desterrados: Reos
de un crimen celeste indultaban su culpa teologal por los caminos de
tiempo, que son los caminos del mundo. Las humanas vidas con todos
sus pasos, con todas sus horas, promovían resonancias eternas que
sellaba la muerte con un círculo de infinitas responsabilidades. Las
almas, al despojarse de la envoltura terrenal, actuaban su pasado
mundano en límpida y hermética visión de conciencias puras. Y este
círculo de eterna contemplación —gozoso o doloroso— era el fin
inmóvil de los destinos humanos, y la redención del ángel en destierro
La peregrinación por el limo de las formas, sellaba un número sagrado
Cada vida, la más humilde, era creadora de un mundo, y al pasar bajo
el arco de la muerte, la conciencia cíclica de esta creación se
posesionaba del alma, y el alma, prisionera en su centro, devenía
contemplativa y extática. Don Roque era varón de muy varias y
desconcertantes lecturas, que por el sendero teosófico lindaban con la
cábala, el ocultismo y la filosofía alejandrina. Andaba sobre los
cincuenta años. Las cejas, muy negras, ponían un trazo de austera
energía bajo la frente ancha, pulida calva de santo románico. El cuerpo
mostraba la firme estructura del esqueleto, la fortaleza dramática de
olivo y de la vid. Su predicación revolucionaria tenía una luz de sendero
matinal y sagrado.
LIBRO TERCERO
CARCELERAS
Bajo la luz de una reja, hacían corro jugando a los naipes hasta
ocho o diez prisioneros. Chucho el Roto tiraba la carta: Era un bigardo
famoso por muchos robos cuatreros, plagios de ricos hacendados
asaltos de diligencias, crímenes, desacatos, estropicios, majezas
amores y celos sangrientos. Tiraba despacio: Tenía las manos enjutas
la mejilla con la cicatriz de un tajo y una mella de tres dientes. En e
juego de albures, hacían rueda presos de muy distinta condición
Apuntaban en el mismo naipe charros y doctores, guerrilleros y
rondines. Nachito Veguillas estaba presente: Aún no jugaba, pero
ponía el ojo en la pinta y con una mano en el bolso se tanteaba la
plata. Vino una sota y comentó, arrobándose:
—¡No falla ninguna!
Volviose y tributó una sonrisa al caviloso jugador vecino, que
permaneció indiferente: Era un espectro vestido con fláccido saco de
dril que le colgaba como de una escarpia. Nachito recaló su atención a
la baraja: Con súbito impulso sacó la mano con un puñado de soles, y
los echó sobre la pulgona frazada que en las cárceles hace las veces
del tapete verde:
—Van diez soles en el pendejo monarca.
Advirtió el Roto:
—Ha doblado.
—Mata la pinta.
—¡Va!
El Roto corrió la puerta y vino de patas el rey de bastos. Nachito
ilusionado con la ganancia cobró y de lleno metiose en los albures. Po
veces se levantaba un borrascón de voces, disputando algún lance
Nachito tenía siempre el santo de cara, y viéndole ganar el caviloso
espectro hepático le pagó la remota sonrisa dirigiéndole un gesto
fláccido de mala fortuna. Nachito, con una mirada, le entregó su
atribulado corazón:
—En nuestra lamentosa situación, ganar o perder no hace
diferencia. Foso-Palmitos a todos iguala.
El otro denegó con su gesto fláccido y amarillo de vejiga
desinflándose:
—Mientras hay vida, la plata es un factor muy importante. ¡Hay que
considerarlo así!
Nachito suspiró:
—¿A un reo de muerte qué consuelo puede darle la plata?
—Cuando menos, este del juego para poder olvidarse... La plata
hasta el último momento, es un factor indispensable.
—¿Su sentencia también es de muerte, hermano?
—¡Pues y quién sabe!
—¿No se fusila a todos por igual?
—¡Pues y quién sabe!
—Me abre usted un rayo de luz. Voy a meter cincuenta soles en e
entrés.
Nachito ganó la puesta, y el otro arrugó la cara con su gesto
fláccido:
—¿Y le sopla siempre la misma racha?
—No me quejo.
—¿Quiere que hagamos una fragata de cinco soles? Usted la
gobierna como le plazca.
—Cinco golpes.
—Como le plazca.
—Vamos en la sota.
—¿Le gusta esa carta?
—Es el juego.
—Quebrará.
—Pues en ella vamos.
El Roto tiraba lentamente, y corrida la pinta para que todos la
viesen, quedábase un momento con la mano en alto. Vino la sota
Nachito cobró, y repartida en las dos manos la columna de soles
cuchicheó con el amarillo compadre:
—¿Qué le decía?
—¡Parece que las ve!
—Ahora nos toca en el siete.
—¿Pues qué juego lleva?
—Gusto y contragusto. Antes jugué la que me gustaba y ahora
corresponde el siete, que no me incita ni me dice nada.
—Gusto y contra gusto llama usted a ese juego. ¡Lo desconocía!
—Mero, mero, acabo de descubrirlo.
—Ahora perdemos.
—Mire el siete en puerta.
—¡En los días de mi vida he visto suerte tan continuada!
—Vamos al tercer golpe en el caballo.
—¿Le gusta?
—Le estoy agradecido. ¡Ya hemos ganado!
—Debemos repartir.
—Vamos a darle los cinco golpes.
—Perdemos.
—O ganamos. La carta del gusto es el cinco, nos corresponde la de
contragusto.
—¡Juego chocante! Reserve la mitad, amigo.
—No reservo nada. Ochenta soles lleva el tres.
—No sale.
—Alguna vez debe quebrar.
—Retírese.
Chucho el Roto, con un ojo en el naipe, medía la diferencia entre las
dos cartas del albur. Silbó despectivo:
—Psss... Van igualadas.
Posando la baraja sobre la manta, se enjugó la frente con un vistoso
pañuelo de seda. Percibiendo a los jugadores atentos, comenzó a tira
con una mueca de sorna y la cara torcida bajo la cicatriz. Vino el tres
que jugaba Nachito. Palpitó a su lado el espectro:
—¡Hemos ganado!
Reclamó Nachito batiendo con los nudillos en la manta:
—Ciento sesenta soles.
Chucho el Roto, al pagarle le clavó los ojos, con mofa procaz:
—Otro menos pendejo, con esa suerte, había desbancado. ¡Ni que
un ángel se las soplase a la oreja!
Nachito, con gesto de bonachón asentimiento, apilaba el dinero y
hacía sus gracias.
—¡Cua! ¡Cua!
Y murmuraba desabrido un titulado Capitán Viguri:
—¡Siempre la Virgen se le aparece a los pastores!
Y Nachito, al mismo tiempo tenía en la oreja el soplo del hepático
espectro:
—Debemos repartir.
Denegó Nachito con un frunce triste en la boca:
—Después del quinto golpe.
—Es una imprudencia.
—Si perdemos, por otro lado nos vendrá la compensación. ¿Quién
sabe? ¡Hasta pudieran no fusilarnos! Si ganamos es que tenemos la
contraria en Foso-Palmitos.
—Déjese, amigo, de macanas y no tiente la suerte.
—Vamos con la sota.
—Es una carta fregada.
—Pues moriremos en ella. Amigo tallador, ciento sesenta soles en la
sota.
Respondió el Roto:
—¡Van!
Se almibaró Nachito:
—Muchas gracias.
Y repuso el tahúr, con su mueca leperona:
—¡Son las que me cuelgan!
Volvió la baraja, y apareció la sota en puerta, con lo cual moviose un
murmullo entre los jugadores. Nachito estaba pálido y le temblaban las
manos:
—Hubiera querido perder esta carta. ¡Ay, amigo, nos tiran la
contraria en Foso-Palmitos!
Alentó el espectro con expresión mortecina:
—Por ahora vamos cobrando.
—Son ciento veintisiete soles por barba.
—¡La puerta nos ha chingado!
—Más debió chingarnos. En una situación tan lamentosa, es de muy
mal augurio ganar en el juego.
—Pues déjele la plata al Roto.
—No es precisamente la contraria.
—¿Va usted a seguir jugando?
—Hasta perder. Solo así podre tranquilizar mi ánimo.
—Pues yo voy a tomar el aire. Muchas gracias por su ayuda y
reconózcame como un servidor: Bernardino Arias.

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Braddom's Physical Medicine and

Rehabilitation, Sixth Edition David X.

Braddom’s Rehabilitation Care: A Clinical Handbook

Essentials of Physical Medicine and Rehabilitation:

Improving Functional Outcomes in Physical

Oxford Handbook of Rehabilitation Medicine 3rd Edition

Oxford Handbook of Rehabilitation Medicine 3rd Edition

Orthopedic Physical Assessment E Book (Musculoskeletal

Integrative Medicine, Fourth Edition David Rake

Integrative Medicine; Fourth Edition David Rakel

Blessen C. Eapen, MD Henry L. Lew, MD, PhD, ABPMR, CCC-A

BRADDOM’S PHYSICAL MEDICINE AND REHABILITATION,

Previous editions copyrighted 2016, 2011, 2007, 2000, and 1996.

International Standard Book Number: 978-0-323-62539-5

Content Strategist: Humayra R. Khan

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

A special thank you to Randy Braddom for the legacy that

Thank you to my amazingly supportive colleagues, staff,

Thank you to the wonderful members of the Office of Rehabilitation

Thank you to the thousands of patients and their family members

Thank you to my family, friends, and other loved ones

Denise M. Ambrosi, MS, CCC-SLP W. David Arnold, MD

Karen P. Barr, MD Mary Caldwell, DO

Jeffrey M. Cohen, MD Katherine Louise Dec, MD

David F. Drake, MD Jonathan Finnoff, DO, FACSM, FAMSSM

Daniel Dumitru, MD, PhD Gerard E. Francisco, MD

R. Norman Harden, MD Lin-Fen Hsieh, Doctor of Medicine

Mark A. Harrast, MD Wei-Li Hsu, PT, PhD

Radha Holavanahalli, PhD Sarah K. Hwang, MD

Carlos Anthony Jaramillo, MD, PhD Lester J. Kiemele, PA-C, MPAS

Jeffrey Jenkins, MD Adam P. Klausner, MD

Scott R. Laker, MD Chuan-Chin Lu, MD

Ram N. Narayan, MBBS, CRND Sofiya Prilik, MD

Brendon Scott Ross, DO, MS Anjali Shah, MD

Neelwant S. Sandhu, MD Lori V. Shuart, MS, RKT

Fantley Clay Smither, MD Chiemi Tanaka, PhD

Olaf Stüve, MD, PhD

Amy K. Wagner, MD Robert P. Wilder, MD

 Essential Elements of the Physiatric History and Physical Examination

Están prontos los caballos para la fuga en el rancho de Ticomaipú

Los chamacos, en el círculo de la lámpara, repentinamente mudos

Ante la reja nocturna, fragante de albahacón, refrenaba su parejeño

La niña ranchera abraza al marido, en el fondo de la sala, y lloriquea

Chino Viejo acercó los caballos, y los ecos de la galopada rodaron

El Fuerte de Santa Mónica, que en las luchas revolucionarias sirvió

Nachito y el estudiante traspasaron la poterna, entre la escolta de

Nachito, suspirando, leía en el muro los grafitos carcelarios

Hilo de la muralla, la curva espumosa de las olas balanceaba una

El tumbo del mar batía la muralla, y el oboe de las olas cantaba e

El planto pusilánime y versátil de aquel badulaque aparejaba un

Un preso, que leía tendido en su hamaca, sacó a luz, de nuevo, e

Don Roque Cepeda convocaba en torno de su hamaca un grupo

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Essential Elements of the Physiatric History and Physical Examination