What components should be included in a comprehensive physical examination in physical medicine and rehabilitation (PM&R)?

Physical Examination in Physical Medicine and Rehabilitation

A comprehensive PM&R physical examination must systematically assess musculoskeletal function, neurological status, cardiovascular fitness, and functional capacity, with particular emphasis on orthopedic and neuromuscular evaluation that directly impacts rehabilitation potential and disability management. 1, 2

Essential Vital Signs and Initial Assessment

• Measure blood pressure in both arms to identify subclavian artery stenosis (difference >15-20 mmHg is significant) 2, 3
• Document pulse rate and regularity, respiratory rate, oxygen saturation, and temperature 1
• Calculate body mass index (BMI) from height and weight measurements 3
• Assess orthostatic vital signs when indicated, particularly in patients with autonomic dysfunction or deconditioning 3

Musculoskeletal Examination (Primary Focus in PM&R)

The musculoskeletal component is the cornerstone of PM&R examination and frequently reveals abnormalities requiring intervention. 4, 5

Joint Assessment

• Evaluate range of motion of all major joints systematically (shoulder, elbow, wrist, hip, knee, ankle) 2
• Identify joint deformities, swelling, tenderness, or instability 2
• Document any limitations in degrees with goniometric precision when possible 6

Muscle Strength Testing

• Test muscle strength in all extremities using standardized grading (0-5 scale) 2, 7
• Assess both proximal and distal muscle groups bilaterally 2
• Evaluate for asymmetry that may indicate neurological or orthopedic pathology 6

Functional Musculoskeletal Assessment

• Observe gait pattern, noting speed, symmetry, and use of assistive devices 2
• Assess ability to perform functional movements (sit-to-stand, reaching, bending) 7
• Identify foot deformities (bunions, hammertoes, prominent metatarsals) that increase pressure points and ulceration risk 2

Neurological Examination

Neurological assessment must include both sensory and motor components to identify deficits affecting rehabilitation potential. 1, 2

Sensory Testing

• Perform 10-gram monofilament testing for protective sensation, particularly in feet 2, 3
• Test pinprick or temperature perception in all extremities 2, 3
• Assess vibration sense using 128-Hz tuning fork at bony prominences 2, 3

Motor and Reflex Assessment

• Evaluate deep tendon reflexes, including ankle reflexes bilaterally 2
• Test coordination through finger-to-nose and heel-to-shin maneuvers 2
• Assess for pathological reflexes (Babinski, clonus) when upper motor neuron lesion suspected 6

Cognitive Function

• Evaluate mental status and cognitive function as baseline for rehabilitation planning 2, 3
• Screen for depression and anxiety that may impact rehabilitation outcomes 1

Cardiovascular and Pulmonary Assessment

• Auscultate heart for rate, rhythm, murmurs, gallops, or rubs 1
• Auscultate lungs for breath sounds, crackles, wheezes, or diminished sounds 1
• Inspect lower extremities for edema and assess for pitting quality 1
• Examine post-surgical or post-procedure wound sites for healing status 1

Vascular Examination

Peripheral vascular assessment is critical for identifying circulation issues that affect healing and exercise tolerance. 1, 2

• Palpate all peripheral pulses (brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial) 1, 2, 3
• Grade pulse intensity numerically: 0=absent, 1=diminished, 2=normal, 3=bounding 1
• Assess capillary refill time (normal <2 seconds) 2, 3
• Evaluate for rubor on dependency and pallor on elevation 2, 3
• Auscultate femoral arteries for bruits indicating arterial disease 1

Skin and Integumentary Assessment

• Remove shoes and socks to inspect feet completely at every visit for high-risk patients 1, 2
• Evaluate skin color, temperature, moisture, and turgor 2, 3
• Identify lesions, ulcerations, calluses, or wounds with precise documentation of location and size 1, 2
• Assess for trophic changes: distal hair loss, skin atrophy, hypertrophic nails 1
• Examine intertriginous areas for maceration or fungal infection 1

Functional Capacity Assessment

Physical fitness evaluation integrates body composition, cardiorespiratory endurance, muscular fitness, and flexibility. 7

• Assess cardiorespiratory endurance through standardized exercise testing when appropriate 7
• Evaluate muscular endurance through repetitive movement testing 7
• Measure musculoskeletal flexibility using standardized tests (sit-and-reach, behind-the-back reach) 7
• Document ability to perform activities of daily living independently 7

Critical Screening Components

Red Flag Screening

• Screen for serious pathology including infection, malignancy, fracture, inflammatory conditions, progressive neurological deficits, and cauda equina syndrome 1
• Identify conditions masquerading as musculoskeletal pain (aortic aneurysm, visceral pathology) 1

Psychosocial Factor Assessment

• Evaluate "yellow flags" including fear-avoidance beliefs, catastrophizing, and recovery expectations 1
• Screen for mood disorders (depression, anxiety) that impact rehabilitation outcomes 1
• Assess social determinants of health affecting rehabilitation adherence 1

Documentation Requirements

• Create individualized treatment plan documenting current status, rehabilitation goals, and intervention strategies 1
• Use validated outcome measures to track progress objectively 1
• Update assessment findings every 30 days for ongoing rehabilitation programs 1

Common Pitfalls to Avoid

Musculoskeletal problems are the leading cause of sports restriction (43.4%) and second leading cause for recommended follow-up (27.8%), yet are frequently under-examined. 4 The examination must be performed by qualified personnel with specific musculoskeletal training 4, 8. Avoid superficial screening that misses subtle deficits affecting function—systematic, thorough examination using standardized techniques and checklists significantly improves detection rates from 35% to 82% 5.