The rehabilitation evaluation of chronic disease often shows lost function. Through the functional history, the physician characterizes the disabilities that have resulted from disease and identifies remaining capabilities. The functional history is considered part of the history of the present illness by some physicians and a separate segment of the patient interview by others. The examiner must know not only the functional status associated with the present illness but also the level of function at one or more times before the present illness; therefore, we prefer to consider it separately.
Although the specific organization of the activities of daily living varies somewhat, the following elements of personal independence remain constant: communication, eating, grooming, bathing, toileting, dressing, bed activities, transfers, and mobility.
When obtaining the functional history, the physician may record in a descriptive paragraph the patient's level of independence in each activity. However, functional stability is best communicated, followed over time, and made accessible for study when the physician uses a standard functional assessment scale.
Communication
A major component of rehabilitation is education; thus, communication is critical. The interviewer must assess the patient's communication options. In the clinical situation, this aspect of the evaluation blurs the distinction between history and physical examination. It is difficult to interact with the patient in a meaningful way without coincidentally examining his or her ability to communicate; significant speech and language deficiencies become obvious. However, for purposes of discussion, certain facets of the assessment relate more specifically to the history and will be discussed here. Additional facets are presented below in the section on the physical examination.
Speech pathology has provided clinicians with numerous classification systems for speech and language disorders. From a functional view, the elements of communication hinge on four abilities (2):
- Listening
- Reading
- Speaking
- Writing
By assessing these factors, the examiner can determine a patient's communication abilities. Representative questions include the following:
- Do you have difficulty hearing?
- Do you use a hearing aid?
- Do you have difficulty reading?
- Do you need glasses to read?
- Do others find it hard to understand what you say?
- Do you have problems putting your thoughts into words?
- Do you have difficulty finding words?
- Can you write?
- Can you type?
- Do you use any communication aids?
Eating
The abilities to present solid food and liquids to the mouth, to chew, and to swallow are basic skills taken for granted by able-bodied people. However, in individuals with neurologic, orthopedic, or oncologic disorders, these tasks can be formidable. Dysfunctional eating can be associated with far-reaching consequences, such as malnutrition, aspiration pneumonitis, and depression. As in the assessment of other skills for activities of daily living, inquiries about eating function should be specific and methodical.
Representative questions include the following:
- Can you eat without help?
- Do you have difficulty opening containers or pouring liquids?
- Can you cut meat?
- Do you have difficulty handling a fork, knife, or spoon?
- Do you have problems bringing food or beverages to your mouth?
- Do you have problems chewing?
- Do you have difficulty swallowing solids or liquids?
- Do you ever choke?
- Do you regurgitate food or liquids through your nose?
Patients with nasogastric or gastrostomy tubes should be asked who helps them prepare and administer their feedings. The type, quantity, and schedule of feedings should be recorded.
Grooming
Grooming may not be considered as important as feeding. However, the inability to make oneself attractive and presentable can have injurious effects on body image and self-esteem, social sphere, and vocational options. Consequently, grooming skills should be of real concern to the rehabilitation team.
Representative questions include the following:
- Can you brush your teeth without help?
- Can you remove and replace your dentures without help?
- Do you have problems fixing or combing your hair?
- Can you apply your makeup independently?
- Do you have problems shaving?
- Can you apply deodorant without assistance?
Bathing
The ability to maintain cleanliness also has far-reaching psychosocial implications. In addition, deficits in cleaning can result in skin maceration and ulceration, skin and systemic infections, and the spread of disease to others. Information about independence in bathing should be sought.
Representative questions include the following:
- Can you take a tub bath or shower without assistance?
- Do you feel safe in the tub or shower?
- Do you use a bath bench or shower chair?
- Can you accomplish a sponge bath without help?
- Are there parts of your body you cannot reach?
For patients with sensory deficits, bathing is also a convenient time for skin inspection, and inquiry about the patient's inspection habits should be made. For patients using a wheelchair, architectural barriers to bathroom entry should be determined.
Toileting
To the cognitively intact person, incontinence of stool or urine can be the most psychologically devastating deficit of personal independence. Ineffective bowel or bladder control has an adverse impact on self-esteem, body image, and sexuality, and it often impairs or prevents employment and social relationships. Dignity may even prohibit the person from venturing from the house for fear of an accident. Soiling of skin and clothing often results in ulceration, infection, and urologic complications. The rehabilitation physician should vigorously pursue questioning about toileting dependency with sensitivity.
Representative questions include the following:
- Can you use the toilet without assistance?
- Do you need help with clothing before or after using the toilet?
- Do you need help with cleaning after a bowel movement?
For patients with indwelling urinary catheters, the usual management of the catheter and leg bag should be examined. If bladder emptying is accomplished by intermittent catheterization, the examiner should learn who performs the catheterization and should have a clear understanding of the technique. For patients who have had ostomies for urine or feces, the examiner should determine who cares for the ostomy and should ask the patient to describe the technique.
Feminine hygiene is generally performed while on or near the toilet, so at this point in the interview, it may be convenient to inquire about problems with the use of sanitary napkins or tampons.
Dressing
We dress to go out into the world: to be employed in the workplace, to dine in restaurants, to be entertained in public places, and to visit friends. Even at home, convention dictates that we dress to entertain anyone except close friends and family. We dress for protection, warmth, self-esteem, and pleasure. Dependency in dressing obviously results in a severe limitation to personal independence and should be investigated thoroughly during the rehabilitation interview.
Representative questions include the following:
- Do you dress daily?
- What articles of clothing do you regularly wear?
- Do you require assistance putting on or taking off your underwear, shirt, slacks, skirt, dress, coat, stockings, panty hose, shoes, tie, or coat?
- Do you need help with buttons, zippers, hooks, snaps, or shoelaces?
- Do you use clothing modifications?
Bed Activities
The most basic stage of functional mobility is independence in bed activities. The importance of this functional level should not be underestimated. Persons who cannot turn from side to side to redistribute pressure and periodically expose skin to the air are at high risk of developing pressure sores over bony prominences and skin maceration from heat and occlusion. For the person who cannot stand upright to dress, bridging (lifting the hips off the bed in the supine position) will allow the donning of underwear and slacks. Independence is likewise enhanced by an ability to move between a recumbent position and a sitting position. Sitting balance is required to accomplish many other activities of daily living, including transfers.
Representative questions include the following:
- Can you turn onto your front, back, and sides without assistance?
- Can you lift your hips off the bed when supine?
- Do you need help to sit or lie down?
- Do you have difficulty maintaining a seated position?
- Can you operate the bed controls on an electric hospital bed?
Transfers
The second stage of functional mobility is independence in transfers. Skills to move between a wheelchair and the bed, toilet, bath bench, shower chair, standard seating, or car seat often serve as precursors to independence in other areas. Although a male patient can use a urinal to void without transferring, a female patient cannot be independent in bladder care without the ability to transfer to the toilet and will probably require an indwelling catheter. Travel by airplane or train is difficult without the ability to transfer from the wheelchair to other seating. Bathing or showering is not independent without the ability to move to the bath bench or shower chair. The inability to transfer to a car seat precludes the use of a motor vehicle with standard seating. Also included in this category is the ability to move from a seated position to a standing position. Low seats without arm supports present a much greater problem than straight-backed chairs with arm supports.
Representative questions include the following:
- Can you move to and from the bed, toilet, bath bench, shower chair, standard seating, or car seat and the wheelchair without assistance?
- Can you get out of bed without difficulty?
- Do you require assistance to rise to a standing position from low or high seats?
- Can you get on and off the toilet without help?
Mobility
Wheelchair Mobility
Although wheelchair independence is more likely than walking to be inhibited by architectural barriers, it provides excellent mobility for the nonwalking person. With today's manual wheelchairs of lightweight materials and efficient engineering, the energy expenditure of wheeling on flat ground is only slightly greater than that of walking. With the addition of a motorized drive, battery power, and controls for speed and direction, a wheelchair can be propelled even by a person without the upper extremity strength necessary to propel a manual wheelchair and, thus, can help maintain independence in mobility.
Quantification of manual wheelchair skills can be accomplished several ways. Patients may report in feet, yards, meters, or city blocks the distance they are able to traverse before resting. Alternatively, the number of minutes they can continuously propel the chair can be specified, or the environment in which they are able to use the chair can be described (e.g., within a single room, around the house, or throughout the community).
Representative questions include the following:
- Do you propel a wheelchair?
- Do you need help to lock the wheelchair brakes before transfers?
- Do you require assistance to cross high-pile carpets, rough ground, or inclines?
- How far or how many minutes can you wheel before you must rest?
- Can you move independently about your living room, bedroom, and kitchen?
- Do you go out to stores, to restaurants, and to friends' homes?
With any of these functional levels of wheelchair mobility, patients should be asked what keeps them from going farther and whether help is needed to lift the wheelchair into an automobile.
Ambulation
The final level of mobility is ambulation. In the narrow sense of the word, ambulation is walking, and we have used this definition to simplify the following discussion. However, within the sphere of rehabilitation, ambulation may be any useful means of movement from one place to another. In the view of many rehabilitation professionals, the person with a bilateral above-knee amputation ambulates with a manual wheelchair, the patient with C-4 tetraplegia ambulates with a motorized wheelchair, and the survivor of polio in an underdeveloped country might ambulate by crawling. To some, driving a motor vehicle also is a form of ambulation. Ambulation ability can be quantified the same way wheelchair mobility is quantified. Persons may report the distance they are able to walk, the duration between necessary rest periods, or the scope of the environment within which they walk.
Representative questions include the following:
- Do you walk unaided?
- Do you use a cane, crutches, or a walker to walk?
- How far or how many minutes can you walk before you must rest?
- What stops you from going farther?
- Do you feel unsteady, or do you fall?
- Can you go upstairs and downstairs unassisted?
- Do you go out to stores, to restaurants, and to friends' homes?
- Can you use public transportation (e.g., bus, subway) without assistance?
Operation of a Motor Vehicle
In the perception of many patients, full independence in mobility is not attained without the ability to operate a motor vehicle independently. Although driving skills are by no means necessary for urban dwellers with readily available public transportation, they may be essential to persons living in a suburban or rural environment. Driving skills should always be assessed in patients of driving age.
Representative questions include the following:
- Do you have a valid driver's license?
- Do you own a car?
- Do you drive your car to stores, to restaurants, and to friends' homes?
- Do you drive in heavy traffic or over long distances?
- Do you use hand controls or other automobile modifications?
- Have you been involved in any motor vehicle accidents or received any citations for improper operation of a motor vehicle since your illness or injury?
Source: Physical Medicine and Rehabilitation – Principles and Practice
Originally posted 2014-04-12 10:57:09.
