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Braddom’s PM&R Fifth Edition: Comprehensive Chapter Notes (Paraphrased)

The Physiatric Foundations and Core Chapters (Paraphrase Notes)

  • Core framework across Braddom’s PM&R Fifth Edition:

    • PM&R centers on function: impairment, activity (disability), participation, and the contextual factors (biopsychosocial model).
    • World Health Organization (WHO) classifications: impairment, activity, participation; evolved from ICIDH to ICF to better reflect interactions among health, environment, and personal factors.
    • Disability is viewed through a biopsychosocial lens and is the net result of health condition interacting with environmental and personal factors.
    • Ethical, practical, and policy dimensions (e.g., ADA, worker’s compensation, Social Security) shape how impairments translate into disability benefits, accommodation, and rehabilitation planning.

  • Key quantitative and qualitative elements you should know across chapters:

    • Impairment vs. disability vs. handicap (ICF/AMA Guides framework).
    • Impairment rating processes (e.g., Diagnosis-Based Impairment (DBI) grids for spine and limbs; combination rules; modifiers GMFH/GMPE/GMCS; the combined rating via numeric grids).
    • Return-to-work dynamics (MMI, transitional/modified duty, work hardening, functional capacity evaluations (FCE), and life-care planning when relevant).
    • The rising prominence of patient-reported outcomes (PROs) and PROMIS in quality/outcome measurement.
    • Importance of standardized testing, risk adjustment, and transparency in quality reporting.

  • Equations and formal structures to remember (LaTeX-ready):

    • Combination of impairment grades within a single limb/unit (DBI framework):
    • ext{Combined impairment} = A + B(1 - A)
      where A and B are decimal equivalents of impairment grades from two related items.
    • Diagnosis-based impairment (DBI) grids: five-class severity (0–4) per region; modifiers adjust for functional history, physical findings, and clinical studies.
    • Return-to-work planning: MMI date determines permanency and residual restrictions; inappropriate prolongation of treatment can extend disability unless justified by functional gains.

  • Chapter 1: The Physiatric History and Physical Examination

    • Purposes of the physiatric H&P:
    • Data platform for treatment planning.
    • Written record for rehabilitation teams and insurers; medicolegal utility.
    • Billing basis; EMR-driven templates and smart phrases aid thorough data capture.
    • WHO definitions (Table 1-1):
    • Impairment: loss/abnormality of structure or function.
    • Activity: level of functioning of the person.
    • Participation: involvement in life situations;
    • Impairment, activity, participation interrelate with contextual factors (environment, personal factors).
    • Essential elements of the physiatric H&P (Table 1-2): chief complaint, HPI, functional history, mobility, ADL/I-ADL, cognition, social history, medications, social environment, past medical/surgical history, ROS, and physical exam components (neurological, cranial nerves, sensory exam, reflexes).
    • World Health Organization 1997 definitions (Table 1-1) and 1997 WHO taxonomy (Impairment, Activity, Participation) framework; 1997 WHO classification adapted to rehabilitation contexts.
    • History-taking in PM&R emphasizes function-focused questions to identify impairments and the impact on ADLs, mobility, and participation (examples: stroke deficits in swallowing, communication, mobility, cognition).
    • Role of EMR in PM&R:
    • Pros: legibility, templates, warnings, billing support.
    • Cons: copy/paste redundancy, data import risks, alarm fatigue.
    • Chief Complaint and HPI components: location, onset, quality, context, severity, duration, modifiers, associated signs and symptoms.
    • Mobility assessment considerations:
    • Bed mobility (risk of skin ulcers, DVT, pneumonia).
    • Transfers (bed to chair, wheelchair to seat, car/shower seats).
    • Wheelchair mobility: independence, distance, maintenance tasks.
    • Ambulation: distance, devices, rest breaks, symptoms with ambulation (chest pain, dyspnea, dizziness).
    • ADL vs. I-ADL framework (Box 1-1): list of ADLs and IADLs used to characterize functional capacity.
    • Cognition, mood, and mental status exam concepts (MSE) and components: attention, orientation, memory, abstract thinking, insight, judgment, mood/affect; aphasia/dysarthria concepts; Glasgow Coma Scale as objective consciousness measure; clock-drawing and Mini-Cog as cognitive screens.
    • Neurologic exam structure: cranial nerves I–XII; sensory testing (dermatomes and nerve distributions); motor exam (strength, tone, coordination, reflexes); gait assessment; cerebellar signs; UMN vs LMN patterns; primitive reflexes and postural reactions.
    • Musculoskeletal (MSK) exam integration with neuro exam; end-feel concepts (soft, firm, hard, empty); ROM assessment with goniometry; manual muscle testing (MMT) scales; reliability caveats; upper- vs lower-limb testing schemas (Tables 1-13 and 1-14).
    • Practical notes on measurement technique and reliability (e.g., using contralateral comparison, maintaining relaxation, end-feel interpretation, and using standard planes).

  • Chapter 2: History and Examination of the Pediatric Patient

    • Developmental focus: milestones (Table 2-1) across gross motor, language, fine motor, and social domains; multiple standardized pediatric tools (e.g., Bayley scales, Denver II, GMFM, MACS, QUEST).
    • Functional and participation measures for children:
    • WeeFIM (adapted FIM for children) and caregiver/family involvement.
    • Denver Developmental Screening Test II (DDST-II) for screening; Bayley scales for ages birth–30 months; Gesell schedule for 4 weeks–6 years.
    • Perception of cognitive function and school readiness; academic achievement measures (WRAT, Woodcock-Johnson, etc.).
    • Pediatric quality of life and adaptive behavior measures (Vineland, PedsQL, CHQ) and family-centered outcomes.
    • Pediatric neurologic assessment considerations:
    • Primitive reflexes and postural reactions; transition to postural reactions around 2 months; asymmetries may indicate pathology (hemiparesis, plexopathy).
    • Distinct pediatric patterns: cerebral palsy indicators, brachial plexus injuries, infantile brachial plexopathy, etc.
    • Growth and development metrics:
    • Growth charts; head circumference tracking (macrocephaly vs microcephaly); birth weight/length expectations; risk factors for prematurity and cerebral palsy.
    • Pediatric examination environment and rapport-building strategies; infant/child-safe exam techniques; special considerations for hearing, vision, and cognition in pediatrics.

  • Chapter 3: Adult Neurogenic Communication and Swallowing Disorders

    • Communication disorders overview: aphasia (types: Broca, Wernicke, conduction, global, transcortical; anomic; crossed aphasia), apraxia of speech (AOS), dysarthria (types: flaccid, spastic, ataxic, hypokinetic, hyperkinetic, mixed).
    • Assessment and treatment implications: role of SLPs in identifying language vs. cognitive-linguistic deficits; use of standardized aphasia measures (e.g., Western Aphasia Battery; Boston Naming Test); AAC (low/high tech) strategies for compensatory communication.
    • Dysphagia (swallowing disorders): oral, pharyngeal, and esophageal stages; signs of aspiration; instrumental assessments (VFSS, FEES, HRM, ultrasonography); cervical auscultation validity; BDCSE (blue dye) limitations.
    • Instrumental swallow assessments:
    • VFSS: dynamic radiographic assessment of oral, pharyngeal, esophageal phases; standard bolus consistencies; observation of airway protection and bolus transport; radiation considerations.
    • FEES: endoscopic view of pharynx/larynx; secrestion levels, residue, penetration/aspiration signs; sensory testing (FEESST variant).
    • Rehabilitation approaches: restorative vs compensatory strategies for dysphagia and dysarthria; therapy examples (Mendelsohn, Masako, effortful swallow, Shaker, EMST); role of cueing, practice intensity, and AAC integration.
    • Cognitive-communication disorders and brain injury: Rancho Los Amigos levels of cognitive functioning as common framework; right-hemisphere and traumatic brain injury (TBI) cognitive-communication profiles; impact on social reintegration and work.
    • Multidisciplinary team emphasis: speech-language pathology, occupational therapy, psychology, dietetics; emphasis on home/community reintegration and school/work transitions (pediatric extension addressed in Chapter 2).

  • Chapter 4: Psychological Assessment and Intervention in Rehabilitation

    • Scope of psychology in PM&R: assessment and intervention across body functions, activities, and participation; standardized measures and normative data; prognostication and treatment planning; capacity assessments (financial, medical) as needed.
    • Stages of acute to postacute rehab: emphasis on cognitive, emotional, and behavioral problems; role in family education and coping strategies; group vs individual formats; motivational interviewing and cognitive-behavioral therapy (CBT) approaches.
    • Key intervention domains:
    • Impaired awareness after brain injury: metacognitive strategies, feedback, task practice; safety considerations; staged interventions (intensity and context).
    • Attention rehabilitation: hierarchy of attention (focused, sustained, selective, alternating, divided); direct attention training vs compensatory strategies; evidence base supports practice standards for outpatient settings; use of Attention Process Training and CBT with metacognitive elements.
    • Memory rehabilitation: restorative vs compensatory strategies; memory notebooks and reminder systems; external vs internal strategies; real-world task training and caregiver involvement.
    • Problem-solving and executive function: formal problem-solving training; metacognitive strategies; real-world applicability; group-based approaches;
    • Emotional problems: depression, anxiety, posttraumatic stress in veterans; pharmacologic and psychotherapeutic approaches; CBT and supportive therapy; suitability considerations in acute vs postacute phases; group therapy advantages; safety and participation considerations.
    • Behavioral problems: agitation, disinhibition, aggression; contingency management; functional behavioral analysis; parent/caregiver training; pharmacologic and non-pharmacologic treatments; multitiered interventions.
    • Maintenance of Certification (MOC) and Practice Improvement Projects (PIPs) within PM&R subspecialties (ABPMR, AAPMR, AANEM) highlighting the push toward evidence-based, outcome-driven practice; examples include Clinical Care PIP, specialty PIPs, and electrodiagnostic PIP.

  • Chapter 5: Practical Aspects of Impairment Rating and Disability Determination

    • Conceptual frameworks and standards:
    • Transition from “medical model” to biopsychosocial model (ICF) with emphasis on impairment, activity, participation; role of environmental and personal factors.
    • ADA definitions and policy implications; workforce-related disability concepts; public policy and accountability.
    • Disability systems in the USA: SSDI, SSI, Veterans Affairs (VBA), workers’ compensation, personal injury claims; the impact of impairment ratings on disability determinations and benefits; life-care planning considerations.
    • Core processes in impairment rating:
    • Identify impairment per regimens (e.g., spine/extremity DBIs); determine permanency and MMI; use of the six-level DBI grids and the role of GMFH, GMPE, GMCS modifiers.
    • The DBI framework units: spine (cervical, thoracic, lumbar, pelvis), upper limb (digits, wrist, elbow, shoulder), lower limb (foot/ankle, knee, hip).
    • The final impairment score is derived through grid-based classification and subsequent modifiers, with the overall formula approach used to adjust the Class score.
    • Key numerical references and processes:
    • TWP (trial work period): 9 months total within a 60-month window; earnings up to $530/month during TWP; EPE extension of cash benefits for 36 months if earnings drop below SGA.
    • SGA levels: threshold figures (e.g., $1070 in 2014 for nonblind SSDI; adjustments over time).
    • Earned income exclusion and blind work expenses: earnings not considered for benefit calculation; employment incentives and public policy changes (e.g., 1619 program).
    • Programs and mechanisms:
    • Workers’ compensation: state vs federal programs; no-fault coverage; medical/rehab benefits; vocational rehab integration; Life care planning in catastrophic injuries.
    • IME (independent medical examination): one-time evaluation; causation and medical necessity; potential liability and professional responsibilities; the spectrum of actions and ethical considerations.
    • Practical tools and forms: patient status reports and return-to-work/fitness-for-duty forms; FCE as a core tool for documenting work capacity; job description and job site evaluation (JSE).

  • Chapter 6: Employment of People with Disabilities

    • Public health framing: disability as a major US public health issue; prevalence data (56.7 million with some disability; 12.6% severely disabled in 2010); high indirect costs via lost productivity.
    • Disability taxonomy and policy:
    • ADA and Rehabilitation Act; civil rights and anti-discrimination in employment; Section 1619 (SSI) provisions; work incentives (TWP, EPE, EI, earned income exclusion); Plan for Achieving Self-Support (PASS).
    • Vocational rehabilitation framework:
    • State VR agencies; testing approaches: aptitude matching (DOT-based), work samples (Valpar), job placement and training, on-the-job training, transportation, and adaptive equipment.
    • Traditional vs newer models: sheltered workshops vs transitional and supported employment; home-based, Projects with Industry; job coaches and workplace accommodations; ILCs and integrated employment models.
    • Incentives and disincentives:
    • SSDI/SSI work incentives; Ticket to Work programs; income exclusions; caps and thresholds; health insurance protections (Medicare/Medicaid)
    • Employer incentives (tax credits like TJTC; Section 190/Section 44 tax credits for accessibility)
    • Program evaluation and outcomes:
    • Evidence for return-to-work benefits; economic and qualitative benefits; life-quality improvements with employment; the need for ongoing supports in supported employment.
    • Practical implications for clinicians:
    • Role of the physiatrist in returning patients to work; inclusion of vocational planning as part of rehabilitation; ensuring accurate job descriptions and essential functions; safety and accommodation decisions in collaboration with employers.

  • Chapter 7: Quality and Outcome Measures for Medical Rehabilitation

    • Core quality concepts:
    • Value in health care (health outcomes per cost) vs. process measures; Donabedian model (structure, process, outcome).
    • National quality strategies and organizations:
    • Centers for Medicare and Medicaid Services (CMS) quality strategy; National Quality Strategy (NQS);
    • National Committee for Quality Assurance (NCQA); Patient Protection and Affordable Care Act (PPACA) aims.
    • Outcome measures and PROs:
    • Functional Independence Measure (FIM) and WeeFIM; CHART; SF-36; PROMIS; 6-minute walk test; PedsQL; Rivermead Mobility Index; Oswestry Disability Index; etc.
    • ICF alignment and measurement frameworks:
    • ICF levels: body functions/structures; activities; participation; environmental and personal factors; measurement strategies across these domains.
    • Evidence-based medicine (EBM) and guidelines:
    • Sackett’s EBM framework (define question, search, appraise, apply); importance of clinical practice guidelines (CPGs) and IOM standards; National Guideline Clearinghouse as a resource.
    • Quality improvement practice and reporting:
    • Donabedian’s structure/process/outcome; the Donabedian model applied to rehabilitation; the Donabedian-activity of reporting for accountability.
    • Measurement challenges:
    • Risk adjustment, data privacy, data security; the need for fair, transparent benchmarks; multi-stakeholder involvement; the balance of accuracy and feasibility.
    • Practical implications for PM&R practice:
    • Use of outcome measures to drive practice improvements; the role of PROs in capturing patient-centered outcomes; the need for pediatric considerations and family-centered metrics.

  • Chapter 8: Electrodiagnostic Medicine

    • Conceptual framework:
    • Electrodiagnostic testing extends clinical evaluation with EMG (needle EMG) and nerve conduction studies (NCS); tests adapt to clinical data and can refine or confirm diagnoses; the tests alter management in roughly 42% of cases.
    • History and exam in electrodiagnosis:
    • History emphasizes symptoms across limbs; differentiating sensory vs. motor pathologies; prior spine conditions; risk factors (diabetes, alcohol use); family history of neurologic disease.
    • Test modalities and anatomy:
    • NCS (motor and sensory), F-waves, H-reflexes; paraspinal EMG; needle vs surface electrodes; concentric needle vs monopolar needles; single-fiber EMG techniques.
    • Nerve injury classifications:
    • Seddon classification (neurapraxia, axonotmesis, neurotmesis);
    • Sunderland classification (Types 1–5) with endoneurial tube involvement, perineurium, epineurium.
    • Indicators and interpretation:
    • EMG patterns: fibrillations, PSWs, CRDs; MUAPs; recruitment patterns; endplate potentials; endplate noise; motor unit recruitment changes.
    • Radiculopathy, plexopathy, entrapments, and polyneuropathy:
    • Distal vs. proximal patterns; importance of paraspinal muscle testing for spine localization; distinguishing radiculopathy from plexopathy and entrapment through pattern analysis; role of SNAPs vs CMAPs in localization.
    • Pediatric electrodiagnosis:
    • Unique considerations: normative pediatric data; heightened need for careful interpretation due to developmental changes; specialized pediatric needles and techniques; temperature control in testing.
    • Techniques and instrumentation:
    • Electrodes (surface and needle), amplifiers, filters, A/D conversion, stimulators; stimulus artifacts and methods to minimize them; safety considerations (sterility, sharps, infection risk).
    • Practical reporting and guidelines:
    • The importance of a structured electrodiagnostic report including history, focused exam, tabulated NCS/EMG data, interpretation, and limitations.
    • Common conditions and electrodiagnostic patterns:
    • AIDP/Guillain–Barré; CIDP; LEMS; myasthenia gravis; ALS; muscular dystrophies; inflammatory myopathies; neuropathies including diabetic polyneuropathy; entrapment neuropathies (CTS, ulnar tunnel, peroneal nerve at fibular head, tarsal tunnel).
    • General caveats and pitfalls:
    • Variability in normative values; the need for standardized reference data; interpretation in the context of age, temperature, comorbidities (diabetes, obesity); cautions about polyneuropathy confounding focal radiculopathy; false positives and the importance of multiple confirming findings.
    • Practical takeaways:
    • Needle EMG is essential in most cases; EMG/NCS combination often required to reach a confident diagnosis; pediatric applications require specialized approaches.

  • Appendices and references (what to know at a glance):

    • Appendix 8A–8C provide detailed instrumental principles, motor unit physiology, and testing guidelines.
    • Extensive reference lists accompany each chapter; key organizations include AANEM, ABPMR, AAPMR; standard texts and guidelines underpin practice standards in EMG/NCS.

  • Cross-cutting connections and exam-ready takeaways:

    • Always anchor PM&R assessment in the ICF/biopsychosocial model; use impairment ratings to inform disability determinations but connect them to real-world function and participation, including work and daily living activities.
    • In rehabilitation planning, integrate medical management with functional goals: mobility, ADL, communication, cognition, return-to-work, and psychosocial well-being.
    • When evaluating the pediatric patient, blend developmental trajectory with family context, school participation, and long-term planning for independence.
    • For dysphagia and dysarthria, differentiate motor speech disorders by site of lesion and mechanism, but tailor therapy to maximize safe swallowing and intelligible communication; use instrumental assessments to guide management.
    • In quality measurement, balance validity, reliability, and feasibility; choose outcome measures that reflect meaningful patient-centered endpoints and can be tracked over time with risk adjustment to compare performance meaningfully.

  • Quick study prompts (for exam prep):

    • Define impairment, activity, participation per WHO/ICF and relate to rehab planning.
    • List the six IOM aims of health care quality and give an example for each in PM&R.
    • Explain the DBI grid concept for spine and limbs and illustrate how GMFH/GMPE/GMCS modifiers affect the final impairment rating.
    • Contrast VFSS vs FEES in swallow evaluation and list one strength and one limitation for each.
    • Describe the TWP, SGA, EPE, and PASS incentives in SSDI/SSI contexts and how they influence return-to-work decisions.
    • Name key pediatric outcome measures and indicate what domain each assesses (gross motor, fine motor, cognition, participation).
    • Outline the main categories of entrapment neuropathies and the classic electrodiagnostic patterns used to confirm them (CTS, Ulnar tunnel, peroneal at fibular head, tarsal tunnel).

  • Note on LaTeX usage in formulas: The main explicit equation you’ll need to recall for exams is the impairment combination formula given above. The context of the other formulas is conceptual (grid-based scoring, modifier integration) and typically not required to reproduce verbatim in exam answers; however, showing the core equation can help you recall how two separate impairment items combine into a single rating.

  • If you want, I can convert these notes into a printable PDF with chapter-wise sections and checklists, or tailor a condensed cram sheet focusing on the chapters you’ll be tested on.