Ongoing and thorough patient assessment is a crucial aspect of the neurorehabilitation process. The goals of assessment change over the clinical course of rehabilitation from the acute hospitalization, to the transfer to a rehabilitation facility or program, to the transition back to the community. Initial concerns often include patient survival, level of consciousness, and response to acute treatments. Later concerns focus on specific neurologic impairments and a patient’s functional abilities.

▪ SPECIAL CLINICAL POINT: Patient evaluation throughout the neurorehabilitation process involves clinical examinations and well-validated standardized measures performed by various members of the interdisciplinary team of rehabilitation specialists.

This team often is composed of the physician (neurologist or physiatrist), nurses, a social worker,
therapists (including physical, occupational, speech, and recreational/vocational), and a psychologist.

The non-neurologist primary care physician will likely benefit from a neurorehabilitation consultation for evaluation of all patients admitted to the hospital with acute neurologic impairments resulting in functional deficits. In addition, patients with chronic medical or neurologic conditions with functional deficits that may be related to deconditioning weakness, reduced joint mobility, or progression of the condition also may benefit from rehabilitation. In principle, a neurorehabilitation evaluation should be obtained for all hospitalized or ambulatory clinic patients with functional decline in any routine daily functions including mobility; transfers; ambulation; or the ability to dress, bathe, feed, groom, speak, or carry out previously routine duties such as vocational or homemaking responsibilities.

The objectives of neurorehabilitation assessment during the acute hospital admission include documentation of the diagnosis, the impairments, and the disabilities as well as identification of treatment needs. Subsequent reevaluation focuses on response to acute-care treatments and any changes in neurologic or medical status. Once patients are medically stable, the evaluation is geared toward identifying those who will benefit from further rehabilitation intervention and determining the appropriate rehabilitation setting. Recommendation may be made for referral to an interdisciplinary rehabilitation program, in an inpatient or an outpatient facility, or for selected individual rehabilitation services in an ambulatory care setting.

On admission to a neurorehabilitation program, assessment is performed to help develop a rehabilitation management plan with realistic goals and to document a baseline level of function for monitoring progress. Periodic weekly or biweekly reassessment during the rehabilitation program allows patient progress to be monitored, treatment regimens to be adjusted when necessary to maximize patient potential, and discharge planning to be facilitated. Objectives of assessment after discharge include the evaluation of patient adaptation to the home environment and community setting, the determination of the need for further rehabilitation services, and the assessment of caregiver burden and needs.

Standardized assessment instruments in neurorehabilitation complement the neurologic examination in evaluating functional recovery. Standardized measurement scales facilitate reliable documentation of severity of functional disabilities, help to increase consistency of treatment decisions, facilitate communication between therapists, and provide a reliable basis for monitoring progress. Scales exist to measure many areas of neurologic function, such as consciousness, cognition, perception, communication, strength, mobility, balance, coordination, somatosensation, and affective function. For example, the Rancho Los Amigos Cognitive Scale often is used to document levels of cognitive recovery following a traumatic brain injury, and the Functional Independence Measure Scale often is used to assess levels of independence in areas of basic daily function. In addition, many other scales exist to help measure and quantify specific functional impairments and disabilities. Limitations of various standardized measurement scales often are counterbalanced by use of other scales and the neurologic examination.

Another important aspect of patient assessment in neurorehabilitation is the clarification of the complex relationship that exists between disease, impairment or severity of objective deficits, and disability or the impact of disease on function in any individual patient.

Specific neurologic impairments may play a role in multiple functional disabilities. For example, a patient’s inability to adequately selffeed, dress, or propel a wheelchair could separately result from impairments in strength, endurance, cognition, comprehension, perception, sensation, coordination, balance, lack of motivation, or the presence of pain or fatigue. Furthermore, individual impairments may have multiple possible etiologies. For example,
fatigue may result directly from a neurologic disease process or it may indirectly result from depression, sedative side effects of various medications, or a lack of adequate sleep. Similarly, a patient’s inability to effectively concentrate and attend to therapies may result from impairments of cognition or perception resulting directly from neurologic disease or indirectly from depression, the side effects of medications, or the distraction of pain. Thus, the role of assessment in neurorehabilitation includes clarification of etiologies contributing to a patient’s disabilities so that appropriate therapeutic interventions may be undertaken at any point during the rehabilitation process. In addition, certain treatments may be contraindicated or recovery may be limited by comorbid chronic conditions such as cardiovascular disease, chronic pulmonary disease, cancer, musculoskeletal disorders, or psychiatric conditions. Evaluation and treatment of poorly controlled comorbid medical conditions also will improve neurorehabilitation outcomes.