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BRADDOM’S
REHABILITATION
CARE
A Clinical Handbook
This page intentionally left blank

BRADDOM’S
REHABILITATION
CARE
A Clinical Handbook
David X. Cifu, MD
Chairman
Department of Physical Medicine and Rehabilitation
Herman J. Flax, MD Professor
Virginia Commonwealth University School of Medicine
Principal Investigator
Veterans Affairs/Department of Defense Chronic Effects of Neurotrauma Consortium
Richmond, Virginia
Henry L. Lew, MD, PhD

Tenured Professor, University of Hawaii School of Medicine
Chair, Department of Communication Sciences and Disorders
Honolulu, Hawaii
Adjunct Professor, Department of Physical Medicine and Rehabilitation
Richmond, Virginia
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
BRADDOM’S REHABILITATION CARE:

A CLINICAL HANDBOOK ISBN: 978-0-323-47904-2
Copyright © 2018 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means,
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This book and the individual contributions contained in it are protected under copyright by
the Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional prac-
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Practitioners and researchers must always rely on their own experience and knowledge
in evaluating and using any information, methods, compounds, or experiments described
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vidual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors,
or editors, assume any liability for any injury and/or damage to persons or property as a
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methods, products, instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data

Names: Cifu, David X., editor. | Lew, Henry L., editor.
Title: Braddom’s rehabilitation care : a clinical handbook / [edited by]
David X. Cifu, Henry L. Lew.
Other titles: Rehabilitation care | Supplement to (expression): Braddom’s
physical medicine & rehabilitation. Fifth edition.
Description: Philadelphia, PA : Elsevier, [2018] | Includes bibliographical
references and index.
Identifiers: LCCN 2017021675 | ISBN 9780323479042 (pbk. : alk. paper)
Subjects: | MESH: Rehabilitation—methods | Handbooks
Classification: LCC RM700 | NLM WB 39 | DDC 617.03—dc23 LC record available at
https://lccn.loc.gov/2017021675
Senior Acquisition Editor: Kristine Jones

Content Development Specialist: Meghan Andress
Publishing Services Manager: Patricia Tannian
Senior Project Manager: Claire Kramer
Design Direction: Amy Buxton
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contributors
Mohd Izmi Bin Ahmad, MBBS, MRehabMed, CIME (USA)
Rehabilitation Physician
Head, Department of Rehabilitation Medicine
Hospital Pulau Pinang
George Town, Penang, Malaysia
Eleftheria Antoniadou, MD, FEBPMR, PhDc

Consultant
Rehabilitation Clinic for Spinal Cord Injury
Patras University Hospital
University of Patras
Patras, Greece
Joseph Burris, MD
Associate Professor of Clinical Physical Medicine and Rehabilitation
University of Missouri
Columbia, Missouri
Maria Gabriella Ceravolo, MD, PhD

Professor of Physical and Rehabilitation Medicine
Department of Experimental and Clinical Medicine
Politecnica delle Marche University
Director of Neurorehabilitation Clinic
University Hospital of Ancona
Ancona, Italy
Chein-Wei Chang, MD
Professor
National Taiwan University
Taipei, Taiwan
Shih-Chung Chang, MD, MS

Chung Shan Medical University
Chung Shan Medical University Hospital
Taichung, Taiwan
Carl Chen, MD, PhD

Director
Chang Gung Memorial Hospital
Taipei, Taiwan
v
vi Contributors
Chih-Kuang Chen, MD
Assistant Professor
Chang Gung Memorial Hospital
Taoyuan, Taiwan
Shih-Ching Chen, MD, PhD

Deputy Dean and Professor
School of Medicine
College of Medicine
Taipei Medical University
Professor and Attending Physician
Taipei Medical University Hospital
Taipei, Taiwan
Chen-Liang Chou, MD
Director and Clinical Professor
National Yang-Ming University
Taipei Veterans General Hospital
Taipei, Taiwan
Willy Chou, MD, HRMS

General Secretary, Superintendent Office
Chief Director, Physical Medicine and Rehabilitation
Chi Mei Medical Center
Associate Professor
Recreation and Health Care Management
Chia Nan University of Pharmacy
Tainan, Taiwan
Tze Yang Chung, MBBS, MRehabMed

Senior Lecturer, Department of Rehabilitation Medicine
University of Malaya
Department of Rehabilitation Medicine
University of Malaya Medical Centre
Kuala Lumpur, Malaysia
David X. Cifu, MD
Chairman
Herman J. Flax, MD Professor
Principal Investigator
Veterans Affairs/Department of Defense Chronic Effects of Neurotrauma
Consortium
Richmond, Virginia
Contributors vii
Andrew Malcolm Dermot Cole, MBBS (Hons), FACRM, FAFRM

Chief Medical Officer
HammondCare
Sydney, Australia
Associate Professor (Conjoint)
Faculty of Medicine
University of New South Wales
Kensington, Australia
Senior Consultant Rehabilitation Medicine
Greenwich Hospital
Greenwich, Australia
Rochelle Coleen Tan Dy, MD

Assistant Professor
Baylor College of Medicine
Houston, Texas
Blessen C. Eapen, MD
Section Chief, Polytrauma Rehabilitation Center
TBI/Polytrauma Fellowship Program Director
South Texas Veterans Health Care System
Associate Professor
UT Health San Antonio
San Antonio, Texas
Julia Patrick Engkasan, MBBS (Mal), MRehabMed (Mal)

Associate Professor
Gerard E. Francisco, MD
University of Texas Health Science Center (UTHealth)
McGovern Medical School
NeuroRecovery Research Center
TIRR Memorial Hermann
Houston, Texas
Francesca Gimigliano, MD, PhD

Associate Professor of Physical and Rehabilitation Medicine
Department of Mental and Physical Health and Preventive Medicine
University of Campania “Luigi Vanvitelli”
Naples, Italy
viii Contributors
Elizabeth J. Halmai, DO
Medical Director, Section Chief
Division of Polytrauma
South Texas Veterans Health Care System
Assistant Professor
University of Texas Health Science Center San Antonio
San Antonio, Texas
Nazirah Hasnan, MBBS, MRehabMed, PhD

Deputy Director (Clinical)
Associate Professor and Rehabilitation Consultant
Ziad M. Hawamdeh, MD
Senior Fellowship of the European Board of Physical Medicine and
Rehabilitation
Jordanian Board of Physical Medicine and Rehabilitation
Professor of Physical Medicine and Rehabilitation
Faculty of Medicine
University of Jordan
Amman, Jordan
Joseph E. Herrera, DO, FAAPMR

Chairman and Lucy G Moses Professor
Mount Sinai Health System
Icahn School of Medicine at Mount Sinai
New York, New York
Ming-Yen Hsiao, MD
Lecturer
National Taiwan University Hospital
College of Medicine
National Taiwan University
Taipei, Taiwan
Lin-Fen Hsieh, MD
Professor
School of Medicine
Fu Jen Catholic University
New Taipei City, Taiwan
Director
Shin Kong Wo Ho-Su Memorial Hospital
Taipei, Taiwan
Contributors ix
Rashidah Ismail Ohnmar Htwe, MBBS, M MED Sc (Rehab Med), CMIA

Associate Professor
Rehabilitation Unit
Department of Orthopedics and Traumatology
Associate Research Fellow
Tissue Engineering Centre
Faculty of Medicine
Universiti Kebangsaan Malaysia
Consultant Rehabilitation Physician
Rehabilitation Unit
Hospital Canselor Tuanku Muhriz
Yu-Hui Huang, MD, PhD

Associate Professor
School of Medicine
Chung Shan Medical University
Director
Physical Medicine and Rehabilitation
Chung Shan Medical University Hospital
Taichung, Taiwan
Chen-Yu Hung, MD
Attending Physician
Physical Medicine and Rehabilitation
National Taiwan University Hospital, Beihu Branch
Taipei, Taiwan
Norhayati Hussein, MBBS, MRehabMed, Fellowship in Neurorehabilitation

Cheras Rehabilitation Hospital
Elena Milkova Ilieva, MD, PhD, Prof.

Head of Department
Physical and Rehabilitation Medicine
Medical Faculty
Medical University of Plovdiv
Head of Department
Physical and Rehabilitation Medicine
“Sv Georgi” University Hospital
Plovdiv, Bulgaria
Lydia Abdul Latif, MBBS, MRM

Professor and Consultant Rehabilitation Physician
Faculty of Medicine
x Contributors
Wai-Keung Lee, MD
Chief, Department of Physical Medicine and Rehabilitation
Tao Yuan General Hospital
Tao Yuan, Taiwan
Henry L. Lew, MD, PhD

Tenured Professor, University of Hawaii School of Medicine
Chair, Department of Communication Sciences and Disorders
Honolulu, Hawaii
Adjunct Professor, Department of Physical Medicine and Rehabilitation
Richmond, Virginia
Chia-Wei Lin, MD
Attending Physician
National Taiwan University Hospital, Hsin Chu Branch
Hsin Chu, Taiwan
Ding-Hao Liu, MD
Taipei Veterans General Hospital, Yuanshan Branch
Yilan, Taiwan
Mazlina Mazlan, MBBS, MRM

Associate Professor
Faculty of Medicine
Matthew J. McLaughlin, MD, MSB

Assistant Professor
Division of Pediatric Rehabilitation Medicine
Children’s Mercy Hospital
Kansas City, Missouri
Amaramalar Selvi Naicker, MBBS (Ind), MRehabMed (Mal)

Professor of Rehabilitation Medicine and Head of Rehabilitation Medicine Unit
Associate Research Fellow
Tissue Engineering Centre
Faculty of Medicine
Universiti Kebangsaan Malaysia
Contributors xi
Mooyeon Oh-Park, MD, MS

Director of Geriatric Rehabilitation
Kessler Institute for Rehabilitation
Vice Chair of Education
Research Professor
Rutgers New Jersey Medical School
Newark, New Jersey
Vishwa S. Raj, MD
Director of Oncology Rehabilitation
Carolinas Rehabilitation
Chief of Cancer Rehabilitation
Department of Supportive Care
Levine Cancer Institute
Carolinas Healthcare System
Charlotte, North Carolina
Renald Peter Ty Ramiro, MD

Dean, College of Rehabilitative Sciences
Cebu Doctors’ University
Mandaue City, Cebu, Philippines,
Head, Physical and Rehabilitation Medicine
Cebu Doctors’ University Hospital
Cebu City, Cebu, Philippines
Head, Rehabilitation Medicine
Mactan Doctors’ Hospital
Lapu-lapu City, Cebu, Philippines
Reynaldo R. Rey-Matias, PT, MD, MSHMS

Chair, Department of Physical Medicine and Rehabilitation
St. Luke’s Medical Center and College of Medicine
Quezon City, Metro Manila, Philippines
Clinical Associate Professor
University of the Philippines–College of Medicine
Manila, Philippines
Desiree L. Roge, MD
Assistant Professor
Baylor College of Medicine
Assistant Professor
Texas Children’s Hospital
Houston, Texas
xii Contributors
Shaw-Gang Shyu, MD
Taipei, Taiwan
Clarice N. Sinn, DO, MHA

Assistant Professor
UT Southwestern Medical Center/Children’s Health
Dallas, Texas
Anwar Suhaimi, MBBS, MRehabMed (Malaya)

Rehabilitation Medicine Specialist
Senior Lecturer
Yi-Chian Wang, MD, MSc

Taipei, Taiwan
Chueh-Hung Wu, MD
Taipei City, Taiwan
Yung-Tsan Wu, MD
Attending Physician and Assistant Professor
Tri-Service General Hospital and School of Medicine
National Defense Medical Center
Taipei, Taiwan
Tian-Shin Yeh, MD, MMS

Attending Physician
National Taiwan University Hospital, Yun-Lin Branch
Yun-Lin, Taiwan
Graduate Institute of Clinical Medicine
National Taiwan University College of Medicine
Taipei, Taiwan
Contributors xiii
Mauro Zampolini, MD
Chief
Department of Rehabilitation
Italian National Health Service, USL UMBRIA 2
Foligno, Perugia, Italy
Tunku Nor Taayah Tunku Zubir, MBBS

Consultant Rehabilitation Physician
Department of Rehabilitation
Gleneagles Hospital

Preface
Over the past 4 years, we have worked diligently with more than 200 authors from
across the international community to create (1) the fifth edition of the textbook
Braddom’s Physical Medicine & Rehabilitation and (2) Braddom’s Rehabilitation Care:
A Clinical Handbook. These complementary resources compile key elements of the
field of disability medicine, ranging from the basic sciences to clinical care. While
the Braddom’s textbook is the premier reference for all academicians and practitio-
ners in physical medicine and rehabilitation, this new clinical handbook represents
the first comprehensive practical guide for trainees and practitioners across all ele-
ments of health care. Any student or clinician who sees, evaluates, manages, or
refers individuals with disability should use this handbook as his or her key source
for information. Whether the patient is a young adult with an acute combat-related
musculoskeletal injury, a teen with a sports medicine injury, an elderly person with
joint or neurologic dysfunction, a child with specialized equipment needs, or a
middle-aged individual after a life-altering trauma, this text can serve as a guide
for each patient’s clinical care. In addition to practical information and clinical
pearls, this handbook also features accompanying online slides and training mate-
rials to enhance understanding, to serve as part of core educational modules, and
to expand on the key points of the text. We are indebted to the authors of Brad-
dom’s Physical Medicine & Rehabilitation for providing the comprehensive materials
from which this clinical handbook was abstracted, the more than 50 authors who
worked meticulously to develop this special edition, and the editorial support staff
at Elsevier. We are hopeful that this handbook will be used throughout the world
to support the training of health care professionals working with individuals with
disabilities and to enhance the clinical care of those individuals with disabilities. It
is a resource that we would see in any health care and training setting and used by
the full range of trainees and practitioners. We also welcome feedback from readers
and users of it to improve the quality and usability of future iterations and editions.
David X. Cifu, MD, and Henry L. Lew, MD, PhD
xv

Foreword
There are more than 1 billion individuals with some degree of disability, physical or
mental, in the world, and there are a growing number of practicing clinicians and
trainees to assist them in achieving and maintaining their independence. However,
there has not been a single, easy-to-use clinical guide to specifically assist these
practitioners to optimize their care. This handbook brings together all the key ele-
ments of practical clinical care in physical and rehabilitation medicine found in the
fifth edition of Braddom’s Physical Medicine & Rehabilitation into a single, convenient
source. The compact size, clinical focus, and state-of-the-art online resources make
it the must-have guide. It has been designed to be invaluable at the bedside, in the
clinic, in the office, and even in the patient’s home. Written in a straightforward
style, supported by online slides, and packed with clinical pearls, this handbook
is perfect for the full range of professionals, from the beginning student to the
advanced practitioner. Created by two of the leading international educators in the
field of physical medicine and rehabilitation, Drs. David Cifu and Henry Lew, this
book was carefully compiled by more than 50 professionals in physical medicine
and rehabilitation from more than 25 countries across the globe to reflect the latest
in the field, while remaining consistent with the Braddom’s reference textbook. It is
truly the must-have resource for all trainees and clinicians who see individuals with
acute and chronic disabilities.
Jianan Li, MD, Immediate Past President, International Society of Physical

and Rehabilitation Medicine (ISPRM)
Jorge Lains, MD, President, ISPRM
xvii

Contents
SECTION I EVALUATION
1 The Physiatric History and Physical Examination, 3

Shaw-Gang Shyu
2 History and Examination of the Pediatric Patient, 14

Chia-Wei Lin
3 Adult Neurogenic Communication and Swallowing Disorders, 18

Ming-Yen Hsiao
4 P sychological Assessment and Intervention in Rehabilitation, 24

Willy Chou
5 Practical Aspects of Impairment Rating and

Disability Determination, 28
Maria Gabriella Ceravolo
6 Employment of People with Disabilities, 34

Renald Peter Ty Ramiro
7 Quality and Outcome Measures for Medical Rehabilitation, 39

Elizabeth J. Halmai
8 Electrodiagnostic Medicine, 44
Chein-Wei Chang
SECTION II TREATMENT TECHNIQUES AND SPECIAL

EQUIPMENT
9 Rehabilitation and Prosthetic Restoration in Upper

Limb Amputation, 51
Joseph Burris
10 Lower Limb Amputation and Gait, 57

Matthew J. McLaughlin
11 Upper Limb Orthoses, 66
Chih-Kuang Chen
12 Lower Limb Orthoses, 75

Tze Yang Chung
13 Spinal Orthoses, 85
Wai-Keung Lee
xix
xx Contents
14 Wheelchairs and Seating Systems, 92

Nazirah Hasnan
15 Therapeutic Exercise, 102

Rochelle Coleen Tan Dy
16 Manipulation, Traction, and Massage, 111

Reynaldo R. Rey-Matias
17 P hysical Agent Modalities, 119

Chueh-Hung Wu
18 Integrative Medicine in Rehabilitation, 126

Tian-Shin Yeh
19 Computer Assistive Devices and Environmental Controls, 129

Shih-Ching Chen
SECTION III COMMON CLINICAL PROBLEMS
20 B ladder Dysfunction, 137

Shih-Chung Chang
21 Neurogenic Bowel: Dysfunction and Rehabilitation, 143

Yu-Hui Huang
22 Sexual Dysfunction and Disability, 150

Tunku Nor Taayah Tunku Zubir
23 Spasticity, 157
Gerard E. Francisco
24 Chronic Wounds, 164

Julia Patrick Engkasan
25 Vascular Diseases, 173

Blessen C. Eapen
26 B urns, 178
Amaramalar Selvi Naicker
27 Acute Medical Conditions, 183

Norhayati Hussein
28 C
hronic Medical Conditions: Pulmonary Disease, Organ
Transplantation, and Diabetes, 190
Chen-Liang Chou
29 Cancer Rehabilitation, 197

Vishwa S. Raj
Contents xxi
30 The Geriatric Patient, 204

Mooyeon Oh-Park
31 Rheumatologic Rehabilitation, 208

Lin-Fen Hsieh
SECTION IV ISSUES IN SPECIFIC DIAGNOSES
32 Common Neck Problems, 216

Carl Chen
33 Low Back Pain, 228

Anwar Suhaimi
34 Osteoporosis, 238
Francesca Gimigliano
35 Upper Limb Pain and Dysfunction, 244

Eleftheria Antoniadou
36 Musculoskeletal Disorders of the Lower Limb, 248

Elena Milkova Ilieva
37 Chronic Pain, 257

Yung-Tsan Wu
38 Pelvic Floor Disorders, 264

Clarice N. Sinn
39 Sports Medicine and Adaptive Sports, 270

Joseph E. Herrera
40 Motor Neuron Diseases, 279
Lydia Abdul Latif
41 Rehabilitation of Patients With Neuropathies, 287

Yi-Chian Wang
42 Myopathy, 299
Ziad M. Hawamdeh
43 Traumatic Brain Injury, 305

Mazlina Mazlan
44 Stroke Syndromes, 315

Mauro Zampolini
45 D
egenerative Movement Disorders of the Central
Nervous System, 319
Andrew Malcolm Dermot Cole
xxii Contents
46 Multiple Sclerosis, 324

Mohd Izmi Bin Ahmad
47 Cerebral Palsy, 331

Desiree L. Roge
48 Myelomeningocele and Other Spinal Dysraphisms, 338

Rashidah Ismail Ohnmar Htwe
49 Spinal Cord Injury, 345

Chen-Yu Hung
50 Auditory, Vestibular, and Visual Impairments, 355

Ding-Hao Liu
Video Contents
SECTION II TREATMENT TECHNIQUES AND SPECIAL
EQUIPMENT
16 Manipulation, Traction, and Massage

Video 16.1. M uscle Energy Technique
17 P hysical Agent Modalities

Video 17.1. Paraffin Bath
SECTION III COMMON CLINICAL PROBLEMS
25 Vascular Diseases
Video 25.1. M onophasic Ar terial Doppler Waveform
31 Rheumatologic Rehabilitation
Video 31.1. Feeding Training with Putty
SECTION IV ISSUES IN SPECIFIC DIAGNOSES
36 Musculoskeletal Disorders of the Lower Limb

Video 36.1. L achman Test
45 Degenerative Movement Disorders of the Central Nervous System

Video 45.1. C arbidopa- and Levodopa-Induced Dyskinesia
xxiii

BRADDOM’S
REHABILITATION
CARE
A Clinical Handbook

SECTION 1
EVALUATION
1 The Physiatric History and Physical Examination

Shaw-Gang Shyu
2 History and Examination of the Pediatric Patient

Chia-Wei Lin
3 Adult Neurogenic Communication and Swallowing Disorders

Ming-Yen Hsiao
4 Psychological Assessment and Intervention in Rehabilitation

Willy Chou
5 Practical Aspects of Impairment Rating and Disability Determination

Maria Gabriella Ceravolo
6 Employment of People with Disabilities

Renald Peter Ty Ramiro
7 Quality and Outcome Measures for Medical Rehabilitation

Elizabeth J. Halmai
8 Electrodiagnostic Medicine
Chein-Wei Chang
1

The Physiatric
History and Physical
1
Examination
Shaw-Gang Shyu
The physiatric history and physical examination are the basis for precise diagnosis
and recognition of the patient’s impairment, and they help in the development of a
comprehensive treatment plan. They also serve as a medicolegal record and a basis
for physician billing. They are documents used for communication between reha-
bilitation and nonrehabilitation health care professionals. The essential elements
of the physiatric history and physical examination are summarized in this chapter
and the accompanying eSlides.
• THE PHYSIATRIC HISTORY

The World Health Organization classification defines impairment as any loss or
abnormality of body structure or a physiologic or psychological function. Activity
is the nature and extent of functioning at the level of the person. Participation refers
to the nature and extent of a person’s involvement in life situations in relation to
impairments, activities, health conditions, and contextual factors. One of the unique
aspects of physiatry is the recognition of functional deficits caused by illness or
injury. Identifying and treating the primary impairments to maximize performance
becomes the primary thrust of physiatric evaluation and treatment. Physicians in
training tend to overassess, but with time the experienced physiatrist develops an
intuition regarding the detail needed for each patient, given a particular presenta-
tion and setting. The time spent in taking a history also allows the patient to become
familiar with the physician, establishing rapport and trust. This initial rapport is crit-
ical for a constructive and productive doctor–patient–family relationship. Patients
are the primary source of information, but if patients are not able to fully express
themselves, the history takers might also rely on the patient’s family members and
friends; other physicians, nurses, and professionals; or previous medical records.
Chief Complaint
The chief complaint is the symptom or concern that caused the patient to seek
medical treatment. Unlike the relatively objective physical examination, the chief
complaint is purely subjective, and the physician should use the patient’s own
words.
History of the Present Illness

The history of the present illness details the chief complaint(s), and it should include
some or all of these eight components related to the chief complaint: location, time
3
4 SECTION I EVALUATION
of onset, quality, context, severity, duration, modifying factors, and associated signs
and symptoms.
Functional Status and Activities of Daily Living

The patient’s functional status provides a better understanding of mobility, activi-
ties of daily living (ADL), instrumental activities of daily living (I-ADL) (eSlide
1.1), communication, cognition, work, and recreation. Assessing the potential for
functional gain or deterioration requires an understanding of the natural history,
cause, and time of onset of the functional problems.
It is sometimes helpful to assess functional status with a standardized scale.
No single scale is appropriate for all patients, but the Functional Independence
Measure (FIM) is the scoring system most commonly used in the inpatient reha-
bilitation setting. Each of 18 different activities is scored on a scale of 1 to 7 (total
score: 18 to 126) (eSlide 1.2), and FIM serves as a kind of rehabilitation shorthand
among team members to quickly and accurately describe functional deficits.
MOBILITY
Mobility is the ability to move about in one’s environment. Bed mobility includes
turning from side to side, changing from the prone to supine positions, sitting up,
and lying down. Transfer mobility includes getting in and out of bed, standing
from the sitting position, and moving between a wheelchair and another seat.
Wheelchair mobility can be assessed by asking if patients can propel the
wheelchair independently, how far or how long they can go without resting,
whether they need assistance with managing the wheelchair parts, and the extent
to which they can move about at home, in the community, and up and down
ramps. Whether the home is potentially wheelchair accessible is particularly
important in cases of new onset of severe disability.
Ambulation and stair mobility can be assessed by the patient’s walking distance
and endurance, the patient’s requirement for assistive devices and need for breaks,
the number of stairs the patient must routinely climb and descend at home or in the
community, and the presence or absence of handrails in their daily lives. Identify-
ing associated symptoms during ambulation and a history of falling or instability
are also important.
Driving (a type of community mobility) is a crucial activity for many people,
and older adults who stop driving face increased depressive symptoms. The risks of
driving are weighed against the consequences of not being able to drive.
COGNITION
Cognition is the mental process of knowing. Because persons with cognitive defi-
cits often cannot recognize their own impairments (agnosia), it is important to also
gather information from other individuals who are familiar with the patient. Cog-
nitive deficits interfere with the patient’s rehabilitation and safety.
COMMUNICATION
Communication skills are used to convey information, including thoughts, needs,
and emotions. Verbal-expression deficits can be subtle. Patients who have deficits
in verbal expression might or might not be able to communicate through other
means, known as augmentative communication strategies. These strategies include
writing and physicality (e.g., sign language, gestures, and body language) and the
use of communication aids (e.g., picture, letter, word board, and electronic devices).
CHAPTER 1 The Physiatric History and Physical Examination 5
Past Medical and Surgical History

The past medical and surgical history allows the physiatrist to understand how pre-
existing illnesses affect the patient’s current status, the precautions and limitations
that will be necessary during a rehabilitation program, and the impact on rehabili-
tation outcomes. Particularly, cardiopulmonary deficits can severely compromise
mobility, ADL, I-ADL, work, and leisure.
All medications should be documented, including prescription medications,
over-the-counter drugs, nutraceuticals, supplements, herbs, and vitamins.
Drug and food allergies should be noted. Particular attention should be paid
to commonly prescribed medications, such as nonsteroidal antiinflammatory
agents.
Social History
Understanding the patient’s home environment and living situation includes ask-
ing whether the patient lives in a house or an apartment and whether elevators,
stairs, or handrails are present. These factors, in conjunction with the level of sup-
port from the patient’s family and friends, will help determine the discharge plans.
Patients should be asked in a nonjudgmental manner about their history of
smoking, alcohol use or abuse, and drug abuse. Sexuality is particularly important
to patients in their reproductive years. Sexual orientation and safer sex practices
should be addressed when appropriate.
VOCATIONAL ACTIVITIES
Vocation is a source of financial security and provides self-confidence and even
identity. The history should include the patient’s education level, recent work his-
tory, and ability to fulfill job requirements subsequent to injury or illness.
FINANCES AND INCOME MAINTENANCE

A social worker may help patients with financial concerns. Whether a patient has
the financial resources or insurance to pay for adaptive devices can significantly
affect discharge planning.
RECREATION
Loss or limitation of the ability to engage in hobbies and recreational activities can
be stressful to most people. Recreation is also a primary outcome in sports medi-
cine. A recreational therapist can be helpful.
PSYCHOSOCIAL HISTORY, SPIRITUALITY, AND BELIEFS

Patients with impairment may feel a loss of overall health, body image, mobil-
ity, independence, or income. Providing assistance in developing coping strategies,
especially for depression and anxiety, can help accelerate the process whereby the
patient learns to adjust to a new disability.
Health care providers should be sensitive to the patient’s spiritual needs and
provide appropriate referral or counseling.
LITIGATION
Litigation (active or pending) can be a source of anxiety, depression, or guilt.
Patients should be asked in a nonjudgmental manner whether they are involved in
litigation. The answer should not change the treatment plan.
Family History
Patients should be asked about the health, or cause and age of death, of parents and
siblings. The family history will help identify genetic disorders within the family
and potential assistance that may be obtained from family members.
Review of Systems
The review of systems identifies problems or diseases that have not yet been
reviewed during the history taking.
• THE PHYSIATRIC PHYSICAL EXAMINATION

Neurologic Examination
Neurologic problems are common in rehabilitation medicine. The precise loca-
tion of the lesion should be identified from an organized neurologic examination.
An accurate and efficient neurologic examination requires that the examiner have
a thorough knowledge of both central and peripheral neuroanatomy before the
examination. Weakness may be seen in both upper motor neuron (UMN) and
lower motor neuron (LMN) disorders. UMN lesions involving the central ner-
vous system are typically characterized by hypertonia and hyperreflexia. LMN
defects are characterized by hypotonia, hyporeflexia, significant muscle atrophy,
fasciculations, and electromyographic changes. UMN and LMN lesions often
coexist, as seen in amyotrophic lateral sclerosis or traumatic brain injury with a
brachial plexus injury.
MENTAL STATUS EXAMINATION

The mental status examination (MSE) should be performed in a comfortable set-
ting where the patient is not likely to be distracted by external stimuli. Bedside
MSE might need to be supplemented by observations in therapy and evaluation by
a neuropsychologist.
The Folstein Mini-Mental Status Examination is a brief and convenient tool
to test general cognitive function. It is useful for screening patients for dementia
and brain injuries. Of a maximum of 30 points, a score of 24 or above is considered
within the normal range. The clock-drawing test is a quick and sensitive test of
cognitive impairment. This task uses memory, visual spatial skills, and executive
functioning. The use of the three-word recall test in addition to the clock-drawing
test, which is known collectively as the Mini-Cog Test, has recently gained popu-
larity in screening for dementia.
Level of consciousness. Consciousness is the state of awareness of one’s surround-

ings. A functioning pontine reticular activating system is necessary for normal con-
scious functioning.
Lethargy is the general slowing of motor processes, such as speech and move-
ment, in which the patient can easily fall asleep if not stimulated but is easily aroused.
Obtundation is a dulled or blunted sensitivity in which the patient is difficult to arouse
and is still confused after arousal. Stupor is a state of semi consciousness characterized
by arousal only by intense stimuli, such as sharp pressure over a bony prominence
(e.g., sternal rub); the patient also has few or even no voluntary motor responses.
In coma, the eyes are closed, sleep-wake cycles are absent, and there is no evi-
dence of a contingent relationship between the patient’s behavior and the environ-
ment. Vegetative state is characterized by the presence of sleep-wake cycles but still
no contingent relationship. Minimally conscious state indicates a patient who remains

severely disabled but demonstrates sleep-wake cycles and inconsistent, nonreflex-
ive, contingent behaviors in response to a specific environmental stimulus. In acute
settings, the Glasgow Coma Scale is the most commonly used objective measure to
document level of consciousness (eSlide 1.3).
Attention. Attention is the ability to address a specific stimulus for a short period
of time without being distracted by internal or external stimuli. Vigilance is the
ability to hold one’s attention over longer periods. Attention is tested by digit re-
call; repeating seven numbers in the forward direction is considered normal, with
fewer than five indicating significant attention deficits.
Orientation. Orientation is composed of four parts: person, place, time, and situ-
ation. Sense of time is usually the first to be lost, and sense of person is typically
the last. Temporary stress can account for a minor loss of orientation, but major
disorientation usually suggests an organic brain syndrome.
Memory. The components of memory include learning, retention, and recall. The
patient is typically asked to remember three or four objects or words and then
asked to repeat the items immediately to assess immediate acquisition (encoding)
of the information. Retention is assessed by recall after a delayed interval, usually
5 to 10 minutes. Normal individuals younger than 60 years should be able to recall
three of four items. Recent memory can be tested by asking questions about the
past 24 hours. Remote memory is tested by asking where the patient was born or
which school or college the patient attended.
General fundamentals of knowledge and abstract thinking. Intelligence is a

global function encompassing both basic intellect and remote memory. The ex-
aminer should note the patient’s highest level of education. Abstraction is a higher
cortical function and should always be considered in the context of intelligence and
cultural differences. It can be tested by asking the patient to interpret a common
proverb or explain a humorous phrase or situation.
Insight and judgment. Insight has been conceptualized into three components:
awareness of impairment, need for treatment, and attribution of symptoms. Recog-
nizing that one has an impairment is the initial step necessary for recovery. A lack
of insight can severely hamper a patient’s progress in rehabilitation.
Judgment is an estimate of a person’s ability to solve real-life problems, and
it is related to the patient’s capacity for independent functioning. Judgment can
be evaluated by simply observing the patient’s behavior or by noting the patient’s
responses to hypothetical situations.
Mood and affect. The examiner should document reactivity and stability of mood.
Mood can be described in terms such as being happy, sad, euphoric, blue, de-
pressed, angry, or anxious. Affect describes how a patient feels at a given moment,
which can be described by terms such as blunted, flat, inappropriate, labile, opti-
mistic, or pessimistic.
COMMUNICATION
Aphasia. Aphasia involves the loss of production or comprehension of language.
Naming, repetition, comprehension, and fluency are the key components. Testing
comprehension of spoken language should begin with single words, progress to

sentences that require only yes/no responses, and then progress to complex com-
mands. Visual naming, repetition of single words and sentences, word-finding
abilities, reading and writing from dictation, and then spontaneous reading and
writing should also be assessed. Some standardized aphasia measures include the
Boston Diagnostic Aphasia Examination and the Western Aphasia Battery (see
Chapter 3).
Dysarthria. Dysarthria refers to defective articulation but unaffected content of

speech. Key sounds include “ta ta ta,” which is made by the tongue (lingual con-
sonants); “mm mm mm,” which is made by the lips (labial consonants); and “ga ga
ga,” which is made by the larynx, pharynx, and palate.
Dysphonia. Dysphonia is a deficit in sound production, which can be secondary

to respiratory disease, fatigue, or vocal cord paralysis. Indirect laryngoscopy is the
best method to examine the vocal cords. Patients are asked to say “ah” to assess
vocal cord abduction and “e” to assess adduction. Patients with weakness of both
vocal cords will speak in a whisper and exhibit inspiratory stridor.
Verbal apraxia. Apraxia of speech involves a deficit in motor planning without

impaired strength or coordination. It is characterized by inconsistent errors when
speaking. Oromotor apraxia is seen in patients with difficulty organizing nonspeech
oral motor activity. It can adversely affect swallowing. Tests for verbal and oral mo-
tor function are listed in Chapter 3.
Cognitive linguistic deficits. Cognitive linguistic deficits involve the pragmatics

and context of communication, such as confabulation. Cognitive linguistic deficits
are distinguished from fluent aphasias (e.g., Wernicke aphasia) by the presence of
relatively normal syntax and grammar.
CRANIAL NERVE EXAMINATION

Cranial nerve I: olfactory nerve. Both perception and identification of smell
should be tested with aromatic, nonirritating materials that avoid stimulation of
the trigeminal nerve. The olfactory nerve is the most commonly injured cranial
nerve (CN) in head trauma.
Cranial nerve II: optic nerve. The optic nerve is assessed by testing visual acuity
and visual fields. Visual acuity refers to central vision. Visual field testing assesses
the integrity of the optic pathway. Testing visual fields is most commonly per-
formed by confrontation. For patients with deficits, further assessment by a neuro-
optometrist or visually trained occupational therapist can be helpful.
Cranial nerves III, IV, and VI: oculomotor, trochlear, and abducens nerves. The
oculomotor nerve innervates the medial rectus muscle (adductor of the eye), supe-
rior rectus and inferior oblique muscles (elevators of the eye), and inferior rectus
muscle (depressor of the eye). The trochlear nerve innervates the superior oblique
muscle, which is responsible for the downward gaze, especially during adduction.
The abducens nerve controls the lateral rectus muscle, which abducts the eye. The
examiner should assess the alignment of the patient’s eyes while the eyes are at rest
and when the eyes are following an object, observing the full range of horizontal
and vertical eye movements in the six cardinal directions. The optic (afferent) and
oculomotor (efferent) nerves are involved with the pupillary light reflex, which
normally results in constriction of both pupils when a light stimulus is presented to
either eye separately. A characteristic head tilt when looking downward is some-
times seen in CN IV lesions.
Cranial nerve V: trigeminal nerve. The three sensory branches of CN V can be

tested along the forehead (ophthalmic branch), cheeks (maxillary branch), and jaw
(mandibular branch) bilaterally. The motor branch of the trigeminal nerve inner-
vates the muscles of mastication, which include the masseters, pterygoids, and tem-
poralis muscles. The corneal reflex tests the ophthalmic division of the trigeminal
nerve (afferent) and the facial nerve (efferent).
Cranial nerve VII: facial nerve. The facial nerve is first examined by observing the
patient while he or she is talking, smiling, closing the eyes, flattening the nasolabial
fold, and elevating one corner of the mouth. The patient is then asked to wrinkle
the forehead (frontalis muscle function), close the eyes while the examiner attempts
to open them (orbicularis oculi function), puff out both cheeks while the examiner
presses on the cheeks (buccinator function), and show the teeth (orbicularis oris
function). A peripheral injury to the facial nerve, such as Bell palsy, affects both
the upper and lower face, whereas a central lesion typically affects mainly the lower
face.
Cranial nerve VIII: vestibulocochlear nerve. The vestibulocochlear nerve com-

prises two divisions: the cochlear nerve, which is responsible for hearing, and the
vestibular nerve, which is related to balance. The cochlear division can be tested by
checking gross hearing by rubbing the thumb and index fingers near each ear of the
patient. Patients with dizziness or vertigo associated with changes in head position
or suspected of having benign paroxysmal positional vertigo should be assessed
with the Dix-Hallpike maneuver (eSlide 1.4).
Cranial nerves IX and X: glossopharyngeal nerve and vagus nerve. Hoarseness

is usually associated with a lesion of the recurrent laryngeal nerve, a branch of the
vagus nerve. Normally, the soft palate should elevate symmetrically, and the uvula
should remain in the midline when the patient says “ah.” In UMN vagus nerve le-
sions, the uvula will deviate toward the side of the lesion, but in LMN lesions, the
uvula will deviate to the contralateral side. Gag reflex can be tested by touching the
pharyngeal wall with a cotton tip applicator until the patient gags. The examiner
should compare the sensitivity of each side (afferent: glossopharyngeal nerve) and
observe the symmetry of the palatal movement (efferent: vagus nerve). The pres-
ence of a gag reflex does not imply the ability to swallow without risk of aspiration.
Cranial nerve XI: accessory nerve. Atrophy or asymmetry of the patient’s trape-
zius and sternocleidomastoid muscles should be checked. Trapezius atrophy results
in a laterally migrated scapula (“open door” winging). To test the strength of the
sternocleidomastoid muscle, the patient should be asked to rotate the head against
resistance.
Cranial nerve XII: hypoglossal nerve. The hypoglossal nerve is tested by asking
the patient to protrude the tongue and noting evidence of atrophy, fasciculation,
or deviation. Fibrillations in the tongue are common in patients with amyotrophic

lateral sclerosis. The tongue typically points to the side of the lesion in peripheral
hypoglossal nerve lesions but away from the lesion in UMN lesions.
SENSORY EXAMINATION (eSlides 1.5 and 1.6)

Evaluation of the sensory system requires testing both superficial sensation (light
touch, pain, and temperature) and deep sensation (position and vibration).
Light touch can be assessed with a fine wisp of cotton or a cotton tip applicator.
Pain is assessed with a safety pin. Thermal sensation can be checked with two dif-
ferent cups, one filled with hot water and one filled with cold water and ice chips.
Proprioception is tested by passive vertical movement of the toes or fingers
when the patient’s eyes are closed. The patient is asked whether the digit is being
moved in an upward or downward direction. It is important to grasp the sides of the
digit rather than the nailbed to avoid the patient perceiving pressure in this area.
Vibration is tested with a 128-Hz tuning fork, which is placed on a bony promi-
nence, such as the dorsal aspect of the malleoli, olecranon, or terminal phalange of
the great toe or finger. The patient is asked to indicate when the vibration ceases.
Two-point discrimination is tested by calipers with blunt ends. The patient
(with closed eyes) is asked to indicate whether one or two stimulation points are
felt. Commonly tested two-point discrimination areas and their normal values are
as follows: lips (2–3 mm), fingertips (3–5 mm), dorsum of the hand (20–30 mm),
and palms (8–15 mm).
Testing for graphesthesia, the ability to recognize numbers, letters, or sym-
bols traced onto the palm, is performed by writing recognizable numbers on the
patient’s palm while the patient’s eyes remain closed. Stereognosis is the ability to
recognize common objects, such as keys or coins, when placed in the hand.
MOTOR CONTROL
Strength. Manual muscle testing (eSlides 1.7 and 1.8) provides an important
method of quantifying strength. Pain can result in give-way weakness. It is impor-
tant to recognize the presence of substitution when muscles are weak or movement
is uncoordinated. Patients who cannot actively control muscle tension (e.g., those
with spasticity) are not appropriate for standard manual muscle testing methods.
A muscle grade of 3 is functionally important because antigravity strength implies
that a limb can be used for activity. Females’ strength typically increases up to 20
years, plateaus through the twenties, and then gradually declines after age 30 years.
Males increase strength up to age 20 years and then plateau until older than 30
years before declining.
Tables 1.13 and 1.14 in Braddom’s Physical Medicine and Rehabilitation, Fifth Edi-
tion (ISBN: 978-0-323-28046-4), summarize joint movements, innervation, and
manual strength testing techniques for all major muscle groups of the extremities.
Examples of tests for shoulder abduction are shown in eSlide 1.9.
Coordination. Ataxia or coordination deficits can be secondary to deficits of sen-

sory, motor, or cerebellar connections. Dysdiadochokinesia describes an inability
to perform rapidly alternating movements.
Lesions affecting the midline cerebellum usually produce truncal ataxia, whereas
lesions that affect the anterior lobe of the cerebellum usually result in gait ataxia.
Lateral cerebellar hemisphere lesions produce limb ataxia, which can be tested by
the finger-to-nose test and heel-to-shin test.
The Romberg test can be used to differentiate a cerebellar deficit from a pro-
prioceptive deficit. If loss of balance is present when the eyes are open or closed,
it is indicative of cerebellar ataxia. If loss of balance occurs only when the eyes are
closed, it is a positive Romberg sign, which indicates a proprioceptive (sensory)
deficit.
Apraxia. Apraxia is the loss of the ability to carry out programmed or planned
movements despite adequate understanding of the task and no weakness or sensory
loss. Ideomotor apraxia occurs when a patient cannot carry out motor commands
but can perform the required movements under different circumstances. Ideational
apraxia refers to the inability to carry out sequences of acts, although each compo-
nent can be performed separately. Dressing apraxia and constructional apraxia are
the result of neglect rather than actual deficits in motor planning.
Involuntary movements. Tremor, the most common type of involuntary move-

ment, is a rhythmic movement of a body part. Myoclonus is a quick jerking move-
ment of a muscle or body part. Chorea constitutes movements that consist of
brief, random, nonrepetitive movements in a fidgety patient who is unable to
sit still. Athetosis consists of twisting and writhing movements and is commonly
seen in cerebral palsy. Dystonia is a sustained posturing that can affect small
or large muscle groups. Hemiballismus occurs when there are repetitive violent
flailing movements.
Tone. Tone is the resistance of a muscle to stretch or passively elongate (see Chap-
ter 23). Spasticity is a velocity-dependent increase in the stretch reflex, whereas
rigidity is the resistance of the limb to passive movement in the relaxed state (non–
velocity-dependent).
Tone can be quantified by the Modified Ashworth Scale (MAS). A pendulum
test can also be used to quantify spasticity. The Tardieu Scale has been suggested
as a more appropriate clinical measure of spasticity than the MAS. Measurements
are usually taken at three velocities (V1, V2, and V3). V1 is measured as slow as
possible, V2 is measured at the speed of the limb falling under gravity, and V3 is
measured when the limb is moving as fast as possible. Responses are recorded at
each velocity and at the angles (in degrees) at which the muscle response occurs.
REFLEXES
Superficial reflexes (eSlide 1.10). The normal plantar reflex consists of flexion
of the great toe or no response. With dysfunction of the corticospinal tract, there
is a positive Babinski sign, which consists of dorsiflexion of the great toe with an
associated fanning of the other toes. A positive Chaddock sign refers to dorsiflex-
ion of the great toe after stroking from the lateral ankle to the lateral dorsal foot.
A positive Stransky sign refers to an upgoing great toe after flipping the little toe
outward.
Muscle stretch reflexes (eSlide 1.11). Muscle stretch reflexes, which were called
deep tendon reflexes in the past, are assessed by tapping the skin overlying the
muscle tendon with a reflex hammer. The response is assessed as 0, no response;
1+, diminished but present and might require facilitation; 2+, usual response; 3+,
brisker than usual; and 4+, hyperactive with clonus. Reinforcement maneuvers,
such as the Jendrassik maneuver, assist examination.
Primitive reflexes. Primitive reflexes are abnormal reflexes that represent devel-
opmental regression, indicating significant neurologic abnormalities in adults. Ex-
amples of primitive reflexes include the sucking reflex, rooting reflex, grasp reflex,
snout reflex, and palmomental response.
GAIT
Gait is a series of rhythmic, alternating movements of the limbs and trunk that
result in the forward progression of the center of gravity. Gait is dependent on
input from several systems, including the visual, vestibular, cerebellar, motor, and
sensory systems. Gait disorders have stereotypical patterns that reflect injury to
various aspects of the neurologic system (eSlide 1.12).
Musculoskeletal Examination
The musculoskeletal (MSK) examination incorporates inspection, palpation, pas-
sive and active range of movement (ROM), assessment of joint stability, manual
muscle testing, joint-specific provocative maneuvers, and special tests. Readers may
view Table 1.9 in Braddom’s Physical Medicine and Rehabilitation, Fifth Edition, for
details and reliability of joint-specific provocative maneuvers.
INSPECTION
Inspection includes observing mood, signs of pain or discomfort, functional
impairments, or evidence of malingering (e.g., Waddell signs). The spine should
be inspected for scoliosis, kyphosis, and lordosis, whereas limbs should be exam-
ined for symmetry, circumference, and contour. Muscle atrophy, masses, edema,
scars, skin breakdown, and fasciculations should also be checked. Joints should be
inspected for deformity, visible swelling, and erythema.
Kinetic chain refers to the summation of individual joint movements linked in
a series, leading to the production of a larger functional goal. A change in move-
ment of a single joint may affect the motion of adjacent, as well as distant, joints
in the chain. This may result in asymmetric patterns causing disease at seemingly
unrelated sites.
PALPATION
Palpation is used to identify tender areas and localize trigger points, muscle guard-
ing, or spasticity. Joints and soft tissues should be assessed for effusion, warmth,
masses, tight muscle bands, tone, and crepitus.
Assessment of joint stability. Bilateral examination is critical because assessment

of the “normal” side establishes a patient’s unique biomechanics. Joint play or cap-
sular patterns assess the integrity of the capsule in positions of minimal bony con-
tact, sometimes referred to as an open-packed position.
Assessment of range of movement general principles. ROM testing is used to

assess the integrity of a joint, monitor the efficacy of treatment regimens, and deter
mine the mechanical cause of impairment. Normal ROM varies according to age,
gender, conditioning, body habitus, and genetics. Passive ROM should be performed
through all planes of motion. Active ROM is performed by the patient through all
planes of motion, without assistance from the examiner. Range is measured with
a universal goniometer (eSlide 1.13). Correct patient positioning and planes of
motion for testing shoulder and hip joint ROM are shown in eSlides 1.14 and 1.15.
For more comprehensive and detailed information regarding measurements of

each joint, the reader may refer to Chapter 1 in Braddom’s Physical Medicine and
Rehabilitation, Fifth Edition.
• ASSESSMENT, SUMMARY, AND PLAN

Only after completing a thorough physiatric history and physical examination is
the physiatrist able to develop a comprehensive treatment plan. The organization
of the initial treatment plan and goals should clearly state the impairments, perfor-
mance deficits (activity limitations), community or role dysfunction (participation
level), medical conditions that can affect achieving both short-term and long-term
functional goals, and goals for the interdisciplinary rehabilitation team. Follow-up
treatment plans and notes are likely to be shorter and less detailed, but they must
address important interval changes since the last documentation and any significant
changes in treatment or goals.
Clinical Pearls
A comprehensive rehabilitation physiatric history and physical examination help
develop a treatment plan with proper goals.
The physiatric history and physical examination begin with the standard medical
format but go beyond that to assess impairment, activity limitation (disability), and
participation (handicap).
Identifying and treating the primary impairments to maximize performance is the
primary thrust of physiatric evaluation and treatment.
Physiatrists’ understanding of the MSK principles and MSK examination distin-
guishes them from neurologists and neurosurgeons. Bilateral examination is critical.
Physiatrists’ understanding of neurology and the neurologic examination distin-
guishes them from orthopedists and rheumatologists.

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commencement regarded them with great contempt, and appears to
have been making the experiment whether hardship would kill them
or not, grew reconciled to his charge, perceiving that they would not
die, and introduced them as they proceeded to various powerful and
wealthy Mongols, who seem to have treated them kindly, offering
them, in return for their prayers, gold, and silver, and costly
garments. The Hindoos, who imagine the East India Company to be
an old woman, are a type of those sagacious Tartars, who, as
Rubruquis assures us, supposed that the pope was an old man
whose beard had been blanched by five hundred winters.
On the 31st of October, they turned their horses’ heads towards
the south, and proceeded for eight days through a desert, where
they beheld large droves of wild asses, which, like those seen by the
Ten Thousand in Mesopotamia, were far too swift for the fleetest
steeds. During the seventh day, they perceived on their right the
glittering peaks of the Caucasus towering above the clouds, and
arrived on the morrow at Kenkat, a Mohammedan town, where they
tasted of wine, and that delicious liquor which the orientals extract
from rice. At a city which Rubruquis calls Egaius, near Lake Baikal,
he found traces of the Persian language; and shortly afterward
entered the country of the Orrighers, an idolatrous, or at least a
pagan race, who worshipped with their faces towards the north,
while the east was at that period the Kableh, or praying-point of the
Christians.
Our traveller, though far from being intolerant for his age, had not
attained that pitch of humanity which teaches us to do to others as
we would they should do unto us; for upon entering a temple, which,
from his description, we discover to have been dedicated to Buddha,
and finding the priests engaged in their devotions, he irreverently
disturbed them by asking questions, and endeavouring to enter into
conversation with them. The Buddhists, consistently with the
mildness of their religion, rebuked this intrusion by the most
obstinate silence, or by continual repetitions of the words “Om, Om!
hactavi!” which, as he was afterward informed, signified, “Lord, Lord!
thou knowest it!” These priests, like the bonzes of China, Ava, and
Siam, shaved their heads, and wore flowing yellow garments,
probably to show their contempt for the Brahminical race, among
whom yellow is the badge of the most degraded castes. They
believed in one God, and, like their Hindoo forefathers, burned their
dead, and erected pyramids over their ashes.
Continuing their journey with their usual rapidity, they arrived on
the last day of the year at the court of Mangou, who was encamped
in a plain of immeasurable extent, and as level as the sea. Here,
notwithstanding the rigour of the cold, Rubruquis, conformably to the
rules of his order, went to court barefoot,—a piece of affectation for
which he afterward suffered severely. Three or four days’ experience
of the cold of Northern Tartary cured him of this folly, however; so
that by the 4th of January, 1254, when he was admitted to an
audience of Mangou, he was content to wear shoes like another
person.
On entering the imperial tent, heedless of time and place,
Rubruquis and his companion began to chant the hymn “A Solis
Ortu,” which, in all probability made the khan, who understood not
one word of what they said, and knew the meaning of none of their
ceremonies, regard them as madmen. However, on this point
nothing was said; only, before they advanced into the presence they
were carefully searched, lest they should have concealed knives or
daggers under their robes with which they might assassinate the
khan. Even their interpreter was compelled to leave his belt and
kharjar with the porter. Mare’s milk was placed on a low table near
the entrance, close to which they were desired to seat themselves,
upon a kind of long seat, or form, opposite the queen and her ladies.
The floor was covered with cloth of gold, and in the centre of the
apartment was a kind of open stove, in which a fire of thorns, and
other dry sticks, mingled with cow-dung, was burning. The khan,
clothed in a robe of shining fur, something resembling seal-skin, was
seated on a small couch. He was a man of about forty-five, of
middling stature, with a thick flat nose. His queen, a young and
beautiful woman, was seated near him, together with one of his
daughters by a former wife, a princess of marriageable age, and a
great number of young children.
The first question put to them by the khan was, what they would
drink; there being upon the table four species of beverage,—wine,
cerasine, or rice-wine, milk, and a sort of metheglin. They replied
that they were no great drinkers, but would readily taste of whatever
his majesty might please to command; upon which the khan directed
his cupbearer to place cerasine before them. The Turcoman
interpreter, who was a man of very different mettle, and perhaps
thought it a sin to permit the khan’s wine to lie idle, had meanwhile
conceived a violent affection for the cupbearer, and had so
frequently put his services in requisition, that whether he was in the
imperial tent or in a Frank tavern was to him a matter of some doubt.
Mangou himself had pledged his Christian guests somewhat too
freely; and in order to allow his brain leisure to adjust itself, and at
the same time to excite the wonder of the strangers by his skill in
falconry, commanded various kinds of birds of prey to be brought,
each of which he placed successively upon his hand, and
considered with that steady sagacity which men a little touched with
wine are fond of exhibiting.
Having assiduously regarded the birds long enough to evince his
imperial contempt of politeness, Mangou desired the ambassadors
to speak. Rubruquis obeyed, and delivered an harangue of some
length, which, considering the muddy state of the interpreter’s brain
and the extremely analogous condition of the khan’s, may very
safely be supposed to have been dispersed, like the rejected prayers
of the Homeric heroes, in empty air. In reply, as he wittily observes,
Mangou made a speech, from which, as it was translated to him, the
ambassador could infer nothing except that the interpreter was
extremely drunk, and the emperor very little better. In spite of this
cloudy medium, however, he imagined he could perceive that
Mangou intended to express some displeasure at their having in the
first instance repaired to the court of Sartak rather than to his; but
observing that the interpreter’s brain was totally hostile to the
passage of rational ideas, Rubruquis wisely concluded that silence
would be his best friend on the occasion, and he accordingly
addressed himself to that moody and mysterious power, and shortly
afterward received permission to retire.
The ostensible object of Rubruquis was to obtain permission to
remain in Mongolia for the purpose of preaching the Gospel; but
whether this was merely a feint, or that the appearance of the
country and people had cooled his zeal, it is certain that he did not
urge the point very vehemently. However, the khan was easily
prevailed upon to allow him to prolong his stay till the melting of the
snows and the warm breezes of spring should render travelling more
agreeable. In the mean while our ambassador employed himself in
acquiring some knowledge of the people and the country; but the
language, without which such knowledge must ever be superficial,
he totally neglected.
About Easter the khan, with his family and smaller tents or
pavilions, quitted the camp, and proceeded towards Karakorum,
which might be termed his capital, for the purpose of examining a
marvellous piece of jewelry in form of a tree, the production of a
French goldsmith. This curious piece of mechanism was set up in
the banqueting-hall of his palace, and from its branches, as from
some miraculous fountain, four kinds of wines and other delicious
cordials, gushed forth for the use of the guests. Rubruquis and his
companions followed in the emperor’s train, traversing a
mountainous and steril district, where tempests, bearing snow and
intolerable cold upon their wings, swept and roared around them as
they passed, piercing through their sheep-skins and other coverings
to their very bones.
At Karakorum, a small city, which Rubruquis compares to the town
of St. Denis, near Paris, our ambassador-missionary maintained a
public disputation with certain pagan priests, in the presence of three
of the khan’s secretaries, of whom the first was a Christian, the
second a Mohammedan, and the third a Buddhist. The conduct of
the khan was distinguished by the most perfect toleration, as he
commanded under pain of death that none of the disputants should
slander, traduce, or abuse his adversaries, or endeavour by rumours
or insinuations to excite popular indignation against them; an act of
mildness from which Rubruquis, with the illiberality of a monk,
inferred that Mangou was totally indifferent to all religion. His object,
however, seems to have been to discover the truth; but from the
disputes of men who argued with each other through interpreters
wholly ignorant of the subject, and none of whom could clearly
comprehend the doctrines he impugned, no great instruction was to
be derived. Accordingly, the dispute ended, as all such disputes
must, in smoke; and each disputant retired from the field more fully
persuaded than ever of the invulnerable force of his own system.
At length, perceiving that nothing was to be effected, and having,
indeed, no very definite object to effect, excepting the conversion of
the khan, which to a man who could not even converse with him
upon the most ordinary topic, seemed difficult, Rubruquis took his
leave of the Mongol court, and leaving his companion at Karakorum,
turned his face towards the west. Returning by an easier or more
direct route, he reached the camp of Batou in two months. From
thence he proceeded to the city of Sarai on the Volga, and
descending along the course of that river, entered Danghistan,
crossed the Caucasus, and pursued his journey through Georgia,
Armenia, and Asia Minor, to Syria.
Here he discovered that, taught by misfortune or yielding to the
force of circumstances, the French king had relinquished, at least for
the present, his mad project of recovering Palestine. He was
therefore desirous of proceeding to Europe, for the purpose of
rendering this prince an account of his mission; but this being
contrary to the wishes of his superiors, who had assigned him the
convent of Acra for his retreat, he contented himself with drawing up
an account of his travels, which was forwarded, by the first
opportunity that occurred, to St. Louis in France. Rubruquis then
retired to his convent, in the gloom of whose cloisters he
thenceforward concealed himself from the eyes of mankind. It has
been ascertained, however, that he was still living in 1293, though
the exact date of his death is unknown.
The work of Rubruquis was originally written in Latin, from which
language a portion of it was translated into English and published by
Hackluyt. Shortly afterward Purchas published a new version of the
whole work in his collection. From this version Bergeron made his
translation into French, with the aid of a Latin manuscript, which
Vander Aa and the “Biographie Universelle” have multiplied into two.
In all or any of these forms, the work may still be read with great
pleasure and advantage by the diligent student of the opinions and
manners of mankind.
MARCO POLO.
Born 1250.—Died 1324.
The relations of Ascelin, Carpini, and Rubruquis, which are

supposed by some writers to have opened the way to the
discoveries of the Polo family, are by no means entitled to so high an
honour. Carpini did not return to Italy until the latter end of the year
1248; Ascelin’s return was still later; and although reports of the
strange things they had beheld no doubt quickly reached Venice,
these cannot be supposed to have exercised any very powerful
influence in determining Nicolo and Maffio to undertake a voyage to
Constantinople, the original place of their destination, from whence
they were accidentally led on into the extremities of Tartary. With
respect to Rubruquis, he commenced his undertaking three years
after their departure from Venice, while they were in Bokhāra; and
before his return to Palestine they had already penetrated into
Cathay. The influence of the relations of these monks upon the
movements of the Polos is therefore imaginary.
Nicolo and Maffio Polo, two noble Venetians engaged in
commerce, having freighted a vessel with rich merchandise, sailed
from Venice in the year 1250. Traversing the Mediterranean and the
Bosphorus, they arrived in safety at Constantinople, Baldwin II. being
then Emperor of the East. Here they disposed of their cargo, and
purchasing rich jewels with the proceeds, crossed the Black Sea to
Soldain, or Sudak, in the Crimea, from whence they travelled by land
to the court of Barkah Khan, a Tartar prince, whose principal
residences were the cities of Al-Serai, and Bolghar. To this khan they
presented a number of their finest jewels, receiving gifts of still
greater value in return. When they had spent a whole year in the
dominions of Barkah, and were beginning to prepare for their return
to Italy, hostilities suddenly broke out between the khan and his
cousin Holagon; which, rendering unsafe all passages to the west,
compelled them to make the circuit of the northern and eastern
frontiers of Kipjak. Having escaped from the scene of war they
crossed Gihon, and then traversing a desert of seventeen days’
journey, thinly sprinkled with the tents of the wandering tribes, they
arrived at Bokhāra. Here they remained three years. At the
termination of this period an ambassador from Holagon to Kublai
Khan passing through Bokhāra, and happening accidentally to meet
with the Polos, who had by this time acquired a competent
knowledge of the Tartar language, was greatly charmed with their
conversation and manners, and by much persuasion and many
magnificent promises prevailed upon them to accompany him to
Cambalu, or Khanbalik, in Cathay. A whole year was consumed in
this journey. At length, however, they arrived at the court of the Great
Khan, who received and treated them with peculiar distinction.
How long the brothers remained at Cambalu is not known; but
their residence, whatever may have been its length, sufficed to
impress Kublai Khan with an exalted opinion of their honour and
capacity, so that when by the advice of his courtiers he determined
on sending an embassy to the pope, Nicolo and Maffio were
intrusted with the conduct of the mission. They accordingly departed
from Cambalu, furnished with letters for the head of the Christian
church, a passport or tablet of gold, empowering them to provide
themselves with guides, horses, and provisions throughout the
khan’s dominions, and accompanied by a Tartar nobleman. This
Tartar falling exceedingly ill on the way, they proceeded alone, and,
after three years of toil and dangers, arrived at Venice in 1269.
Nicolo, who, during the many years he had been absent, seems to
have received no intelligence from home, now found that his wife,
whom he had left pregnant at his departure, was dead, but that she
had left him a son, named Marco, then nineteen years old. The
pope, likewise, had died the preceding year; and various intrigues
preventing the election of a successor, they remained in Italy two
years, unable to execute the commission of the khan. At length,
fearing that their long absence might be displeasing to Kublai, and
perceiving no probability of a speedy termination to the intrigues of
the conclave, they, in 1271, again set out for the East, accompanied
by young Marco.
Arriving in Palestine, they obtained from the legate Visconti, then
at Acre, letters testifying their fidelity to the Great Khan, and stating
the fact that a new pope had not yet been chosen. At Al-Ajassi, in
Armenia, however, they were overtaken by a messenger from
Visconti, who wrote to inform them that he himself had been elected
to fill the papal throne, and requested that they would either return,
or delay their departure until he could provide them with new letters
to the khan. As soon as these letters and the presents of his holiness
arrived, they continued their journey, and passing through the
northern provinces of Persia, were amused with the extraordinary
history of the Assassins, then recently destroyed by a general of
Holagon.
Quitting Persia, they proceeded through a rich and picturesque
country to Balkh, a celebrated city, which they found in ruins and
nearly deserted, its lofty walls and marble palaces having been
levelled with the ground by the devastating armies of the Mongols.
The country in the neighbourhood had likewise been depopulated,
the inhabitants having taken refuge in the mountains from the
rapacious cruelty of the predatory hordes, who roamed over the vast
fields which greater robbers had reaped, gleaning the scanty plunder
which had escaped their powerful predecessors. Though the land
was well watered and fertile, and abounding in game, lions and other
wild beasts had begun to establish their dominion over it, man
having disappeared; and therefore, such travellers as ventured
across this new wilderness were constrained to carry along with
them all necessary provisions, nothing whatever being to be found
on the way.
When they had passed this desert, they arrived in a country richly
cultivated and covered with corn, to the south of which there was a
ridge of high mountains, where such prodigious quantities of salt
were found that all the world might have been supplied from those
mines. The track of our travellers through the geographical labyrinth
of Tartary it is impossible to follow. They appear to have been
prevented by accidents from pursuing any regular course, in one
place having their passage impeded by the overflowing of a river,
and on other occasions being turned aside by the raging of bloody
wars, by the heat or barrenness, or extent of deserts, or by their utter
inability to procure guides through tracts covered with impervious
forests or perilous morasses.
They next proceeded through a fertile country, inhabited by
Mohammedans, to the town of Scasom, perhaps the Koukan of
Arrowsmith, on the Sirr or Sihon. Numerous castles occupied the
fastnesses of the mountains, while the shepherd tribes, like the
troglodytes of old, dwelt with their herds and flocks in caverns
scooped out of the rock. In three days’ journey from hence they
reached the province of Balascia, or Balashghan, where, Marco
falling sick, the party were detained during a whole year, a delay
which afforded our illustrious traveller ample leisure for prosecuting
his researches respecting this and the neighbouring countries. The
kings of this petty sovereignty pretended to trace their descent from
the Macedonian conqueror and the daughter of Darius; making up,
by the fabulous splendour of their genealogy, for their want of actual
power. The inhabitants were Mohammedans, and spoke a language
peculiar to themselves. It was said, that not many years previous
they had possessed a race of horses equally illustrious with their
kings, being descended from Bucephalus; but as it was asserted that
these noble animals possessed one great advantage over their
kings, that of bearing upon their foreheads the peculiar mark which
distinguished the great founder of their family, thus proving the purity
of the breed, they very prudently added that the whole race had
recently been exterminated.
This country was rich in minerals and precious stones, lead,
copper, silver, lapis lazuli, and rubies abounding in the mountains.
The climate was cold, and that of the plains insalubrious,
engendering agues, which quickly yielded, however, to the bracing
air of the hills; where Marco, after languishing for a whole year with
this disorder, recovered his health in the course of a few days. The
horses were large, strong, and swift, and had hoofs so tough that
they could travel unshod over the most rocky places. Vast flocks of
wild sheep, exceedingly difficult to be taken, were found in the hills.
Marco’s health being restored, our travellers resumed their journey
towards Cathay, and proceeding in a north-easterly direction, arrived
at the roots of a vast mountain, reported by the inhabitants to be the
loftiest in the world. Having continued for three days ascending the
steep approaches to this mountain, they reached an extensive table-
land, hemmed in on both sides by still loftier mountains, and having
a great lake in its centre. A fine river likewise flowed through it, and
maintained so extraordinary a degree of fertility in the pastures upon
its banks, that an ox or horse brought lean to these plains would
become fat in ten days. Great numbers of wild animals were found
here, among the rest a species of wild sheep with horns six spans in
length, from which numerous drinking-vessels were made. This
immense plain, notwithstanding its fertility, was uninhabited, and the
severity of the cold prevented its being frequented by birds. Fire, too,
it was asserted, did not here burn so brightly, or produce the same
effect upon food, as in other places: an observation which has
recently been made on the mountains of Savoy and Switzerland.
From this plain they proceeded along the foot of the Allak
mountains to the country of Kashgar, which, possessing a fertile soil,
and an industrious and ingenious population, was maintained in a
high state of cultivation, and beautified with numerous gardens,
orchards, and vineyards. From Kashgar they travelled to Yarkand,
where the inhabitants, like those of the valleys of the Pyrenees, were
subject to the goitres, or large wens upon the throat. To this province
succeeded that of Khoten, whence our word cotton has been
derived. The inhabitants of this country, an industrious but unwarlike
race, were of the Mohammedan religion, and tributaries to the Great
Khan. Proceeding in their south-easterly direction, they passed
through the city of Peym, where, if a husband or wife were absent
from home twenty days, the remaining moiety might marry again;
and pursuing their course through sandy barren plains, arrived at the
country of Sartem. Here the landscape was enlivened by numerous
cities and castles; but when the storm of war burst upon them, the
inhabitants, like the Arabs, relied upon famine as their principal
weapon against the enemy, retiring with their wives, children,
treasures, and provisions, into the desert, whither none could follow
them. To secure their subsistence from plunder, they habitually
scooped out their granaries in the depths of the desert, where, after
harvest, they annually buried their corn in deep pits, over which the
wind soon spread the wavy sand as before, obliterating all traces of
their labours. They themselves, however, possessed some unerring
index to the spot, which enabled them at all times to discover their
hoards. Chalcedonies, jaspers, and other precious stones were
found in the rivers of this province.
Here some insurmountable obstacle preventing their pursuing a
direct course, they deviated towards the north, and in five days
arrived at the city of Lop, on the border of the desert of the same
name. This prodigious wilderness, the most extensive in Asia, could
not, as was reported, be traversed from west to east in less than a
year; while, proceeding from south to north, a month’s journey
conducted the traveller across its whole latitude. Remaining some
time at the city of Lop, or Lok, to make the necessary preparations
for the journey, they entered the desert. In all those fearful scenes
where man is constrained to compare his own insignificance with the
magnificent and resistless power of the elements, legends,
accommodated to the nature of the place, abound, peopling the
frozen deep or the “howling wilderness” with poetical horrors
superadded to those which actually exist. On the present occasion
their Tartar companions, or guides, entertained our travellers with the
wild tales current in the country. Having dwelt sufficiently upon the
tremendous sufferings which famine or want of water sometimes
inflicted upon the hapless merchant in those inhospitable wastes,
they added, from their legendary stores, that malignant demons
continually hovered in the cold blast or murky cloud which nightly
swept over the sands. Delighting in mischief, they frequently exerted
their supernatural powers in steeping the senses of travellers in
delusion, sometimes calling them by their names, practising upon
their sight, or, by raising up phantom shapes, leading them astray,
and overwhelming them in the sands. Upon other occasions, the
ears of the traveller were delighted with the sounds of music which
these active spirits, like Shakspeare’s Ariel, scattered through the
dusky air; or were saluted with that sweetest of all music, the voice
of friends. Then, suddenly changing their mood, the beat of drums,
the clash of arms, and a stream of footfalls, and of the tramp of
hoofs, were heard, as if whole armies were marching past in the
darkness. Such as were deluded by any of these arts, and
separated, whether by night or day, from their caravan, generally lost
themselves in the pathless wilds, and perished miserably of hunger.
To prevent this danger, travellers kept close together, and suspended
little bells about the necks of their beasts; and when any of their
party unfortunately lagged behind, they carefully fixed up marks
along their route, in order to enable them to follow.
Having safely traversed this mysterious desert, they arrived at the
city of Shatcheu, on the Polonkir, in Tangut. Here the majority of the
inhabitants were pagans and polytheists, and their various gods
possessed numerous temples in different parts of the city. Marco,
who was a diligent inquirer into the creed and religious customs of
the nations he visited, discovered many singular traits of superstition
at Shatcheu. When a son was born in a family, he was immediately
consecrated to some one of their numerous gods; and a sheep,
yeaned, perhaps, on the birthday of the child, was carefully kept and
fed in the house during a whole year: at the expiration of which term
both the child and the sheep were carried to the temple, and offered
as a sacrifice to the god. The god, or, which was the same thing, the
priests, accepted the sheep, which they could eat, in lieu of the boy,
whom they could not; and the meat being dressed in the temple, that
the deity might be refreshed with the sweet-smelling savour, was
then conveyed to the father’s dwelling, where a sumptuous feast
ensued, at which it may be safely inferred the servants of the temple
were not forgotten. At all events, the priests received the head, feet,
skin, and entrails, with a portion of the flesh, for their share. The
bones were preserved, probably for purposes of divination.
Their exit from life was celebrated with as much pomp as their
entrance into it. Astrologers, the universal pests of the east, were
immediately consulted; and these, having learned the year, month,
day, and hour in which the deceased was born, interrogated the
stars, and by their mute but significant replies discovered the precise
moment on which the interment was to take place. Sometimes these
oracles of the sky became sullen, and for six months vouchsafed no
answer to the astrologers, during all which time the corpse remained
in a species of purgatory, uncertain of its doom. To prevent the dead
from keeping the living in the same state, however, the body, having
been previously embalmed, was enclosed in a coffin so artificially
constructed that no offensive odour could escape; while, as the soul
was supposed to hover all this while over its ancient tenement, and
to require, as formerly, some kind of earthly sustenance, food was
daily placed before the deceased, that the spirit might satisfy its
appetite with the agreeable effluvia. When the day of interment
arrived, the astrologers, who would have lost their credit had they
always allowed things to proceed in a rational way, sometimes
commanded the body to be borne out through an opening made for
the purpose in the wall, professing to be guided in this matter by the
stars, who, having no other employment, were extremely solicitous
that all Tartars should be interred in due form. On the way from the
house of the deceased to the cemetery, wooden cottages with
porches covered with silk were erected at certain intervals, in which
the coffin was set down before a table covered with bread, wine, and
other delicacies, that the spirit might be refreshed with the savour.
The procession was accompanied by all the musical instruments in
the city; and along with the body were borne representations upon
paper of servants of both sexes, horses, camels, money, and costly
garments, all of which were consumed with the corpse on the funeral
pile, instead of the realities, which, according to Herodotus, were
anciently offered up as a sacrifice to the manes at the tombs of the
Scythian chiefs.
Turning once more towards the north, they entered the fertile and
agreeable province of Khamil, situated between the vast desert of
Lop and another smaller desert, only three days’ journey across. The
natives of this country, practical disciples of Aristippus, being of
opinion that pleasure is happiness, seemed to live only for
amusement, devoting the whole of their time to singing, dancing,
music, and literature. Their hospitality, like that of the knights of
chivalry, was so boundlessly profuse, that strangers were permitted
to share, not only their board, but their bed, the master of a family
departing when a guest arrived, in order to render him more
completely at home with his wife and daughters. To increase the
value of this extraordinary species of hospitality, it is added that the
women of Khamil are beautiful, and as fully disposed as their lords to
promote the happiness of their guests. Mangou Khan, the
predecessor of Kublai, desirous of reforming the morals of his
subjects, whatever might be the fate of his own, abolished this
abominable custom; but years of scarcity and domestic afflictions
ensuing, the people petitioned to have the right of following their
ancestral customs restored to them. “Since you glory in your shame,”
said Mangou to their ambassadors, “you may go and act according
to your customs.” The flattering privilege was received with great
rejoicings, and the practice, strange as it may be, has continued up
to the present day.
Departing from this Tartarian Sybaris, they entered the province of
Chinchintalas, a country thickly peopled, and rich in mines, but
chiefly remarkable for that salamander species of linen,
manufactured from the slender fibres of the asbestos, which was
cleansed from stains by being cast into the fire. Then followed the
district of Sucher, in the mountains of which the best rhubarb in the
world was found. They next directed their course towards the north-
east, and having completed the passage of the desert of Shomo,
which occupied forty days, arrived at the city of Karakorum,
compared by Rubruquis to the insignificant town of St. Denis, in
France, but said by Marco Polo to have been three miles in
circumference, and strongly fortified with earthen ramparts.
Our travellers now turned their faces towards the south, and
traversing an immense tract of country which Marco considered
unworthy of minute description, passed the boundaries of Mongolia,
and entered Cathay. During this journey they travelled through a
district in which were found enormous wild cattle, nearly approaching
the size of the elephant, and clothed with a fine, soft, black and white
hair, in many respects more beautiful than silk, specimens of which
Marco procured and brought home with him to Venice on his return.
Here, likewise, the best musk in the world was found. The animal
from which it was procured resembled a goat in size, but in
gracefulness and beauty bore a stronger likeness to the antelope,
except that it had no horns. On the belly of this animal there
appeared, every full moon, a small protuberance or excrescence,
like a thin silken bag, filled with the liquid perfume; to obtain which
the animal was hunted and slain. This bag was then severed from
the body, and its contents, when dried, were distributed at an
enormous price over the world, to scent the toilets and the persons
of beauties in reality more sweet than itself.
Near Changanor, at another point of their journey, they saw one of
the khan’s palaces, which was surrounded by beautiful gardens,
containing numerous small lakes and rivulets and a prodigious
number of swans. The neighbouring plains abounded in partridges,
pheasants, and other game, among which are enumerated five
species of cranes, some of a snowy whiteness, others with black
wings, their feathers being ornamented with eyes like those of the
peacock, but of a golden colour, with beautiful black and white
necks. Immense flocks of quails and partridges were found in a
valley near this city, where millet and other kinds of grain were sown
for them by order of the khan, who likewise appointed a number of
persons to watch over the birds, and caused huts to be erected in
which they might take shelter and be fed by their keepers during the
severity of the winter. By these means, the khan had at all times a
large quantity of game at his command.
At Chandu, three days’ journey south-west of Changanor, they
beheld the stupendous palace which Kublai Khan had erected in that
city. Neither the dimensions nor the architecture are described by
Marco Polo, but it is said to have been constructed, with singular art
and beauty, of marble and other precious materials. The grounds of
this palace, which were surrounded by a wall, were sixteen miles in
circumference, and were beautifully laid out into meadows, groves,
and lawns, watered by sparkling streams, and abundantly stocked
with red and fallow deer, and other animals of the chase. In this park
the khan had a mew of falcons, which, when at the palace, he visited
once a week, and caused to be fed with the flesh of young fawns.
Tame leopards were employed in hunting the stag, and, like the
chattah, or tiger, used for the same purpose in the Carnatic, were
carried out on horseback to the scene of action, and let loose only
when the game appeared.
In the midst of a tall grove, there was an elegant pavilion, or
summer-house, of wood, supported on pillars, and glittering with the
richest gilding. Against each pillar stood the figure of a dragon,
likewise richly gilt, with its tail curling round the shaft, its head
touching the roof, and its wings extended on both sides through the
intercolumniations. The roof was composed of split bamboos gilded
and varnished, and so skilfully shelving over each other that no rain
could ever penetrate between them. This beautiful structure could
easily be taken to pieces or re-erected, like a tent, and, to prevent it
from being overthrown by the wind, was fastened to the earth by two
hundred silken ropes. At this palace the khan regularly spent the
three summer months of June, July, and August, leaving it on the
28th of the last-named month, in order to proceed towards the south.
Eight days previous to his departure, however, having solemnly
consulted his astrologers, the khan annually offered sacrifice to the
gods and spirits of the earth, the ceremony consisting in sprinkling a
quantity of white mare’s milk upon the ground with his own hands, at
the same time praying for the prosperity of his subjects, wives, and
children. Kublai Khan was in no danger of wanting milk for this
sacrifice, since he possessed a stud of horses, nearly ten thousand
in number, all so purely white, that like certain Homeric steeds, they
might, without vanity, have traced their origin to Boreas, the father of
the snow. Indeed, much of this imperial nectar must have streamed
in libations to mother earth on less solemn occasions; since none but
persons of the royal race of Genghis Khan were permitted to drink of
it, with the exception of one single family, named Boriat, to whom this
distinguished privilege had been granted by Genghis for their
prowess and valour.
Our travellers now drew near Cambalu, and the khan, having
received intelligence of their approach, sent forth messengers to
meet them at the distance of forty days’ journey from the imperial
city, that they might be provided with all necessaries on the way, and
conducted with every mark of honour and distinction to the capital.
Upon their arrival, they were immediately presented to the khan; and
having prostrated themselves upon the ground, according to the
custom of the country, were commanded to rise, and most graciously
received. When they had been kindly interrogated by the emperor
respecting the fatigues and dangers they had encountered in his
service, and had briefly related their proceedings with the pope and
in Palestine, from whence, at the khan’s desire, they had brought a
small portion of holy oil from the lamp of Christ’s sepulchre at
Jerusalem, they received high commendations for their care and
fidelity. Then the khan, observing Marco, inquired, “Who is this
youth?”—“He is your majesty’s servant, and my son,” replied Nicolo.
Kublai then received the young man with a smile, and, appointing
him to some office about his person, caused him to be instructed in
the languages and sciences of the country. Marco’s aptitude and
genius enabled him to fulfil the wishes of the khan. In a very short
time he acquired, by diligence and assiduity, a large acquaintance
with the manners of the Mongols, and could speak and write fluently
in four of the languages of the empire.
When Marco Polo appeared to have acquired the necessary
degree of information, the khan, to make trial of his ability,
despatched him upon an embassy to a city or chief called Karakhan,
at the distance of six months’ journey from Cambalu. This difficult
commission our traveller executed with ability and discretion; and in
order still further to enhance the merit of his services in the
estimation of his sovereign, he carefully observed the customs and
manners of all the various tribes among whom he resided, and drew
up a concise account of the whole in writing, which, together with a
description of the new and curious objects he had beheld, he
presented to the khan on his return. This, as he foresaw, greatly
contributed to increase the favour of the prince towards him; and he
continued to rise gradually from one degree of honour to another,
until at length it may be doubted whether any individual in the empire
enjoyed a larger portion of Kublai’s affection and esteem. Upon
various occasions, sometimes upon the khan’s business, sometimes
upon his own, he traversed all the territories and dependencies of
the empire, everywhere possessing the means of observing
whatever he considered worth notice, his authority and the imperial
favour opening the most secluded and sacred places to his scrutiny.
As our traveller has not thought proper, however, to describe these
various journeys chronologically, or, indeed, to determine with any
degree of exactness when any one of them took place, we are at
liberty, in recording his peregrinations, to adopt whatever
arrangement we please; and it being indisputable that Northern
China was the first part of Kublai’s dominions, properly so called,
which he entered, it appears most rational to commence the history
of his Chinese travels with an outline of what he saw in that division
of the empire.
The khan himself, whose profuse munificence enabled Marco Polo
to perform with pleasure and comfort his long and numerous
expeditions, was a fine handsome man of middle stature, with a

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Braddom’s Rehabilitation Care: A

Clinical Handbook David X Cifu

Braddom's Physical Medicine and Rehabilitation, Sixth

Clinical Orthopaedic Rehabilitation: A Team Approach

Oxford Handbook of Rehabilitation Medicine 3rd Edition

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For technical assistance:

Henry L. Lew, MD, PhD

BRADDOM’S REHABILITATION CARE:

Copyright © 2018 by Elsevier, Inc. All rights reserved.

Library of Congress Cataloging-in-Publication Data

Senior Acquisition Editor: Kristine Jones

Printed in the United States of America

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

Eleftheria Antoniadou, MD, FEBPMR, PhDc

Maria Gabriella Ceravolo, MD, PhD

Shih-Chung Chang, MD, MS

Carl Chen, MD, PhD

Shih-Ching Chen, MD, PhD

Willy Chou, MD, HRMS

Tze Yang Chung, MBBS, MRehabMed

Andrew Malcolm Dermot Cole, MBBS (Hons), FACRM, FAFRM

Rochelle Coleen Tan Dy, MD

Julia Patrick Engkasan, MBBS (Mal), MRehabMed (Mal)

Francesca Gimigliano, MD, PhD

Nazirah Hasnan, MBBS, MRehabMed, PhD

Joseph E. Herrera, DO, FAAPMR

Rashidah Ismail Ohnmar Htwe, MBBS, M MED Sc (Rehab Med), CMIA

Yu-Hui Huang, MD, PhD

Norhayati Hussein, MBBS, MRehabMed, Fellowship in Neurorehabilitation

Elena Milkova Ilieva, MD, PhD, Prof.

Lydia Abdul Latif, MBBS, MRM

Henry L. Lew, MD, PhD

Mazlina Mazlan, MBBS, MRM

Matthew J. McLaughlin, MD, MSB

Amaramalar Selvi Naicker, MBBS (Ind), MRehabMed (Mal)

Mooyeon Oh-Park, MD, MS

Renald Peter Ty Ramiro, MD

Reynaldo R. Rey-Matias, PT, MD, MSHMS

Clarice N. Sinn, DO, MHA

Anwar Suhaimi, MBBS, MRehabMed (Malaya)

Yi-Chian Wang, MD, MSc

Tian-Shin Yeh, MD, MMS

Tunku Nor Taayah Tunku Zubir, MBBS

David X. Cifu, MD, and Henry L. Lew, MD, PhD

Jianan Li, MD, Immediate Past President, International Society of Physical

1 The Physiatric History and Physical Examination, 3

2 History and Examination of the Pediatric Patient, 14

3 Adult Neurogenic Communication and Swallowing Disorders, 18

4 P sychological Assessment and Intervention in Rehabilitation, 24

5 Practical Aspects of Impairment Rating and

6 Employment of People with Disabilities, 34

1 The Physiatric History and Physical Examination, 3

2 History and Examination of the Pediatric Patient, 14

3 Adult Neurogenic Communication and Swallowing Disorders, 18

4 P sychological Assessment and Intervention in Rehabilitation, 24

6 Employment of People with Disabilities, 34

7 Quality and Outcome Measures for Medical Rehabilitation, 39

SECTION II TREATMENT TECHNIQUES AND SPECIAL

10 Lower Limb Amputation and Gait, 57

12 Lower Limb Orthoses, 75

14 Wheelchairs and Seating Systems, 92

15 Therapeutic Exercise, 102

16 Manipulation, Traction, and Massage, 111

17 P hysical Agent Modalities, 119

18 Integrative Medicine in Rehabilitation, 126

19 Computer Assistive Devices and Environmental Controls, 129

SECTION III COMMON CLINICAL PROBLEMS

20 B ladder Dysfunction, 137

21 Neurogenic Bowel: Dysfunction and Rehabilitation, 143

22 Sexual Dysfunction and Disability, 150

24 Chronic Wounds, 164

25 Vascular Diseases, 173

27 Acute Medical Conditions, 183

29 Cancer Rehabilitation, 197

30 The Geriatric Patient, 204

31 Rheumatologic Rehabilitation, 208

SECTION IV ISSUES IN SPECIFIC DIAGNOSES

32 Common Neck Problems, 216

33 Low Back Pain, 228

35 Upper Limb Pain and Dysfunction, 244

36 Musculoskeletal Disorders of the Lower Limb, 248

37 Chronic Pain, 257

38 Pelvic Floor Disorders, 264

39 Sports Medicine and Adaptive Sports, 270

41 Rehabilitation of Patients With Neuropathies, 287

43 Traumatic Brain Injury, 305

44 Stroke Syndromes, 315

46 Multiple Sclerosis, 324

47 Cerebral Palsy, 331

48 Myelomeningocele and Other Spinal Dysraphisms, 338

49 Spinal Cord Injury, 345

50 Auditory, Vestibular, and Visual Impairments, 355

16 Manipulation, Traction, and Massage

17 P hysical Agent Modalities

SECTION III COMMON CLINICAL PROBLEMS

SECTION IV ISSUES IN SPECIFIC DIAGNOSES

36 Musculoskeletal Disorders of the Lower Limb

45 Degenerative Movement Disorders of the Central Nervous System