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Rehabilitation Medicine Department
The Rehabilitation Medicine Department provides comprehensive evaluation and treatment to all NIH patients with disabilities in Physical Medicine, Physical Therapy, Occupational Therapy, Speech-Language Pathology assessment, and Recreation Therapy and Biomechanics. The staff supports and collaborates with NIH investigators in clinical research.
New clinical programs include a) provision of acupuncture treatments to patients referred with pain; b) development of an acute stroke management team; and c) provision of relaxation training using vibroacoustic methods.
The Medical Section has devised a comprehensive musculoskeletal screening evaluation and recently applied it to children with Beckwith-Wiedemann Syndrome. The findings suggest that in this population of 55 children, 70 percent had joint laxity, particularly of the knees, elbows and digits. Sixteen percent had scoliosis and 65 percent had thoracic cage asymmetry. There were nine who had discrepancies in limb length or girth of upper or lower extremities when one side was compared with the other. These findings indicate the importance of regular evaluations to assure proper treatment for scoliosis/joint instability when present.
The Medical Section has shown that, in a collaborative study with NIAMS, patients with recent onset inflammatory arthritis are likely to have significant problems with performance and mobility early in the course of their disease if they have more than ten involved joints. Further, patients with seropositive rheumatoid arthritis are more likely than those who lack RF to be fatigued, have poor sleep and poor performance.
The Biomechanics Laboratory continues to develop and test techniques designed to explore the complex relationship between impairments of the neuromusculoskeletal system, functional limitations and disability. One study of 18 normal subjects investigated the effect of dramatically different walking speeds on the mechanics of walking. Through the use of mechanical power analysis, it was demonstrated that two modes of walking may exist rather than a continuum of a single walking strategy. Another study evaluated a new technique for determining the role each major muscle group of the lower extremity plays in providing support to, and propulsion of, the body during walking. The results indicate forward progression was produced primarily by the ankle plantar flexors with a significant assist from the knee extensors. The results of these studies suggest that a complete and numerically consistent mechanical characterization of human movement is feasible. The application of these analytic techniques to the evaluation of human motion will have implications for rehabilitation and surgical treatment in patient populations.
The Occupational Therapy Section has implemented a study to better understand the complex phenomenon of occupational therapy process as it occurs in routine treatment sessions. Analysis of 20 subjects has been completed. Twenty patients (ten male, ten female) of mixed ethnicity were treated by four expert and two novice therapists (six female). Patients represented a wide variety of diagnoses [(mental illness (n=7, 35 percent), neurological (n=5, 25 percent), cancer (n=4, 20 percent), musculoskeletal (n=2, 10 percent) and spinal cord injury (n=2, 10 percent)]. Patient goals centered on work/productive roles (n=12, 60 percent) and activities of daily living (n=8, 40 percent). Patients were administered a focused interview following routine treatment sessions using the personal computer. Transcribed interviews were analyzed using principles of content analysis, including frequency counts and Spearman Correlation. Four process elements were found: occupational form, occupational performance, goals of treatment and reflection. The most prevalent element cited was reflection (patient=48 percent; therapist=37 to 40 percent). Further study of occupational therapy process is recommended.
The Speech and Swallowing Imaging Laboratory studied 12 patients post-pallidotomy for Parkinson's and were unable to identify significant changes in swallow, speech or voice following surgery. The purpose of this project is to evaluate the ability of noninvasive ultrasound imaging to contribute to the diagnosis of impaired swallow and speech and to evaluate the oropharyngeal structures (tongue, palate, oral muscles, hyoid, larynx) in normal and abnormal populations.
In cooperation with DCD and NCI, we continue to use ultrasound imaging to track head and neck tumor growth and tissue change during experimental treatments with paclitaxel being conducted concurrently with radiation therapy and other experimental treatments in patients with advanced tumors. It completed analysis of ultrasound swallowing studies and functional swallowing outcomes of the 23 patients seen initially. It was able to track the natural evolution of swallowing function, and has charted the course of recovery of oral motor function and mortality in this group of subjects. It has successfully built and tested an ultrasound transducer stabilizing device to alleviate the errors intrinsic to data collection using the hand held system we have used in the past. It can now study patient change resulting from treatment with enhanced reliability.
The Speech and Swallowing Imaging Laboratory has initiated a rigorously designed pilot study of the effects of viscosity on swallowing using ultrasound imaging. It anticipates this information will be valuable for the many individuals with dysphagia who are prescribed special diets.
This past year, the Speech and Swallowing Imaging Laboratory has focused its ultrasound (US) and videofluoroscopic (VF) studies of swallowing on a new group of patients with progressive supranuclear palsy (PSP) and has begun to follow some of the original patients with cystinosis whom it studied in 1989-1991. It is currently examining the affects of denepezil on oral motor and swallowing function in patients with PSP. Patients do not receive treatment but are reevaluated using US and VF before, during and after drug administration. The laboratory has seen 14 patients and is halfway through the study.
The Speech and Swallowing Imaging Laboratory is also using the computerized swallowing programs it developed last year to conduct a frame-by-frame analysis of timing and displacement of the hyoid bone. It has completed a study using simultaneous EMG and VF to assist in its understanding of the ability of the deglutitve motor system to accommodate to changing tasks demands required in differing swallowing patterns. The concept of a delay in the pharyngeal swallow has been considered as a primary diagnostic sign of dysphagia on the VF examination. The laboratory is studying this finding and it appears that the pattern may be part of the normal swallow.