Rehabilitation medicine.

This article presents a limited overview of the assistance rehabilitation medicine can offer the elderly surgical patient. Appropriately timed rehabilitation can positively affect surgical outcome of elderly patients by restoring physical abilities and promoting independent function. Specific techniques and programs that follow rehabilitation principles can help offset organ system impairment associated with the aging process itself. Moreover, predictable complications of postoperative bed rest and deconditioning that negatively impact functional mobility and self-care can be prevented or rapidly reversed by adhering to sound rehabilitation precepts. The surgeon should be familiar with the concepts of preserving and restoring function, the members of the rehabilitation team, and the array of programs and settings available for the physically impaired and disabled elderly patient.

Motions of the posterior pharyngeal wall in swallowing.

The motions of the posterior pharyngeal wall during swallowing were studied in four asymptomatic males using a new method for videoradiography. Radiopaque markers of 4 mm diameter were affixed to the pharyngeal wall by suction. Ventrodorsal and axial components of motion were measured frame by frame. Large axial motions occurred during the pharyngeal stage of swallowing. Cephalad displacement of each marker occurred early and was followed by caudad motion. Within the pharyngoesophageal segment, there were cephalocaudal motions measuring as much as 25 mm. A late caudad motion beyond the reference position was observed in this segment in two participants. This late motion may play a role in passing the bolus through the pharyngoesophageal segment. The findings support the concept of an "engulfment" mechanism in pharyngeal kinesiology.

Mechanisms of gastric distention in esophageal atresia with distal tracheoesophageal fistula.

This paper explains how the chest of the crying infant with the common form of esophageal atresia is a pump for ventilating the distal esophagus and inflating the stomach. Esophageal inflation from the trachea occurs during inspiration and esophageal deflation into the stomach during cry.

Using ventilators for speaking and swallowing.

An inflated cuff, although commonly thought to be required for the ventilator-dependent patient with a tracheostomy cannula, precludes speaking and has adverse implications for swallowing. Clinical trials with five ventilator-dependent, cognitively intact individuals with glottic control document that a deflated cuff is compatible with ventilation, preserves oral communication, and restores safe alimentation by mouth.

Dynamic imaging for swallowing reeducation.

Dynamic imaging is frequently indispensable for the rational treatment of disordered swallowing. The effects of test feeding techniques, bolus modification, patient positioning, and respiratory maneuvers are all best documented by visualizing and recording the swallowing of radiopacified boluses. What is seen becomes the basis of patients' reeducation in swallowing. Greatest effectiveness results when the radiologic examination is shared with those responsible for the patient's rehabilitation in swallowing.

Dysphagia: predicting laryngeal penetration.

Fifteen patients with pharyngeal stage dysphagia were studied clinically and by motion fluoroscopy. Eleven patients demonstrated laryngeal penetration during swallowing. There was high incidence of impaired pharyngeal gag and wet-hoarse voice quality among this group. Other observations were found to correlate poorly with penetration. Cough was an unreliable indicator of laryngeal penetration. Penetration was most likely when liquids were swallowed and least likely when semisolids were swallowed. Motion fluoroscopy of swallowing was necessary for detecting penetration reliably, identifying that dysphagia depends, in part, on bolus qualities, and planning a feeding approach consistent with remaining swallowing functions.

Head-control system for severely paralyzed patient.

A device to provide controlled suspension of the head of the severely paralyzed patient while seated is described. Mounted on the wheelchair, it permits functional range-of-motion of the head on the neck. It does not contact the neck or chin.

Electromyography of the pharyngeal musculature: technical considerations.

Thirty-one EMG studies of the pharyngeal musculature using three types of electrodes were performed. Electrode characteristics are compared according to criteria developed specifically for the pharynx; techniques for electrode positioning are described in detail; and technical difficulties encountered in performing these studies are discussed. Needle electrodes were best for analyzing individual potentials. For analyzing the timing of myoelectric activity, we preferred the hooked wire electrode (for palatopharyngeus or cricopharyngeus) or bipolar suction electrode (for pharyngeal constrictors). Pharyngeal electromyography is technically feasible and has a role in studying normal and pathologic processes.

Curves of the achondroplastic spine: a new hypothesis.

The profile of the achondroplastic dwarf reflects abnormalities in the shape of the spine, particularly in the lumbosacral area. We hypothesize that these abnormalities and the resultant symptoms are secondary and avoidable rather than heritable and inevitable. Because the heads of achondroplastic children are enlarged (n = 50), loading of the vertical spine is increased. Unusually lax ligaments and misshapen vertebrae predispose the spine to yielding under vertical stress. Children and adults uniformly have hip flexion contractures (n 105); these are hypothesized to be the result of uncorrected lumbosacral lordosis. The volume of the spinal canal, reduced by the spinal stenosis of achondroplasia, is decreased additionally by lordosis; some neurologic deficits of achondroplasia are caused by this abnormal curvature. This hypothesis bears practically on treating this common form of dwarfism.

Achondroplasia: effectiveness of an orthosis in reducing deformity of the spine.

Deformity of the spine and its complications have long been accepted as characteristics of achondroplasia. We have sought to prevent these with a spinal orthosis. This report includes a description of the orthosis and an analysis of its use in achondroplastic children and adults. Nineteen dwarfs between 11 and 52 months of age were fitted with a light truncal polyform orthosis. The effect on the thoracolumbar (TL) and lumbosacral curves (LS) in the seated and standing child were compared by measurements made from lateral roentgenograms with and without the orthosis. The group mean reduction in TL curve of the seated dwarfs was 23 degrees (range 2 degrees to 73 degrees) and the reduction in the LS curve in the standing position was 15 degrees (range 1 degree to 44 degrees). Seventeen older children aged 4-1/2 to 11-2/3 years were equipped with an aluminum version of the orthosis. Their TL curve sitting was reduced by a mean of 31 degrees (range 6 degrees to 45 degrees) and their LS curve standing was decreased by 16 degrees (range 6 degrees to 30 degrees). Thirty-one achondroplastic children and adults were braced for back pain and/or neurologic deficits. Most were relieved of their symptoms to some degree. These and other data lead us to conclude that this form of treatment reduces deformity and alleviates symptoms.

Psychosocial services in rehabilitation medicine: an interdisciplinary approach.

Psychosocial adjustment to disability is an area of special need, often requiring intervention by mental health professionals, including social workers, psychologists, and psychiatrists. While the availability of all these disciplines is optimal for comprehensive psychosocial intervention, the use of multiple mental health disciplines may create problems of role confusion, overlapping efforts, and discontinuity of care. This paper presents the development of a psychosocial team as a method for identifying service goals, differentiating roles, coordinating psychosocial care, and educating rehabilitation staff on the expertise and proper use of the psychosocial disciplines. Four stages of team development are described: I. Identification of Purpose; II. Role Definition; III. Task Assignment; IV. Integration. A case example illustrates the functions of the interdisciplinary psychosocial team.

Scintigraphy for the detection and quantification of subglottic aspiration: preliminary observations.

Eleven patients with previously documented aspiration underwent a radioisotopic swallowing study to detect and quantify airway penetration. In those subjects able to complete a rapid-acquisition phase during swallowing, no laryngotracheal penetration was seen despite previous evidence of aspiration. However, sequential static pulmonary imaging showed significant aspiration in three individuals. Attempts were made to measure the percentage of ingested material aspirated and the clearance rate from the airways. Eight patients (73%) failed to show definite evidence of aspiration on scintigrams. It is hypothesized that the lack of scintigraphic detection in previously proven aspirators was due either to interval improvement of the dysphagia or to difficult-to-detect laryngotracheal aspiration. Isotopic imaging during swallowing appears to have little utility; however, after ingestion, the technique can demonstrate more distal penetration not detected on videofluoroscopy. More studies are suggested to better define the sensitivity and specificity of scintigraphy in aspiration detection and to determine whether these techniques have prognostic value that could alter patient management.

Dysphagia and expiratory air flow.

Expiratory air flow preserves the freedom of the upper airway from foodway contamination in patients with dysphagia. Valving the tracheostomy cannula, "quad coughing," the Heimlich maneuver, the "supraglottic swallow," and coupling to a ventilator each has a place among the measures used for treating aspiration.

The Swallowing Center: concepts and procedures.

This paper describes the purpose and organization of a dedicated center at The Johns Hopkins Medical Institutions for the evaluation of swallowing problems. The multidisciplinary approach outlined will permit a better understanding and more accurate diagnosis of the functional or organic lesions affecting the swallowing mechanisms. Illustrative cases are presented.