A 56-year-old patient experienced sudden headache and vomiting during lunch, and was diagnosed with stroke after being sent to the hospital with right hemiplegia and left facial nerve palsy. The most likely location of the lesion is the basal ganglia. Stroke patients with left hemiplegia and sensory loss, with better mobility in the lower limb than the upper limb, likely have a lesion in the middle cerebral artery. A 55-year-old male with sudden right hemiplegia and urinary incontinence was diagnosed with an embolic stroke; after two months, his right upper limb recovered nearly normally but his right lower limb remained weak, indicating a likely lesion in the internal carotid artery.

1. Rehabilitation 國考題 _CVA
R 吳易澄

3. 腦中風
Stroke

4. 腦中風
期末考最後一名，
我爸氣到中風…

5. • 一位 56 歲的病人在吃午餐時，突然發生頭痛
，隨即有嘔吐現象，送到醫院時發現其右側上
下肢無力，左側顏面神經麻痺，經臨床診斷為
腦中風，其最可能的病變位置在下列何處？
(101-2-65,100-2-56)
1.基底核（ basal ganglion ）
2.視丘（ thalamus ）
3.小腦（ cerebellum ）
4.橋腦（ pons ）

9. • 腦中風病人半側偏癱及感覺受損，患側下
肢動作明顯比上肢靈活，則病灶最可能在 ?
(95-1-55)
1.前大腦動脈（ anterior cerebral artery)
2.中大腦動脈（ middle cerebral artery ）
3.後大腦動脈（ posterior cerebral artery ）
4.脊椎動脈（ vertebral artery ）

10. • 一位 55 歲男性病人，突然發生右側肢體無力，小
便失禁，經診斷為梗塞性腦中風。經過兩個月後，
右上肢恢復到幾乎正常，但右下肢仍明顯無力，在
診斷上最可能是那一條血管梗塞？ (95-2-46)
• 前腦動脈（ anterior cerebral artery ）
• 內頸動脈（ internal carotid artery ）
• 基底動脈（ basilar artery ）
• 中腦動脈（ middle cerebral artery ）

11. • 圖中病人在復健科被教導依 ABCD 順序穿
上衣，病人最可能罹患下列何種疾病？ (98-
1-67)
• 左側大腦梗塞
• 右側大腦出血
• 左側腦幹出血
• 右側小腦腫瘤

14. • 49 歲男性，平時有高血壓，
突然右側肢體無力，
根據此緊急 CT ，則其診斷是： (95-1-96)
• 視丘出血性中風（ Thalamic hemorrhage ）
• 被殼出血性中風（ Putaminal hemorrhage ）
• 橋腦出血性中風（ Pontine hemorrhage ）
• 內囊出血性中風（ Internal capsular hemorrhage ）

17. 中風評估

18. • 下列何者不是常用來評估個人日常生活功
能之工具 ? (103-1-70)
1.布朗氏等級表 (Brunnstrom stage)
2.功能獨立評估表 (functional independence
measure)
3.巴氏量表 (Barthel index)
4.肯尼自我照顧評估表 (Kenny self care
evaluation)

19. • 腦中風半側偏癱的患者，其患側肢的手部
可以做出掌面抓握（ palmar prehension ）
的動作，依照布朗氏分期（ Brunnstrom’s
stage ）來判定，應該屬於第幾期？ (96-2-
57)
• Stage II
• Stage III
• Satge IV

20. • 下列何者不是腦中風病人發病半年內常見
的預後不佳因子？ (103-2-64)
1.坐姿不穩（ poor sitting balance ）
2.尿失禁（ incontinence ）
3.心智改變（ mental change ）
4.肢肌肉張力增強（ spasticity ）

21. • Poor prognosis associated also with:
– No measurable grasp strength by 4 weeks
– Severe proximal spasticity
– Prolonged “flaccidity” period
– Late return of proprioceptive facilitation
(tapping) response > 9 days
– Late return of proximal traction response
(shoulder flexors/adductors) > 13 days

22. • Brunnstrom (1966, 1970) and Sawner (1992) also described the process of
recovery following stroke-induced hemiplegia. The process was divided
into a number of stages:
• 1. Flaccidity (immediately after the onset)
No “voluntary” movements on the affected side can be
initiated.
• 2. Spasticity appears.
Basic synergy patterns appear.
Minimal voluntary movements may be present.
• 3. Patient gains voluntary control over synergies.
Increase in spasticity.

23. • 4. Some movement patterns out of synergy are mastered (synergy
patterns still predominate).
Decrease in spasticity.
• 5. If progress continues, more complex movement
combinations are learned as the basic
synergies lose their dominance over motor acts.
Further decrease in spasticity.
• 6. Disappearance of spasticity.
Individual joint movements become possible and
coordination approaches normal.
• 7. Normal function is restored.

24. Upper Lower Hand
I flaccid
II
spasticity developing
Associated
movement/reaction
• Little or no active
finger flexion
III
Synergy pattern
Muscle tone
• Triple
extension(lock
knee 、 tip
toe 、 ankle
inversion)
• Mass grasp
• Use hook grasp but
no release
• No voluntary
extension

25. Upper Lower Hand
IV
Block synergy
pattern
• Placing the hand
behind the body
• Elevated the
arm to 水平
• 屈肘可做
supination
坐著時
•Ankle dorsiflexed
•Knee isolated
extened
• Lateral
prehension( 夾虎口
動作 ) ， release by
thumb movement
• Semivoluntary
finger extension
V
Block synergy
pattern
• Arm-raised
forward and
overhead
• 伸肘可做
supination-
pronation
站著
•Ankle dorsiflexion
•Knee isolated flexed
•Ankle
Inversion/eversion
• Palmar prehension
掌面抓握
VI
只在 RAM o r 交替
動作異常
可以只動一隻手指

26. • 一位 2 歲的小女孩下肢肌肉有明顯的高張力痙攣
（ spasticity ），將踝關節作被動式背屈運動
（ passivedorsiflexion ）時，在大於 50% 的關節活動
度（ range of motion, ROM ）之中，肌肉張力有明
顯的增加，但是這些張力可以很容易被移除，根據
modified Ashworth scale ，分數大約為幾分？ (103-
1-55)
1. 1
2. 1+
3. 2
4. 4

28. Theories for stroke rehabilitation
• Brunnstrom theory
• PNF theory
• Motor relearning theory
• Bobath theory:
– NDT: Neural-Developmental Theory

29. 06/13/15 Jenny 29
Brunnstrom Theory
• Aim
– To encourage the return of voluntary movement in
hemiplegia patient through the use of reflex
activity and a range of sensory stimulation.
– The choice of stimulation varies depending on
which stage the patient has reached in the
recovery process.

30. Brunnstrom Theory
• Treatment
– The process is employed until the primitive
synergies are established, then facilitation is used
to develop some voluntary control.
– The preparation for walking should be
emphasized early but that extensive walking
should be postponed in order to avoid the
development of a poor gait pattern

31. 06/13/15 Jenny 31
PNF Theory
• Proprioceptive Neuromuscular Facilitation
• Primary for the patient with neuromuscular
dysfunction
• Aim
– to promote movement and functional synergies
of movement by maximizing peripheral inputby maximizing peripheral input

32. 06/13/15 Jenny 32
PNF Theory
• Basis of practice
– People who move normally have passed through a
developmental sequencedevelopmental sequence
– Diagonal and spiral patternsDiagonal and spiral patterns of active and passive
movements are encouraged
• Treatment
– Providing appropriate sensory stimulus
– Following activities in a developmental sequence
• Patterns and techniques

33. 06/13/15 Jenny 33
Motor relearning Theory
• By Carr and Shepherd
• Aim
– To enable the disabled person to learn how toto learn how to
perform or improve performanceperform or improve performance of actions critical
to everyday life.
– Utilizing theories of learningtheories of learning, in particular the use
of practice and knowledge of results to encourage
people to learn and self monitor
– Knowledge of biomechanics for analyzing
movements and performance of tasks

34. 06/13/15 Jenny 34
Motor relearning Theory
• Basis of practice
– The motor control of posture and movement are
interrelated and that appropriate sensory input will help
modulate the motor response to a task
– The program is based on
• Elimination of unnecessary muscle activity
• Feedback
• Practice
• The link between postural adjustment and movement
• Task analysis and measurement are viewed as
essential elements of the framework.

35. 06/13/15 Jenny 35
Motor relearning Theory
• Treatment
– Movement analysis and training follow the four steps
• Analysis of the task
• Practice of the missing components
• Practice of the task
• Transference of training
– A series of task has been chosen because learning by
normal subjects has been shown to be task-specific with
minimal carry-over from one activity to another

36. 06/13/15 Jenny 36
Bobath theory: NDT
• Aim
– To improve the quality of movement on the affected sidethe quality of movement on the affected side
– Key point controlKey point control is to allow patients the experience of
normal afferent input
• Basis of practice
– The movement will be abnormal if it stems from a
background of abnormal toneabnormal tone
– Performing abnormal movements will reinforce more
abnormal movements
– Tone could be influenced by altering the position or
movement of proximal joints of the body

37. 06/13/15 Jenny 37
Bobath Theory: NDT
• Treatment
– Treatment centre around the facilitation of
corrected movement by a therapist who handles
the body at key points of controlkey points of control
– In recent years treatment has become more activeactive
, dynamic and functionally directed, dynamic and functionally directed..
– Movement are not isolated to individual joints but
take place in patterns

38. 06/13/15 Jenny 38
Bobath theory: NDT
– To help the patient to gain control over the
released patterns of spasticity by their own
inhibition
• Auto-inhibition
– Give patient normal kinematics sensation input to
facilitated normal posture and movement
– Muscle strengthening is notnot viewed as part of
treatment
– There are no set “Bobath exercise”

39. 中風併發症

40. • 我們請某腦中風病人在每條橫線的中間點標示
記號（ bisection test ），結果如圖所示，這位
病人罹患什麼症狀？ (100-1-55)
• 左側偏盲
• 左眼眼盲
• 右側斜視
• 左側忽略

41. • 右側大腦中風的病人除了會造成左側肢體無力及 左
側感覺鈍化 (hypesthetic) 之外，也常常併發其他的
症狀，諸如左側忽略 (left neglect) 和左側偏盲 (left
hemianopia)
• 目前評估是否合併忽略症狀可使用
– confrontation test
– 仿畫測試 (copy test)
– spontaneous drawing test
– behavioral inattention test
– 線二等分測驗 (line bisection test)
– 刪除測驗 (cancel- lation test)

42. • 忽略是對受傷大腦對側的刺激察覺能力降低，罹患該症
的病人無法察覺左側物體的存在。
• 右側大腦中風的病人其視覺運用能力降低，除了忽略之
外尚有偏盲。
• 偏盲一般成因是由於眼睛視神經到視皮質的病變而造成
視野縮小或缺損的情況。
• 只有偏盲未合併忽略的病人可能以轉頭或轉動眼球的方
式代償來看見左側物品，病人若合併忽略症狀就沒有代
償能力。

43. • 有文獻指出，中大腦動脈支配區域發生病
灶會產生純忽略症 (pure neglect)
• 後大腦動脈支配的區域受損會產生純偏盲
症 (pure hemianopia)
• 中大腦動脈及後大腦動脈支配區域皆發生
病灶者即會產生兩種病症。

44. • 半邊忽略現象（ hemineglect ）是最常出現
於腦部何處之病變？ (97-1-55)
• 基底核（ basal ganglion ）
• 額葉（ frontal lobe ）
• 顳頂葉（ temporoparietal lobe ）
• 枕葉（ occipital lobe ）

45. • 下圖所示是病人在紙上畫出的房子、花和
時鐘，此病人有何種問題？ (96-1-58)
• 左側偏盲（ left hemianopsia ）
• 左側忽略（ left hemineglect ）
• 左側失用症（ left side apraxia ）
• 左眼眼盲（ left eye blindness ）

46. • 腦中風病人常發生患側肩關節疼痛僵硬等問題
，下列敘述何者錯誤？ (100-2-59)
• 腦中風病人約 70-80% 有肩關節問題
• 維持被動性關節活動與肩外展運動最為重要
• 急性期不可使用肩帶或吊帶，以免僵硬惡化
• 肩關節問題發生在病人痙攣期（ spastic
phase ）比無力期（ flaccid phase ）多

47. POSTSTROKE SHOULDER PAIN
• 70–84% of stroke patients with hemiplegia have
shoulder pain with varying degrees of severity.
• The majority (85%) will develop it during the
spastic phase of recovery.
• The most common causes of hemiplegic shoulder
pain are complex regional pain syndrome type I
(see below) and soft tissue lesions (including
plexus lesions).

48. • 腦中風病人容易併發反射性交感神經失養
症（ Reflex sympathetic dystrophy ），下列
何者不是其典型的症狀？ (100-2-57)
• 肩痛
• 手肘活動度受限
• 手腕水腫
• 手背皮膚變薄

49. Complex Regional Pain Syndrome
Type I (CRPS Type I)
• Also known as reflex sympathetic dystrophy
[RSD], shoulder-hand syndrome, or Sudeck
atrophy.
• Disorder characterized by
– sympathetic-maintained pain
– related sensory abnormalities
– abnormal blood flow
– abnormalities in the motor system
– and changes in both superficial and deep structures
with trophic changes.

51. Stages
• Stage 1 (acute): Lasts 3 to 6 months.
– burning pain
– diffuse swelling/edema
– exquisite tenderness
– hyperpathia and/or allodynia
– vasomotor changes in hand/fingers (increased nail
and hair growth, hyperthermia or hypothermia,
sweating).

52. Stages
• Stage 2 (dystrophic): Lasts 3 to 6 months
– pain becomes more intense and spreads proximally
– skin/muscle atrophy
– brawny edema
– cold insensitivity
– brittle nails/nail atrophy, decreased ROM,
– mottled skin
– early atrophy, and osteopenia (late)

53. Stages
• Stage 3 (atrophic):
– pain decreases
– trophic changes occur: hand/skin appear pale and
cyanotic with a smooth, shiny appearance, feeling
cool and dry
– bone demineralization progresses with muscula
weakness/atrophy, contractures/flexion
deformities of shoulder/ hand, tapering digits
– no vasomotor changes.

54. • 一位中風患者在復健過程中主訴肩關節疼痛，理學
檢查顯示肩關節半脫位（ subluxation ），下列相關
敘述何者最為正確？ (99-2-56)
• 使用三角巾將肩關節固定於內轉（ internal
rotation ）角度
• 常伴隨複雜性區域疼痛症候群第二型（ complex
regional pain syndrome type 2 ）的發生
• 可使用功能性電刺激於三角肌（ deltoid ）與棘上肌
（ supraspinatus ）
• 步行訓練時須將手臂置於身體背後

55. Shoulder Subluxation
Treatment
•Shoulder sling use is controversial.
– Pros: may be used when patient ambulates to support extremity (may prevent
upper extremity trauma, which in turn may cause increase pain or predispose
to development of RSD).
– Cons: may encourage contractures in shoulder adduction/internal rotation,
elbow flexion(flexor synergy pattern).
•Other widely used treatments for shoulder subluxation:
– Functional electrical stimulation (FES)
– Arm board, arm trough, lapboard—used in poor upper-extremity recovery,
primary wheelchair users.
– Arm board may overcorrect subluxation.
– Overhead slings—prevents hand edema (may use foam wedge on arm
board).

56. • 因慢性腦中風或腦性麻痺所引起的偏癱步
態（ hemiparetic gait ）不會有下列何項特
徵？ (101-1-56)
• 膝部外翻（ genu valgum ）
• 髖部環繞動作（ circumduction ）
• 上肢協同收縮（ co-contraction ）
• 足部內翻（ inversion ）