不錯的一份ppt 謝謝吳易澄同學

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. 10/11/15 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. 10/11/15 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. 10/11/15 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. 10/11/15 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. 10/11/15 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. 10/11/15 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. 10/11/15 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. 10/11/15 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. 10/11/15 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 ）