確胺皘洛畍の龟策洛畍
癡絤もの痜┬砏絛

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

            癩刮猭┌├洛皘狶だ皘

 

 

            確胺         絪

            洛厩 毙▅〆穦

 

い地チ瓣る璹

ヘ魁

1.確胺痜┬龟策洛畍毙厩癡絤璸购の戮砫.3

2.確胺痜┬皘洛畍毙厩癡絤璸购の斗...8

3.痜菌糶璶翴10

(1).Stroke..12

(2).Spinal cord injury..15

(3).Low back pain.17

4.確胺盽ǎ浪琩19

(1)EMG/NCV 竒肚旧硉/筿瓜浪琩20

(2)Soft tissue Ultrasonography 硁舱麓禬猧...20

(3)UrodynamicsЭ笆厩浪琩..20

(4)Gait Analysis˙篈だ猂..21

(5)Kincom Isokinetic Evaluation单硉蝶︳.23

(6)BMCA (Brain Motor Control Analysis) 笲笆北                 蝶︳.24

(7)Cardi-O2 Exercise Testみ笲笆代刚..25

5.確胺盽ǎ痚痜の矪竚虏ざ.26

1). Cerebrovascular Accident.27

2). Traumatic Brain Injury .29

3). Spinal Cord Injury 31

4). Amputee33

5). Orthopedic.36

6). Neurogenic Bladder...38

7). Physical Modality .47

8). Pressure sore..49

9). Autonomic dysreflexia..51

10). Functional independence measure...53

11). Cerebral palsy..54

12). Spasticity..59

13). Botox62

6.        Case conference 絛セ..64

7.        痜菌糶盽ǎ拜肈のэ到某...67

8.        毙厩膟...68

9.        確胺の闽ヘ戳ヘ魁...72

10.   痜┬矪竚砏絛...73

1). On foley...74

2). On NG tube feeding.79

3). EKG examination87

確胺痜┬龟策洛畍毙厩癡絤璸礶の戮砫

 

 

毙厩癡絤璸礶

1.癡絤ず甧

A.  確胺洛厩阀猵

B.  確胺洛励癘魁ぇ莱ノ

C.  畕も代刚

D.  闽竊笆ぇ代秖

E.  荐筿单祸竟ぇ芠集

F.  竒肚旧籔筿瓜ぇ芠集

G.  笲笆ネ瞶蝶︳ぇ芠集

H.  タ盽籔钵盽˙篈ぇ挪

I.  竒毁锚眞ぇ稰谋笲笆浪琩籔確胺

J.  癌ч籔闽竊砃ぇ確胺

K.  硁舱麓癌纅闽竊ぇ確胺

L.  も场ぇ確胺

M.  みぇ確胺

N.  や琜竡矪よ籔浪琩ぇ芠集

O.  瞶獀励膀セ瞶阶のよ猭

P.  戮獀励膀セ瞶阶籔よ猭

Q.   粂ē獀励膀セ瞶阶籔よ猭

 2.癡絤ず甧灿玥の厩砃笆

  1).羬龟策灿玥羬皘洛畍厩策皘痜眞ぇ矪瞶

翴

龟策兜ヘ

繵瞯

弧

璽砫洛畍

痜┬

1.把洛厩穦某

–秅ㄢΩ

²         把籔贬穦の龟策洛畍癡絤揭祘癚阶

秅と07:30

獀洛畍

羆洛畍

2.痜┬ǖ禘

–ぱΩ

²         把籔琩┬ǖ禘籔娩毙厩(–龟策洛畍蛤繦旧ぇ獀洛畍の皘洛畍秈︽)

 

3.钡穝

跌惠璶

²         籔皘洛畍钡恶糶锣の皘痜菌

 

4.痜菌糶

┮璽砫ぇ痜眞–ぱΩ

²         癘魁皘眞痜菌の–ぱ痜薄秈甶

 

5.洛篷矪瞶

跌惠璶

²         皘洛畍矪瞶洛篷秨ミ虫沮旧Э璆恨闽竊の竫猔甮

 

痁

1.矪瞶╆ぃ続

2.  矪瞶羬祇ネぇ猵

3.  钡穝皘の锣痜眞

ぱ痁(–る痁)

²         痁洛畍矪瞶痜猵

²         籔皘洛畍钡

²         皘洛畍矪瞶

 

 

 

2)  .毙厩笆龟策洛畍近秸材ぱ莱璽砫ぇ羆洛畍厨厨翴5G

             痜┬だ璽砫ぇ獀洛畍の皘洛畍–秅パ羆洛畍璽砫

             龟策洛畍毙▅揭祘把ぉセ兜毙▅笆

秅计

厩策ヘ夹

揭祘ず甧

璽砫

材秅

1.秆確胺吏挂籔盽砏

2.確胺や琜竡籹ざ残

 

²         吏挂の盽砏ざ残

²         洛畍à︹籔

²         瞶獀励ざ残

²         戮獀励ざ残

²         粂ē獀励ざ残

羆洛畍

3.福い皘痜眞獀励家Α

²         福い皘痜眞獀励

²         獀励璸礶砞﹚

²         盽ǎぇㄖ痝虏ざ

²         ㄖ痝ぇ矪瞶

獀洛畍

材秅

1.盆端痜眞ぇ獀励家Α

²         盆端痜眞獀励

²         獀励璸礶砞﹚

²         盽ǎぇㄖ虏ざ

²         ㄖ痝ぇ矪瞶

獀洛畍

2.ㄤ禘の皘痚痜虏ざ

3.確胺厩の祘狝叭いみ虏ざ

²         ㄠ担確胺

²         摸痥礹確胺獀励

²         摸癌闽竊痜確胺獀励

²         秆ヘ玡確胺龟喷

²         肈の闽祸竟ぇ虏ざ

羆洛畍

 

毙厩癡絤璽砫籔旧畍虫

1.毙厩癡絤璽砫 繟骸洛畍

2.旧畍獀洛畍

     把σゅ膍

1.   Krusen / Handbook of Physical Medicine and Rehabilitation

2.   Delisa / Rehabilitation Medicine : Principle and Practice

3.   Braddom / Physical Medicine & Rehabilitation

4.   Grabois/ Physical medicine & Rehabilitation: The complete approach

戮砫

1.痜┬

1).Ν边痜┬贝高痜眞冈灿癘更眞痜薄

2).盞ち猔種眞痜薄ぇ祇甶籔洛篷ぇ龟琁薄Τ疭跑て莱ミ厨皘洛畍┪羆洛畍矪瞶

  3).把ヴ獀洛畍羆洛畍の皘洛畍琩┬琩┬莱罙眞秈甶薄猵繦篕璶癘更痜菌洛畍矗厨

4).皘洛畍琩Lab data琩┬ǖ跌痜矪瞶洛篷on NGFoleystat and regular ICPresting EKG单

  5).ちづ︽秨ミ浪琩璶ノ媚筁LabSMA-12ぃ絋﹚叫叫ボVS┪R

  6).痜┬紀斌叫叭ゲだ摸メ斌╊絬芭鹅溅苃АΤ盡妮竚ICP/Foleyぇ10cc皐璶だ秨メ璝ぃ睲贰叫拜臔瞶

7).叫ぉVSのR癚阶籔痜┪產妮秆睦痜薄Τゲ璶玥洛畍叫ボよ眔ぇ

8).フ痁钡new patientぃ禬筁5玥10パ皘洛畍跌薄猵秸俱

9).穝皘痜眞斗ず盢痜菌瞶厩浪琩の浪琩ЧΘ莱赣矪竚璶皑秨ミorder磅︽

   -- Sciatica  patientbed side sustained pelvic traction

   -- CVA patientPT/OT/ST单

10).莱籔臔瞶のセ玂▆ぇ闽玒

2.痁

1).讽らAM 8:00 ~ 筳ら8:00だㄢ琿

 讽らAM 8:00- PM 4:00 磅︽┮Τ皘皘痜ICP

  PM 4:00- 筳らAM 8:00 籔痁

2).ゲ斗痙痁on duty

3).腨窽ㄖ痁笻眖腨某矪

4).痁钡New Patientぃ禬筁3玥5パ皘洛畍跌薄猵秸俱

5).璝Τㄆ斗传痁叭ゲ矗Ν硄臔瞶5G8Hの讽ら痁R斗竒CR︽ぇ荡癸窽ゎ传痁粇洛励

.痜菌糶

1)  .Progress note叭ゲぶ–ぱ糶Ω安らョ

2)  .秨order璶糶progress note弧

3)  .Admission / acceptation note叫宽酚痜菌糶璶翴硋兜癘魁 Native place膟砮璶糶

 

.厩砃笆

– W2W3 5G癚阶Τmeeting叭ゲ非畊畊癘魁

 Θ罿σ璶把σ

 W2 07:30 W3 07:30 Book Reading conference ┪Journal meeting & case conference

 

き.σ快猭

1.      パ皘洛畍の獀洛畍沮ら盽瞷meeting presentationの掸刚Θ罿∕﹚だσの蝶だ

2.      σず甧珹

癡絤ず甧

蝶糵兜ヘ

skill

knowledge

judgement

1.虏ざ確胺洛厩ぇ絛瞅の狝叭癸禜

 

v

v

2.把芠ざ残瞶の戮獀励ぇ祸竟の穨よΑ

 

v

v

3.贺近慈や琜確胺竟粄醚

v

v

v

4.福い痜眞ぇ蝶︳酚臮籔確胺

v

v

v

5.篊┦痚痜ぇ蝶︳籔確胺ヘ夹ぇ絋ミ

v

v

v

6.盆穕端痜ぇ蝶︳酚臮籔確胺

v

v

v

7.篒痜眞ぇ蝶︳酚臮籔確胺

v

v

v

8.確胺痜眞籋癡絤ぇмォ

v

v

v

9. 弄穦の弄阶ゅぇみ眔厨

v

v

v

10. 痜菌糶旧

v

v

v

確胺痜┬皘洛畍毙厩癡絤璸礶の斗

 

1.  確胺材皘洛畍癡絤翴の厩策兜ヘ

1)      皘痜眞羬禘励癡絤珹痚痜ぇ禘耞蝶︳獀励の確胺ヘ夹ぇミ

a.   福い

b.  盆穕端

c.   繷场端のㄤ福场痜跑

d.  癌纅ψ╰参

2)  .瞶獀励ぇ粄醚

戮獀励ぇ粄醚

粂ē獀励ぇ粄醚

や琜竡近慈ぇ粄醚

3)  .й弄穦ゅ膍厨癡絤

4)  .ACLS癡絤

5)  .毕м砃癡絤陈綤近癡

6)  .把籔厩砃癚穦

7)  .竒ず近癡癡絤

 

2.確胺材皘洛畍癡絤翴の厩策兜ヘ

1)      皘痜眞羬禘励癡絤珹福い盆穕端繷场端の癌纅ψ╰参单

2)  .筿厩禘耞顶癡絤

a.   筿瓜

b.  笲笆の稰谋护祇筿

c.   笲笆北蝶︳

3)  .徊ㄣ膀セ籹мォぇ粄醚の癡絤

4)  .й弄穦ゅ膍厨癡絤

5).毙厩癡絤

a.   ǎ策龟策洛畍

b.  確胺臔

6)  .近秸ㄤ竒み纽ず俱楞縎端单

7)  .把籔洛厩╯˙癡絤

8)  .把籔厩砃癚穦

 

3.確胺材皘洛畍癡絤翴の厩策兜ヘ

1)  .兜確胺癡絤ぇ眏

2)  .酚穦癡絤

a.   CVA

b.  SCI

c.   Orthopedic

d.  ず╰

e.   Pediatric

f.    ╰の端

3)  .禘痜禘励癡絤

4)  .seminar

5)  .筿厩禘耞弄

6)  .硁舱麓禬猧巨の弄

7)  .Э笆厩巨の弄

8)  .A.ネ厩

a.   ˙篈だ猂

b.  单硉蝶︳

c.   ì┏溃

B. 笲笆ネ瞶蝶︳

7)  .毙厩旧ǎ策龟策洛畍の確胺臔ぇ毙厩

8)  .把籔洛厩阶ゅ╯

9)  .把籔厩砃癚穦

4. 確胺材皘洛畍癡絤翴の厩策兜ヘ

1)  .兜確胺癡絤ぇ眏の膥尿癡絤

a.   穦禘

b.  禘

c.   兜浪琩の確胺洛厩祘

2)  .︽現癡絤逼痁穦某洛畍の痜┬秸单

3)  .ACLS癡絤

4)  .毙厩旧皘洛畍のǎ策龟策洛畍確胺臔ぇ毙厩

5)  .阶ゅ矗厨

6)  .把籔厩砃癚穦

7)  .確胺獀励痜眞ぇ蝶︳の璸购璹﹚

痜菌糶璶翴

 

1.  痜菌癘更筿福糶

2.  皘禘耞Final Diagnosis

1)  .皘ら戳獀洛畍帽彻ゲ斗Ч俱

2)  .程禘耞ゲ斗籔皘痜菌篕璶厚虫ぇ皘禘耞璓

3)  .タ絋ぃノDittoの虏糶

3.  拜肈旧Problem Oriented Sheet

  拜肈祇ネの矪瞶よ猭絋龟恶糶

4.  皘痜菌篕璶Discharge Summary

1)  .痜膀セ戈皘锣の皘ら戳ゲ斗Ч俱

2)  .皘の皘禘耞絋龟恶糶ぃノDittoの虏糶

3)  .–逆А絋龟恶糶ぃフゼ浪琩兜ヘ糶Nil

4)  .皘獀励竒筁ゲ斗爹獀励玡ぇ痜猵祇甶Brunnstromˇs stagefunctional status单

5)  .皘ボ逆ゲ斗爹皘ぇノ媚の琌OPD F/U

6)  .獀洛畍の皘洛畍帽彻ゲ斗Ч俱

5.  洛篷虫Order Sheet

1)  .埃候猵ゲ斗ㄏノ筿福洛篷

2)  .洛篷Τ粇ゲ斗ㄌ砏﹚эぃ额эよΑぇ

3)  .羬の戳洛篷ぇ癬﹍逆ゲ斗タ絋

4)  .皘ぇ猵の禘丁ゲ斗恶糶

5)  .┮Τ洛篷А斗Τ皘洛畍┪獀洛畍帽

6.  皘癘魁Admission Note

ゲ斗珹兜

Chief Complaint

Present Illness

Past History

Family History

Physical Examination

Neurological Examination

Laboratory Data璝礚浪喷玥糶not available

Impression

Plan

7.  痜祘癘魁Progress Note

1)  .–ぱ糶Ω珹安ら

2)  .锣ゲ斗恶糶Transfer NoteのAcceptance Note

3)  .獀洛畍琩┬ぇcomment斗癘魁

4)  .獀洛畍–秅程ぶ斗帽ㄢΩ

8.  浪喷癘魁虫Laboratory Sheet

絋龟癘魁恶糶

 

Date  /  /  REHABILITATION ADMISSION/ACCEPTION NOTE CNS lesion

 

CHIEF COMPLAINT:

 

PRESENT ILLNESS:                           Native place:__________

 

 

 

 

PAST HISTORY:previous( )stroke/( )HI/( )Trauma Hx.during_____Ys/Ms/Ds ( )DM ,( )H/T,( )HEART DIS,( )BRAIN DIS,( )LIVER DIS,( )KIDNEY DIS,

( )RESPIRATORY DIS,( )INFECTIOUS DIS,( )ALLERGY,sequalae:_________

 

PERSONAL HISTORY:

( )smoking:____PPD,___Ys/Ms/Ds;( )Alcohol drinking____C/B, Ys / Ms/ Ds; ( )Chineseherbs:____Pkg___ Ys/Ms/Ds;OTHER:________.

 

FAMILY HISTORY:

( )DM ,( )H/T,( )HEART DIS,( )BRAIN DIS,( )LIVER DIS,( )KIDNEY DIS,

( )RESPIRATORY DIS,( )INFECTIOUS DIS,( )ALLERGY,sequalae:_________

 

PHYSICAL EXAMMINATION:

Vital sign:T___,P___,R____,B/P___/___mmHG.

HEENT: ( )gross normal,( )abnormal;conjunctiva,( )pale;sclera:( )icteric

Neck: ( )supple/( )rigid;( )JVE;( )LAP;( )goiter;( )bruit

Chest:symmetric expansion(+/-) breathing sound: ( )clear;( )coarse;( )wheezing;

( )rales.

Heart: ( )RHB,no murmur noted;( )irregular,______________

Abdomen: ( )soft & flat;( )tenderness;Bowel sound: ( )normal,( )hyperactive,

 ( )hypoactive.

Extremities: ( )freely movable /( ) hemiplegia/ ( )paraplegia;( )cyanosis; ( )clubbing ;( )pitting edema.

 NEUROLOGICAL EXAMINATION:

   CONSCIOUSNESS: ( )clear & alert,( )drowsy GCS:E__V__M__

   MENTAL STATUS:JOMAC: ( )good,( )fair,( )poor.

CRANIAL NERVE:

 CN I : sense of smell: ( )intact,( )not testable,( )abnormal__________

 CN II:visual acuity & field: ( )intact,( ) abnormal__________

 CN III IV VI:eyelids: ( )intact,( )ptosis,( )retraction,( )blepharospasm,describe:______

 PUPILS                                  

ITEMS

R'T

L'T

size(mm)

 

 

shape

 

 

light reflex(D)

 

 

light reflex(I)

 

 

 

EOM      RˇT       LˇT

 

CN V:facial skin sensation : ( )intact,( )not testable,( )abnormal__________

      corneal reflex: ( )RˇT/( )LˇT.

CN VII:facial palsy: ( )central, ( )peripheral.

CNVIII: hearing impaired: ( )intact,( )not testable,( )abnormal. ( )RˇT/( )LˇT/( )BIL

       Nystgmus:

CN IX XXII:gag reflex( )RˇT/( )LˇT,uvula deviation--( )RˇT/( )LˇT.

           swallowing: ( )intact/on NG/( )dysphagia( )liquid,( )soild

           motor control of tongue: ( )intact,( )not testable,( )abnormal__________

CN XI:turning head (sternocleidomastoid): ( )intact,( )not testable,( )abnormal_____

      shrugging shoulder(trapezius)-- ( )intact,( )not testable,( )abnormal

      describe:________________

 

MOTOR FUNCTION

Brunnstrom stage:

ITEMS

R'T

L'T

upper limbs(p)

 

 

upper limbs(d)

 

 

lower limbs

 

 

SENSORY

DTR

ANS FUNCTION:sphincter tone: ( )intact,( )flaccid,( )hyper.

                ( )bulbocavernous reflex; ( )anal reflex

              Urine:( )retention/( )incontinence;Stool:( )impaction/( )incontinence

 

FUNCTIONAL STATUS

 (1.total assist,2.partial assist 3.supervision,4.independence)

   ( )personal care,( )rolling,( )sitting,( )standing,( )transfer,( )ambulation:

   (wheelchair,walk) with/without device.

SPEECH   ( )fluency,( )comprehension,( )repetition,( )naming.(+:intact,-:impaired)

   if aphasia,describe:________________________________

SPECIAL EXAM FINDING:

 

IMPRESSION:

 

REGAB GOAL:

 

PLAN:

 

Date  /  /  REHABILITATION ADMISSION/ACCEPTION NOTE    SCI

 

CHIEF COMPLAINT:

 

PRESENT ILLNESS:                   Native place:__________

 

 

PAST HISTORY:previous paraplegia/quadriplegia Hx( )________year ago;DM( ),

H/T( ),HEART DIS( ),BRAIN DIS( ),LIVER DIS( ),KIDNEY DIS( ), RESPIRATORY DIS( ),INFECTIOUS DIS( ),ALLERGY( ):

PERSONAL HISTORY:

Smoking:____PPD___yrs;alcohol drinking____cup/bottle___yrs Chineseherbs:____Pkg___yrs.

FAMILY HISTORY:

PHYSICAL EXAMMINATION:

 Vital sign:

 General appearance:

 HEENT:gross normal( ),trauma( ),deformity( ),conjunctiva:pale( ),sclera:icteric( )

 Neck:supple( ),or rigid( ),JVE( ),LAP( ),goiter( ),bruit( ),if(+):

 Chest :symmetric expansion(+/-) breathing sound:clear( ),coarse( ),wheezing( ),

       rales( )if(+):

 Respiratory condition: breathing pattern:normal( ) if abnormal refer to special sheet.

 Heart:regular heart beat,no murmur noted( ),if(-):

 Abdomon :soft & flat( ),tenderness( ),Bowel sound:normal( ),hyperactive( ),

          hypoactive( )

 Extremities:freely movable( ),cyanosis( ),clubbing( ),pitting edema( )

Skin:dryness( ),dehydration( ),pressure sore( ) if(+):location___________, grade_______________

NEUROLOGICAL EXAMINATION:

  CONSCIOUSNESS:clear & alert ( ),drowsy GCS:E__V__M__

  MENTAL STATUS:JOMAC (good or poor)

 

  MUSCLE POWER:

 

UPPER

RT

LT

RT

LT

LOWER

LIMB

 

 

 

 

LIMB

C5

 

 

 

 

L2

C6

 

 

 

 

L3

C7

 

 

 

 

L4

C8

 

 

 

 

L5

T1

 

 

 

 

S1

 

  SENSORY:

  POSITIONAL SENSE:

  DEEP TOUCH:

  DTR:

 

ANS FUNCTION:Sphincter tone:flaccid( ),normal( ),hyperactive( )

                Bulbocavernous reflex( ), anal reflex( )

                Urine (retention/incontinence),Stool (impaction/incontinence)

FUNCTIONAL STATUS (0.not testible.1.poor 2.fair 3.good )

        rolling( ),siting( ), standing( ),ambulation(with/without) device( )

ADL:dependent( ),partial dependent( ), partial independent( ), independent( ),

SPECIAL EXAM FINDING:

 

IMPRESSION:

 

GOAL:

 

PLAN:

 

Date   /   /   REHABILITATION ADMISSION/ACCEPTION NOTE  LBP

 

CHIEF COMPLAINT:

PRESENT ILLNESS:

 

 

 

PAST HISTORY:

  Previous (  )trauma/(  )back pain Hx.during         Ys/Ms/Ds

  (  )DM;(  )H/T;(  )Heart dis.;(  )Brain dis.;(  )Liver dis.;

  (  )Kidney dis.;(  )Respiratory dis.;(  )Infectious dis.;(  )Allergy

  Sequelae:                                                   .

PERSONAL HISTORY:

  (  )Smoking   PPD         Ys/Ms/Ds,

  (  )Alcohol drinking   cc/Bt         Ys/Ms/Ds

  (  )Chinese herbs   pkg         Ys/Ms/Ds

  Others:                                                     .

FAMILY HISTORY:

  (  )DM;(  )H/T;(  )Heart dis.;(  )Brain dis.;(  )Liver dis.;

  (  )Kidney dis.;(  )Respiratory dis.;(  )Infectious dis.;(  )Allergy

  Sequelae:                                                   .

PHYSICAL EXAMINATION:

  Vital sign: T   P   R   ,BP   /   mmHg

  HEENT: Grossly (  )normal/(  )abnormal

         Conjunctiva(  )pale;Sclera(  )icteric

  Neck: (  )Supple/(  )Rigid;(  )JVE;(  )LAP;(  )Goiter;(  )Bruit

  Chest: Symmetric expansion(+/-)

         BS:(  )Clear/(  )Coarse,(  )Wheezing,(  )Rales

  Heart: (  )RHB/(  )Irregular

         Murmur(+/-):Gr      over                             .

  Abdomen: (  )Soft♭ (  )Tenderness

           Bowel sound:(  )normal/(  )hyperactive/(  )hypoactive

  Extremities: (  )Freely movable/(  )Hemiplegia/(  )paraplegia

            (  )Cyanosis;(  )Clubbing;(  )Pitting edema;

            (  )Intermittent claudication

            Walking on toe:R(  )/L(  ); Walking on heel:R(  )/L(  )

            SLRT:R   /L   ; Crossed SLRT:R(  )/L(  )

            Fabere test:R(  )/L(  )
  Back: (  )Scoliosis spine; (  )Pelvic tilt; (  )SI joint tenderness

        (  )Knocking pain; (  )Night pain

        Trigger point over                              .

  ROM: (  )C-/L- spine forward bending   ,pain(+/-)

                       backward extension   ,pain(+/-)

                       lateral bending   ,pain(+/-)

NEUROLOGICAL EXAMINATION:

  Consciousness: (  ) clear & alert/(  )drowsy(  ); GCS:E   M   V  

  Mental status: JOMAC: (  )good/(  )/fair/(  )/poor

  Muscle power:

  Sensory:

  DTR:

  ANS function: Sphincter tone: (  )intact/(  )flaccid/(  )hyper

               (  )Urine/(  )Stool (  )Continence/(  )Incontinence

FUNCTIONAL STATUS: (1:total assist, 2:partial assist, 3:supervision, 4:independence.)

  (  )Personal care;(  )Rolling;(  )Sitting;(  )Standing; (  )Transfer

  (  )Ambulation: (  )Wheelchair/(  )Walk (  )with/(  )without device

SPECIAL EXAM.FINDINGS:

IMPRESSION:

REHAB.GOAL:

PLAN:

 

確胺盽ǎ浪琩

 

EMG/NCV 竒肚旧硉/筿瓜浪琩

Soft Tissue Ultrasonography 硁舱麓禬猧

UrodynamicsЭ笆厩浪琩

Gait Analysis˙篈だ猂

きKincom Isokinetic Evaluation单硉蝶︳

せBMCA (Brain Motor Control Analysis) 笲笆北蝶︳

Cardi-O2 Exercise Testみ笲笆代刚

 

EMG/NCV 竒肚旧硉/筿瓜浪琩

筿瓜浪琩筿禘耞厩场ウㄤ龟琌竒肚旧硉浪琩Nerve Conduction Velocity, NCVの皐伐筿瓜Needle Electromyography, Needle EMGㄢ兜浪琩虏嘿璶ノㄓ羬洛畍禘耞竒のψ╰参よ痚痜

(1). 竒肚旧硉浪琩Nerve Conduction Velocity, NCV

    ノ筿縀琘兵竒パ筿縀矪竒狠癘魁筿伐钡Μ竒肚旧筿猧┮惠丁の┮ǐ禯瞒传衡竒肚旧硉狦竒Τ痜跑┪溃竒肚旧硉穦獽篊猧э跑

(2). 皐伐筿瓜浪琩Needle Electromyography, Needle EMG

    ノ皐伐ψ癘魁ψ繰ゎのΜ罽筿笆и匡拒兵ψㄓ﹚竒ψ痜跑ぇ疭┦场絛瞅の腨Τㄇ痜眞ぃ続暗兜浪琩珹1.Τ﹀渡狝ノк井﹀警┪﹀ね痜眞2.钵盽┪Τ╰参┦稰琕3.Τみ纽盲饯钵盽┪盲饯竚传

 

Soft Tissue Ultrasonography 硁舱麓禬猧

ノ蔼秆猂龟丁(high-resolution real-time)ぇ蔼繵禬猧秈︽ψ癌纅╰参硁舱麓禬猧浪琩浪琩絛瞅珹▂得闽竊㏄娩硁舱麓芺渐斤闽竊㏄娩硁舱麓ㄠ弊繴单皐癸竫祇┪耞吊﹀竳竳紽ミ陪钩ぇ紇钩禘耞ノ眒︹常扒禬猧Color Duplex Sonography, CDSだ猂硁舱麓ず﹀恨だの﹀瑈硉

 

UrodynamicsЭ笆厩浪琩

Э笆厩浪琩セノ竒┦籋neurogenic bladder浪琩浪琩兜ヘ珹

(1).籋溃瓜cystometry, CMGH2Oい单硉拈猔籋蝶︳籋

   拈猔ぇ甧秖籔溃跑て薄罙秆代籋稰谋眏sensitivity

   铆﹚stability続莱┦complianceのΜ罽contrctility

(2).珹筿瓜sphincter electromyography, sphincter EMG筿瓜

   筿伐癘魁▃㏄瞅ぇψ笆薄

(3).Э笵溃瓜urethral pressure profile, UPP俱兵Э笵ず溃籋

   繰ゎ篈┮代眔嘿繰篈Э笵溃瓜static UPP逼Э┮代眔

   嘿笆篈Э笵溃瓜dynamic UPP

 

Gait Analysis˙篈だ猂

    ˙篈だ猂璶Τ╰参

暏  (1)丁˙篈だ猂╰参

暢  (2)硈尿┦ì┏溃˙篈だ猂╰参

    (3)ì┏溃代秖╰参(Foot pressure)

 

(1).丁˙篈だ猂╰参

丁˙篈だ猂╰参(Gait Analysis System)1.夹粁╰参(marker system)Τ笆祇夹粁の砆笆は夹粁р笲笆瓂格陪ボㄓ2.尼紇诀盢笲笆瓂格癘魁ㄓ璝璶弘絋だ猂丁笲笆ぶ璶Τ4~5 场尼紇诀˙癘魁 3.筿福のだ猂笲衡硁砰: Τ贺砞称獽冈龟だ猂笲笆篈硂碞琌┮孔笲笆厩 (kinematics)だ猂4.代狾(force plates)Τ㏕﹚代狾遏 5.筿瓜(electromyography)代笲笆俐丁琘场ψタノのノ癸祘Τぶ皌代狾笆厩(kinetics)だ猂代秖闽竊┮┯痻

続ノ絛瞅珹

    1.獀励玡蝶︳览﹚程獀励家Α:

    I.福┦陈肤眞福┦陈肤眞パも砃э到笲笆程Τì秈 甶硂よ˙篈だ猂ш簍帝讽璶à︹虑パ˙篈だ猂и笵˙︽讽いê兵ψΤぃタ盽は莱┪琌闽竊笆┦沮ち耞ㄤ竒や皌┪琌盢ψ锣ㄏ眞莉眔タ盽˙篈の耕笲笆II.癌よ洞盿穕端┪癌ч瘤竒も砃確˙篈だ猂矗ㄑ┦浪琩匡ノも砃よΑэ秈˙篈だ猂常ㄣΤ砃玡蝶︳箇 代砃Θ狦 III.俱砰も砃よ IV.媚╯よぃ媚舱癸ぺ此ん痝(Parkinsonism)笲笆 э到み纽癐很眞竒媚獀励˙︽秖薄都皊秖癸 ˙︽铆﹚Τ紇臫......单

    2.竡罛ㄣ徊竟瘪砞璸莱ノ籔癡絤

    3.箇ň洛厩籔瑈︽痜厩よи笵禴Θρ材繧虑˙篈だ猂т旧璓禴繧Ν戳逼埃硂ㄇ甧禴倒ぉρ続讽矫毙癡絤ら盽ネ秸続┪皌ぉ˙︽徊竟瘪┪パ酚盢碩產畑の穦璽踞皐癸璂闽竊笲笆端甡Ы场﹀睪碻吏单痚痜籔ネ厩贝癚タ硋亥酱玨祇甶


 

(2).硈尿┦ì┏溃˙篈だ猂

    硈尿┦ì┏溃˙篈だ猂(computer dynography, CDG)琌甅˙篈だ猂╰参,ウ镑代秖代˙︽ì┏溃硈尿跑て秈τだ猂˙︽铆﹚┦癸嘿┦の璽だ薄

CDG程ノ菏代刚˙︽いみ锣簿铆﹚┦ㄢ竲˙篈癸嘿┦ì┏璽のだ薄τ硂ㄇ戈癸羬洛畍蝶︳痜˙篈Τ腊癸竒╰参よ痚痜い┪ㄤい枷竒㏄娩竒痜跑癌纅闽竊╰参痚痜闽竊ま癬痥礹癌чぃ▆隆 硑Θㄢ竲ぃ单贺闽竊も砃┪ψ竫洞盿单硁舱麓拜肈常ノCDGウ癸˙篈硑Θ紇臫ノㄓ蝶︳獀励狦癸癌чも砃ガ︽璽薄ノCDG暗﹚秖代秖硁舱麓も砃ブ盲单痜も砃˙︽ョノCDG暗蝶︳ 媚癸痜笲笆北┪ψ眎紇臫ノCDGㄤ˙篈э跑˙篈毁锚痜確胺筁祘い˙篈秈˙薄ノCDG痙癘魁癸贺ぃ竡杆ㄣ徊竟狦ノCDG暗芠ゑ耕

 

(3)ì┏溃代秖╰参(Foot pressure)

ì┏溃代秖蹦EMED╰(Novel Gmbh, Munich, Germany)ぇPEDAR-system癘魁ì┏溃だ跋办EMED╰参ㄤ砞称蛮綾乖ぇ溃稰莱竟(sensors)ㄤ–キよそだΤ溃稰莱竟ノㄓ代秖代ミ┪︽ǐ┮ 玻ネぇì┏溃跑て薄竒旧絬肚癳癟腹硈ぇ筿福竒┮硁砰秈︽戈俱瞶籔だ猂眔闽ぇ溃だ计籔瓜
きKincom Isokinetic Evaluation单硉蝶︳

(1)单硉祸

单硉祸莱ノ約獂ψ癌纅╰参蝶︳の癡絤ヘ玡ョ崩約竒ψ╰参蝶︳の癡絤矗ㄑ眞冈灿蝶︳の獀励セ╯Kincom单硉祸ㄑ羬╯蝶︳の獀励

(2)癡絤

癡絤沮璽颤笲笆硉のψΜ罽盢癡絤だ贺

1.        单笲笆(isometric exercise)单笲笆ボ笲笆筁祘いψ蝴ぃ跑羭匡も羭ㄤ繷㎝繷常ΤΜ罽ノㄤ纔翴琌甧磅︽の闽竊笆ㄏノ

2.        单眎笲笆(istonic exercise)单眎笲笆琌笲笆筁祘い┮┯璽颤㏕﹚纔翴砞称虏虫甧琁︽笆篈┦癡絤

3.        单硉笲笆笲笆筁祘い硉蝴﹚单硉笲笆ㄤ癡絤沮癡τ﹚ョ癡ㄤ玂笲笆硉眖眔ョ瞷癡笆篈┦

(3)羬莱ノ

羬蝶︳の╯单硉祸ぃ度蝶︳ψ秖ョ蝶︳ψ瑻ウ矗ㄑ砛芠计沮畃痻Ρ絬羆秖キА瞯の瑻ゑ单パ单硉代刚┮眔计沮ㄣΤ蔼獺の蔼珿続暗羬蝶︳の╯

(4)单硉笲笆疭┦

1.Τ┦2.┦3.秸続┦单硉祸沮癡ψΜ罽倒ぉ続讽秸続┦4.闽竊ず5.糤闽竊緄だㄑ倒6.ネ瞶犯瑈瞷禜(physiological overflow)单硉笲笆蔼硉┮眔糤ョ锣簿硉糤眏7.硉眯癡絤(velocity spectrum training)ぃ硉皌ㄓ暗癡絤璸礶糤贺硉才ら盽ネ┦惠―8.芠┦癹鮔9.笲笆端甡箇ňの笲笆匡も縵匡
せBMCA (Brain Motor Control Analysis) 笲笆北蝶︳

 

ㄓ笲笆赤ア┪毁锚確胺洛厩烩办い羬獀励祇甶常玗ㄇ肚参┦獀励мォの纕┦惫琁笲笆ぃ镑瞶稱ㄤい闽笲笆北╯㎝蝶︳玥琌ヘ玡伐荐Τ辨瘆瞺繴厩砰笲笆北埃い枷癘拘㏄娩笲笆稰谋璶ㄓ癌纅ψ濒(muscle spindle)㎝蔼膀竫竟﹛(Golgi tendon organ)ㄓ稰笲笆┮惠硂贺稰谋ノ秸竊秈︽い笲笆まΩヴ叭磅︽┮笲笆北琌ノい枷玡竚璸购е硉耞㎝秸俱莱ノ㏄娩稰谋癹鮔非絋タ㎝磅︽τ程笲笆мォ矗狜玥璶綼ぃ耞竒喷㎝厩策

 

羬璶┦

笲笆北蝶︳羬璶┦疭い枷竒穕端確胺獀励パい枷竒穕端繷场端い┪盆穕端单硑Θ逞摧緇笲笆北璓ㄏ玻ネぃ▆墩㎝笆礚猭Τ北祇甶ぃ▆北家Α秈τ紇臫笲笆箇┮Ν戳秈︽福笲笆北蝶︳(brain motor control assessment, BMCA)皐癸ㄤ笲笆瞷翴览タ絋獀励よ竒パ瞶㎝戮獀励痜Ν戳ミ穝Τ笲笆北玻ネ穝タ絋墩㎝笆舱筀ゎぃ▆北家Α㎝墩笆舱
.Cardi-O2 Exercise Testみ笲笆代刚

 

笲笆膀セㄣ琌ψ砰の笲笆瞷琌瞏紇臫ㄤい珹秖块瞯(珹Τ㎝礚秖)闽竊笆琗硁竒ψ秸мォ籔み瞶单紇臫砰竒筁笲笆癡絤玻ネ┦の篊┦ネ瞶跑て玡琌笲笆讽いの笲笆ō砰┮玻ネ贺贺钵ヰ篈ネ瞶瞷禜琌ō砰竒筁琿丁は滦笲笆縀┮玻ネネ瞶跑て笲笆獀励確胺獀励癡絤い璶吏ゲ斗罙秆み癌纅ψ单疭┦芠の厩て祸竟ㄓ代﹚ㄤ程絛瞅矗ㄑ痜眞タ絋砰癡絤よ猭の璶烩ㄏ祇揣笲笆獀励程箇戳狦

 

み代刚よ猭

    代刚程尼秖祸竟贺摸珹秸俱硉の℡糹盿Α禲˙诀秸俱Α玡近璽颤竲今óも穘óの竲穘ó㊣砰Μ栋杆竚贺摸よ珹砰Μ栋砋旧恨の栋竛盢Μ栋て阂の緻竒筁夹非そΑ传衡Θ砰砰縩τ代眔笲笆尼秖確胺痜眞福い盆穕端篒单痜眞ㄤ砰笆毁锚┪摧礚猭ノ禲˙诀代刚ㄣ珿福い痜眞ㄏノ竲今ó┪竲穘ó代刚ㄣパ贺笲笆熬ψ笆τψ笆秖ぶ代眔程尼秖ゑㄏノ禲˙诀キАぶ5%オ代刚玡絋玂痜眞の舦痲ゲ斗琵痜眞秆代刚ヘの繧┦

 

羬莱ノ:

1.福﹀恨痜跑沮参璸福い痜眞い60%ㄖΤみ纽﹀恨痚痜硂ㄇ痜眞逼笲笆獀励璸购ぇゲ斗みτ砰笆毁锚礿潘捌れㄏノ单ㄏ痜眞˙︽┮ㄏノΘセ(oxygen cost)眖0.15糤0.54ml/kg-mオ続讽笲笆癡絤э到み猵﹀溃北单

2.籔˙篈闽玒Θ滴続キ铆薄猵タ盽˙︽硉–だ牧70~80そへ秖–そょ砰惠12睝どパ確胺い篒痜眞盆穕端福┦陈肤ㄠ担ㄤ砰摧礚┪北ぃ▆珿ㄤ˙︽螟糤癸τē硑Θ˙︽硉搭絯の秖糤確胺˙︽癡絤莱眖э跑钵盽˙篈┪糤の秸甄ぶ˙︽い秖穕

3.笲笆洛厩烩办い程尼秖籔琘ㄇ笲笆兜ヘい禯瞒辽禲村猘单笲笆Θ罿瞷Τ盞ち闽玒癸硂贺惠璶尿┦方ㄑ莱笲笆兜ヘ程尼秖禫蔼笲笆ㄤ瞷莱纔钵

 

確胺 盽 ǎ 痚 痜の矪竚虏ざ

 


CEREBROVASCUAR ACCIDENT

 

1.      Definition:

   a sudden neurological deficit characterized by loss of motor control, altered sensation, cognitive or language impairment, and disequilibrium or coma, caused by nontraumatic brain injury resulting from occlusion or rupture of cerebral blood vessels

 

2.      Classification:

1). Hemorrhagic:

(1)   .ICH (Intracerebral Hemorrhage): HTN, tumor, AVM

(2)   .SAH (Subarachnoid Hemorrhage): AVM or aneurysm rupture

2). Ischemic:

  (1).Thrombosis: atherosclerotic cerebrovascular disease at major vascular branching site, often associated with HTN

  (2).Embolism: mostly from cardiac origin(e.g.atrial fibrillation)

     (3).Others: cerebral vasculitis or cerebral hypoperfusion eg. SLE

 

3.  Risk factor

--Major risk factors

Age

Hypertension

Cardiac disease

Diabetes

  Previous stroke or transient ischemic attack

 

4.Stroke-related impairment

1). Motor control and strength

2). Motor coordination and balance

3). Sensation

4). Language and communication

5). Apraxia

6). Neglect syndrome

7). Dysphagia

8). Uninhibited bladder and bowel

 

5.Brunnstromˇs staging

--for evaluation of the motor condition of brain lesion

Stage  I : Flaccid

Stage II : Associated reaction

        Spasticity(+)

        DTR(+) 

Stage III: Start of voluntary movement with synergy

        Spasticity(+)

        DTR increase

Stage  IV: Voluntary movement with break of synergy

          Spasticity(+)

          DTR increase

Stage  V : Voluntary movement with less synergy than stage IV

          Spasticity decrease

          DTR may return to normal or remain increased

          Fine movement(+)

Stage  VI: Nearly normal

          No spasticity

 

6.  Ashworth Scale

0=normal tome

1=slight hypertonus, a ¨catch〃 when limb is moved

2=miod hypertonus, limb moves easily

3=moderate hypertonus, passive limb movement difficult

4=severe hypertonus, limb rigid

 

Functional condition:

1.  sitting balance: good; fair; poor

2.  standing balance: good; fair; poor

3.  walking balance: crutch; walker; cane; stick; etc.

4.  ADL (activity of daily living):

        Independent; partial dependent; partial independent; dependent

TRAUMATIC BRAIN INJURY

 

1.  Definition: all injuries to the brain caused by trauma

 

2.Subtypes of brain injury

1)  .Traumatic brain injury

(1)   .Closed head injury: dura remained intact

(2)   .Open head injury: dura was opened

(3)   .Penetrating head injury: a foreign object penetrated the dura and entered the brain

2)  .Nontraumatic brain injury

(1)   .Stroke

(2)   .Anoxic brain injury(hypoxic encephalopathy)

(3)   .Toxic brain injury and metabolic brain injury

 

3.  Assessment

1)  .Glasgow coma scale (GCS)

Patientˇs Response

Score

Eye opening

  Eyes open spontaneously

  Eyes open when spoken to

  Eyes open to painful stimulation

  Eyes do not open

Motor

  Follows commands

  Makes localizing movement to pain

  Makes withdrawal movements to pain

  Flexor(decorticate)posturing to pain

  Extensor(decerebrate)posturing to pain

  No motor response to pain

Verbal

  Oriented to place and data

  Converses but is disoriented

  Utters inappropriate words, not conversing

  Makes incomprehensible nonverbal sounds

  Not vocalizing

 

4

3

2

1

 

6

5

4

3

2

1

 

5

4

3

2

1

 

  2). Severity of TBI

Mild

 

 

 

 

 

Moderate

Severe

GCS score of 13-15 at lowest point after resuscitation

 Additional criteria:

1.  Loss of consciousness<20min

2.  No TBI-related abnormalities on neurological exam.

and normal CT scan of the brain (if positive, classify

patient as moderate TBI or mild TBI with complications)

GCS score of 9-12 at lowest point after resuscitation

GCS score of 3-8 at lowest point after resuscitation

 

3)  . Rancho Los Amigos medical center levels of cognitive functioning

Level

Name

Description

I

 

II

 

 

III

 

 

IV

 

V

VI

 

 

VII

 

 

 

VIII

 

No response

 

Generalized response

 

 

Localized response

 

 

Confused-agitated

 

Confused-inappropriate

Confused-appropriate

 

 

Automatic-appropriate

 

 

 

Purposeful-appropriate

Appears to be in deep sleep; no

  response to any stimulation

Appears to be resting quietly;

  makes gross movement in response

  to noxious stimulation

Makes spontaneous, purposeful 

  movement; may follow commands

  inconsistently

Confused, amnestic and inattentive;

  may be aggressive

Not agitated, confused and amnestic

Lacks initiative and problem

  solving; functional with

  structure and supervision

Follows daily routines; needs

  supervision for home and

  community skills; independent in

  self-care within physical ability

Independent in home and community

  skills; may have cognitive deficits

 

SPINAL CORD INJURY

 

1.  Neurological level of SCI

1)  .Motor level:ō砰オㄢ凹ㄣΤタ盽笲笆诀ぇ程盆场沮

             10兵闽龄(Key muscles)ぇτ﹚

 

a.      Key muscles 

          C5  Elbow flexors

            C6  Wrist extensors

            C7  Elbow extensors

            C8  Finger flexors

            T1  Finger abductors    

        L2  Hip flexors

            L3  Knee extensors

            L4  Ankle dorsiflexors

            L5  Long toe extensors

            S1  Ankle plantar flexors

 

b.     Muscle power

0=total paralysis

1=palpable or visible contraction

2=active movement, gravity eliminated

3=active movement, against gravity

4=active movement, against some resistance

5=active movement, against full resistance

 

c.      Motor levelぇ∕﹚赣场闽龄ぇgrade 3grade 3竊闽龄ぇゲ斗琌grade 4

 

2)  .Sensory level:オㄢ凹28 dermatomeぇkey sensory point

a.      代pin-prick籔light-touch sensation

b.     0=absent

1=impaired

2=normal

c.      Sensory levelぇ∕﹚:ō砰オㄢ凹ㄣΤタ盽稰谋诀ぇ程盆场

 

 

ASIA Impairment Scale

 

A= Complete: No motor or sensory function is preserved in the sacral segments S4-S5

B= Incomplete: Sensory but not motor functions preserved below the neurological level and extends through the sacral segments S4-S5

C= Incomplete: Motor function is preserved below the neurological level, and the majority of key muscles below the neurological level have a muscle grade less than 3

D= Incomplete: Motor function is preserved below the neurological level, and the majority of key muscles below the neurological level have a muscle grade greater than or equal to 3

E= Normal: Motor and sensory function is normal

 

Frankel classification

 

A= motor and sensory function complete without any movement or sensation below the lesion

B= motor complete with some sensory sparing

C= motor and sensory incomplete without functional motor recovery

D= functionally useful movement below the lesion

E= motor and sensory recovery to normal function but residual clinical evidence of SCI may still be present

 

 

AMPUTEE

 


1. Incidence: L/E>U/E(3:1)

           L/E: BK>AK

2. Indication of amputation

   1).PVD(peripheral vascular disease)- mostly

   2).trauma

   3).infection

   4).malignancy

   5).nerve injury

   6).congenital deformity

   7).non-union of fracture

3. Level of amputation

1).stump as longer as possible, but residual limb must be functional

   2).Doppler pressure measurement --ischemic index>0.45

4. U/E prosthesis

   1).Body powered prosthesis

   2).External powered prosthesis

5. L/E prosthesis

   1).Foot

      --SACH foot(solid ankle cushing heel)

      --Single axis footàmulti-axis foot

      --Energy-storing foot : Seatle foot, Carbon copy II, Quantum foot, Flex foot

   2).Socket

      --Plug-in socket

      --Quadrilateral socket

      --CAT-CAM(contoured adducted trochanteric- controlled alignment

        method)

   3).CAD-ACM(computer aided design-computer aided manufacturing)

Rehabilitation of amputee

New surgical techniques, improvement in pre-op, post-op care, advance in prosthetic technology, better understand of psychosocial implication of limbs loss.

Prothesis must assure comfortable, cosmetic, functional goal.

Etiology: U/E: trauma, disease.

        L/E: disease, trauma.

        Tumor, DM, peripheral vascular disease.

Amputation surgery:

To provide best potential for rehab & prosthetic restoration, plastic & reconstructive procedure, beveling the ends, sharp transection of nerve, appropriate myofascial closure of muscle, myodesis, skin incision avoid bony prominences.

Level selection: good healing, adequate full-thickness skin cover, vascular perfusion (Doppler analysis, Xenon washout study).

Low extremity

1.        Toe amputations

2.        Ray resections.

3.        Transmetatarsal amputations.

4.        Syme amputation. (disarticulation of the foot)

5.        B-K amputation

6.        Knee disarticulation.

7.        A-K amputation.

8.        Hip disarticulation.

9.        Hemipelvectomy.

Upper extremity

1.        finger or thumb amputation.

2.        Ray resection.

3.        Transcarpal resection.

4.        Wrist disarticulation.

5.        B-E amputation.

6.        Elbow disarticulation.

7.        A-E amputation.

8.        Shoulder disarticulation.

9.        Forequarter amputation.

Patient evaluation and management.

Pre-prosthetic management.

Pre-OP

Make decision, ROM, strength, mobility, ambulation, ADL, self-care skill, social support, reaction to the planned surgery.

Patient desires & needs.

Patients are more able to absorb and comply with a therapy program during the pre-op period than early post-op.

Post-OP

   Goal: heal of the incision

Pain control.

Residual limb preparation.

Maintaining of ROM, muscle strength.

Independent mobility

Independence in self-care and ADL

Education about prosthetic fitting and care

Support for adaptation to changes (denial, anger, depression, coping, acceptance)

Muscle strengthening in gluteus medius, maximus, hamstring, quadriceps trapezius, serratus ant. Pectoralis major, deltoid, biceps

   Prosthetic fitting

Needs, objectives, abilities, select from available prosthetic designs & component.

Prosthetic fitting are no hard and fast rules regarding who is or isnˇt a prosthetic candidate.

Reasonable cardiovascular reserve, adequate healing, skin coverage, ROM, muscle strength, motor control, learning ability, balance.

Poor candidates: vascular dysfunction, open or poorly healed incision, A-K amputee with 45 degree hip flexion contracture, B-E amputee with flail elbow and shoulder. >45 y/o in full-length prosthesis, significant fluctuations in BW.

   Design:

Functional, cosmetic, specific vocational, recreational, social needs.

   Timing:

Early fitting in U/E to ensure better functional use, return to activity & occupation (30 days) golden period.

Controversial in L/E

Immediate prosthetic fitting not recommended for vascular amputee.

   Prosthetic fabrication:

Preparatory prosthesis

Temporary, provisional, preparatory plastic prosthesis/ thermoplastics better fit, more durable

Definitive prosthesis

When residual limb shaping and shrinking process completed.

   Prosthetic construction design

Exoskeletal v.s. endoskeletal

Choice of socket, joint components, terminal device, method of suspension

Socket

Suspension

Interposing joint as needs by the level of amputation

Terminal device or devices

Control system:

1.        body-powered or conventional

2.        externally powered or electric

3.        passive cosmetic

special precaution of amputee

1.        proper positioning to prevent contracture.

2.        ROM & stretching exercise if contracture happened.

3.        Tilting table to overcome postural hypotension.

4.        Balance training (sitting balanceà standing balance à dynamic balance)

5.        Transfer skill training (bed-to-chair, chair-to-commode, chair-to-mat, etc.)

6.        Ambulation training (parabarà walking aids)

7.        Safe falling skill.

8.        Strengthening exercise (trunk, stump, unaffected limb)

Education for elastic bandage use.

ORTHOPEDIC

 

# Rehabilitation after fracture

 

1.     Principle

1)  .All joints that do not require immobilization should be mobilized early to maintain function.

2)  .Gait training should be instituted as soon as possible , with assistive devices.

3)  .Mobilization of the injured areas should begin when adequate fracture stability exists.

4)  .Local modalities should be used for pain control and reduction of muscle spasm.

5)  .Muscle strengthening of the involved areas should begin as fracture stability allows.

 

2.     Gait training

1)  .Non-weight bearing: intra-articular or unstable fracture.

2)  .Partial weight bearing: most commonly used in first 6- weeks. eg. Non-comminuted femoral shaft fracture

3)  .Gait pattern: point gait - 3-point, 4-point, 2-point

             swing gait (swing to, swing through)

 

3.  Range of motion( ROM ) exercise

1)  .Passive

2)  .Active assisted

3)  .Active

4)  .Active resistive

 

4.  Strengthening

1)  .Isometric exercise

2)  .Isotonic exercise

3)  .Isokinetic exercise

 

# Arthroplastic rehabilitation

 

1.  Purposes of total joint arthroplasty

1)  .Relieve pain

2)  .Correct deformity

3)  .Reestablish function

4)  .Prevent painful secondary effects on adjacent joint

 

2.  Post-operative program

1)  .Anti-edema measurement

2)  .Gentle, prolonged passive ROM exercise

3)  .Neuromuscular reeducation of basic movement

4)  .Gentle, active( assistive ) ROM exercises

5)  .Redevelopment of the proper use of the muscle and light functional activities

6)  .Redevelopment of accuracy and speed( coordination)

 

NEUROGENIC BLADDER

 

」 Urodynamic study

”Uroflowmetry:

1. max. flow rate: ●≠ 15ml/sec; ○≠ 20 ml/sec; young: 20-30 ml/sec

2. time to max. flow rate: in the early 1/3 of urination period

too late: delayed relaxation of bladder neck and ext. sphincter

too early: unstable bladder

3. flow pattern

4. voided volume

5. residual urine

”CMG

normal Pves: 10-25 cm H2O, should not > 50 cm H2O

normal bladder's compliance: > 10 mL/cm H2O

1. Detrusor hyperreflexia: detrusor contraction (phasic pressure) > 15 cm H2O

a. bladder volume < normal △ involuntary detrusor contraction△ incontinence

b. lesion higher than micturition center (pons): sphincter synergy: ok

c. lesion between pons and sacral reflex center: DSD

d. cause of Pves ◆:

bladder neck dysfunction: eg: T-SCI

BPH

DSD

urethral stricture

2. Detrusor instability:

a. during H2O infiltration, full sensation△ detrusor contraction, Pdet > 15 cm H2O

b. cause: parasymp hyperactivity, detrusor m. is involved only (other N. pathway: ok)

idiopathic

obstruction (BPH, urethral stricture)

acute cystitis

c. Tx: correct underline Dz, anticholinergics

3. low compliant bladder

a. cause:

chronic urethral obstruction

parasymp. denervation

chronic infection△ fibrosis

s/p R/T

b. high Pves△ VU reflux, hydronephrosis

c. Tx: OP, -blocker, anticholinergics

4. Detrusor areflexia:

a. cause:

over distension△ destruction of NMJ in detrusor

sacral/plexus injury is not likely to cause detrusor areflexia (☆ggl at detrusor)

b. Tx: abd strain, ICP

5. CNS injury without detrusor ggl destruction: decentralization: urecholine test (+)

  CNS injury with detrusor ggl destruction: denervation

6. urecholine test:

a. Cannon's law of denervation: an end-organ becomes supersensitive to its neurotransmitter when denervated

b. used in p't with possible infrasacral lesions when the detrusor is areflexic

c. bladder infiltration with 100 cc H2O△ urecholine 2.5 mg SC, if Pves > baseline 20 (25) cmH2O: (+): supersensitive reaction

d. the test is only (+) in complete decentralization

」specific Dz

 

reflex

urge

DSD

Emptying

Tx

CVA

◆

∠

⌒

Complete

anticholinergics

musculotropics

Parkinson's Dz

◆

∠

⌒

Incomplete

difficult

ICP

TBI,brain tumor

dementia

◆

∠

 

Complete

collection device

brain/cord (MS)

◆

 

 

 

ICP

●:sphincterotomy

SCI (complete)

◆

 

∠

Incomplete

 

SCI(incomplete)

 

∠

 

Complete

 

conus,

cauda equina

peripheral N.

⌒

⌒

⌒

⌒

ICP,

●:-blocker

○:straining

cord+conus

myelodysplasia

◆,or

combine

 

∠

 

ICP, drug

OP: reconstruction

 

」Management

”behavioral management

1. timed voiding

2. bladder stimulation

3. Valsalva's and Crede's maneuvers

a. Valsalva's: is most effective in○, but may△stress incontinence

b. Crede's: abd. wall must be relaxed, risk of ureteral reflux

4. anal stretch voiding

”urine collection devices

1. ext. condom catheters

2. indwelling catheters

3. adult diapers

”CIC

1. ICP: for low-pressure bladder of adequate capacity (>300 mL)

2. if the bladder is not sufficiently areflexic and compliant, anticholinergics or musculotropics can be used

3.●with lesion at C7 and below can manage self-catheterization

4. q8h (min), ∝600 mL

5.  if CIC results in frequent infection: catheter is soaked in Cydex or boiled

6.  the most common problems with self-catheterization: symptomatic bacteriuria, trauma

 

”ICP

   If R/U(ml)            ICP Frequency

   400 (350-450)          Q6H

   300 (250-350)Q8H

   200 (150-250)          Q12H

   100 (75-150)           QD

 

”drugs

1. cholinergics:

a. detrusor is innervated by cholinergic muscularinic (M2) receptors.

b. for partially innervated bladder: parenteral Bethanechol is useful, but PO is not

2. anticholinergics

a. propantheline

b. oxybutynin (Ditropan)

c. imipramine (Tofranile)

3. Ca blocker: no useful

4. adrenergic antagonists

a. phenoxybenzamine (Dibenyline): 1 and2-blocker

b. prazosin (Minipress): more specific 1 -blocker

c. for AD, Dibenyline is more effective than Minipress

5. mm. relaxants: no proved effect

”surgery on the bladder or bladder nerves

1. bowel procedures:

a. augmentation

b. continent diversion

2. denervation procedures: no use widely

a. SPR: S3

b. bil S2-4 rhizotomy: loss of reflex erection and worsening of the bowel evacuation

3. ES

a. at present, the only site being used is the sacral roots

b. bil S2-4 rhizotomy is usually performed

c. the striated pelvic floor mm. relaxes more quickly than the detrusor (smooth m)

4. surgery on the bladder outlet

*□outlet resistance△ incontinence is more common in:

children with myelodysplasia

○ with infrasacral lesions

denervated pelvic floor

a. injection therapy

b. external compressive procedures

c. sphincterotomy

indicator for good outcome:

low volume (<200 mL)

spontaneous contraction (detrusor) with a quick rise time (<20'')

adequate amplitude (> 50 cm H2O)

adequate duration on approximately≠2'

」Complication

1. bacteriuria

a. asymptomatic bacteriuria: urease-producing organisms may warrant treatment

b.common pathogen: E. coli, Proteus, Klebsiella, Pseudomonas, Serratia,Providencia, enterococci, staphylococcus

c. mild-to-moderate illness: oral antibiotics:

fluoroquinolone: Negacide, ciprofloxacin: cover P. aeruginosa

Baktar: no coverage for P. aeruginosa

d. more seriously ill: IV antibiotics: ampicillin+GM, or imipenem+cilastatin

condition should improve within 24-48 hr as condition stable: shift to oral form for 7-14 days

2. AD

3. hypercalciuria and stones

a. in all SCI, loss of Ca occur, esp: young ●

UCa◆begins about 4 wks, max: 16 wks, persist for 12-18 months

b. risk factor:

white●< 21 y/o

higher level

complete lesion

prolonged immobilization

b. urolithiasis

 

cause

Tx

renal stone

<9months: UCa◆

10 yr: infection

 

bladder stone

ICP: 2.3%

Foley: 8.8%

1. electrohydraulic lithotripsy

2. hemiacidrin sol'n retention for 30' QD

calyceal stone

 

1. asymptomatic, small stone: observation

2. symptomatic:

   a. <1 cm: ESWL

   b. >3 cm: percutaneous approach

ureter stone

dangerous, esp in no renal sense

Percutaneous nephrostomy

retrograde stent +endoscopic removal/ESWL

4. ureteral reflux and upper tract dilation

a. in child: Pdet >40 cm H2O & no urine leakage△ VUR

」 F/U

1. 3-6 months: image study as baseline (IVP)

2. 1 yr: U/A, RU, U/C, BUN, Cr, Ccr, Echo, renal isotope screening test

if normal: recheck every year for 5 years, then every 2 years

if abnormal: shortening the period of F/U and Tx

」neurogenic bladder in children

1. newborn: postvoid residual≠20 ml: urinary retention: ICP

2. 5 y/o: teach ICP

」high risk for IVP: Cr >1.5, IDDM

」afferent N△ pelvic & hypogastric N△ spinal cord

reflex: cremaster L1-2; bulbocavernosus S2-4; anal S2-4

」sexual function:

1. erection:

a. psychogenic erection:

med. preoptic-ant. hypothalamus△ lat. columns of the spinal cord△ T-L sympathetic and sacral pathway

b. reflex erection:

penile N.△ pudendal N.△ sacral cord△ pelvic N. (parasympathetic)△ cavernosal N.

2. emission + close the baldder neck: T-L sympahtetic stimulation

3. ejaculation: sacral parasympathetic and somatic efferent stimulaiton

」balanced bladder:

1. the p't can pass adequate urine on reflex or easily with suprapubic tapping and Valsalva's maneuver

2. RU∝100ml

3.     there are no pathological changes in the genitourinary tract

NEUROGENIC BLADDER

 

A neurogenic bladder results from a disruption of the afferent or efferent pathway, or both, connecting the bladder to the controlling centers of the spinal cord, brainstem, and cortex.

 

Classification according to clinical symptom:

(1)              Uninhibited bladder allows for normal filling. The patient perceives bladder fullness and voiding. However the patient cannot inhibit the detrusor contractions making voiding imperative. Residual urine may or may not present. The     uninhibited bladder is seen in patients with cerebrovascular accident, brain tumor, head injury, multiple sclerosis, Parkinsonism, and enuresis.

(2)              Reflexic bladder contracts reflexively and is often accompanied by a small volume capacity. Relatively high residual urine volumes may occurs The reflex arc is at the spinal cord level. The patient voids involuntarily.The patient voids involuntarily. The reflexic bladder in associated with spinal cord trauma, inflammation, tumor, and multiple sclerosis.

(3)              Detrusor‑external urethral sphincter dyssynergia. Dyssynergia is usually observed in reflexic bladders. Patients usually have traumatic spinal cord injury or multiple sclerosis.

(4)              Areflexic bladder fails to contract in the face of increasing bladder volumes. There are three types. Dysfunction of the upper motor neuron can temporarily result in an areflexic type bladder, seen in early spinal cord injury. Disruption of the central reflex arch  produce absent bladder sensation, negligible intravesical pressure and, frequently, flaccidity of external urethral and anal sphincters. This situation is seen in spinal tumor or trauma and multiple sclerosis. Lesion of the‑afferent loop can produce a large capacity bladder with absent detrusor contraction. The person may initiate voiding voluntarily. Retroperitoneal surgery and peripheral neuropathy (e.g., diabetes mellitus, lues, and other causes) can be associated with this kind of areflex bladder.

 

Classification according to site of lesion

Upper motor neuron type

Lower motor neuron type

Mixed type

 

B. Upper motor neuron bladder

 

10.    Clinical characteristics

                    (a) Bulbocavernosus reflex (+), superficial anal reflex (+)

(b) Cystometry show uninhibited contraction of detrusor

(c) Ice water test: (+)

(d) Low bladder capacity

(a) Hyperactive sphincter

(f) Detrusor‑sphincter dyssynergic may occur

11.    Training method

(a) Reflexic bladder contraction may occur within 2‑8 weeks after injury

(b) Stimulating the lower abdomen and inguinal area every 2 hour in the day time

12.    In quadriplegic patient, stimulation may be given by the family

4.     For some patient, the reflexic bladder contraction in not strong enough, bethanechol chloride may be given.

5.     Valium or baclofen may be prescribed to the patient with spastic external sphincter

6.     Excessive reflexic detrusor contraction may be inhibited by administration of probanthine or Geaurin

 

C.      Lower motor neuron bladder

 

1.    Clinical characteristic

       (a) Bulbocavernosus reflex (‑), superficial anal reflex (‑)

(b) Cystometry: detrusor contraction

(c) High bladder capacity

(d) Ice water test (‑)

(e) EMG of external sphincter: denervation change

 

 2. Training method

         (a) Bethanechol is the drug of choice in stimulating detrusor activity

         (b)Crede and Valsalve maneuvers should stimulate a truly denervated bladder to contract

         (c) ICP do as upper motor neuron bladder

 

D. Residual urine check

 

1.    Empty the bladder

2.    Drink 500 cc water

3.    One hour latter, try to void by stimulation or abdominal strain, record the urine amount as self voiding urine.

4.    Catheterization and record the urine amount as residual urine.

5.    When self voiding/residual urine= 3/1, balanced bladder is called.

TO DETERMINE THE TYPE OF NEUROGENIC BLADDER

1.        According to the vertebral lesion

(a)     The sacral segments are usually intact in fracture at the level of  Tll or above. Upper motor neuron lesion is likely.

(b)     Fracture at the level of Ll or below injury‑ the sacral segment or cauda equina. , Lower motor neuron lesion is likely.

(c)     Lower, upper or mixed motor neuron may occur in T12 fracture.

2.        The presence of bulbocavernosus reflex and superficial anal reflex indicating preserved sacral segments.

3.        Cystometry: identify the pattern of bladder contraction

4.        Ice water test: positive in upper motor neuron lesion

5.        Cystometry and sphincter EMG: determine the coordination between the detrusor muscle and external sphincter.

 

BLADDER TRAINING

 

A.      Intermittent catheterization program (ICP)

1.             Adequate water intake, 100 cc/hour (may increase amount during sweating).

2.             Intermittent catheterization q4h , try self voiding by stimulating (LMN) or abdominal strain (LMN) before each catheterization.

3.             Record the urine amount of self voiding and residual urine (catheterized urine) each time.

4.             Indwelling catheterization at night time with full opening.

5.       *When the residuals are less than, 400 ml for two days, reduce ICP to q6h.

*When the residuals are less than 300 ml for two days, reduce ICP to q8h.

*When the residuals are less than 200 ml for two days, reduce ICP to q12h.

*When the residuals are less than 100 ml for two days, discontinue the formal catheterization Program. Perform a postvoid residual every two days for a week then once the next week, and finally once & month for‑ two months. Catheterization checks may discontinued completely if the residual urine is less than 100 ml.

6.        Stop ICP and change to indwelling catheterization when UTI occurs.

PHYSICAL MODALITIES

 

1.  Definition: use heat, cold, light, friction, and pressure as physical agents

 

2.  Content:

1)  . Superficial heat: hot packs, heat lamps, hydrotherapy, paraffin bath

  2). Diathermy: ultrasound, short wave, microwave

  3). Cryotherapy: ice pack, ice massage

  4). Contrast bath

5)  . Electrical therapy: TENS, iontophoresis, FES, electromagnetic field. IFC

  6). Ultraviolet

  7). Vibration

8)  . Low energy laser

 

3.General introduction of heat & cold therapy

  1). General indications for therapeutic heat

Pain

Muscle spasm

Contracture

Tension myalgia

Production of hyperemia

Acceleration of metabolic processes

Hematoma resolution

Bursitis

Tenosynovitis

Fibrositis

Fibromyalgia

Superficial thrombophlebitis

Induction of reflex vasodilation

Collagen vascular diseases

 

 

  2). General contraindications and precautions for therapeutic heat

Acute inflammation, trauma, or hemorrhage

Bleeding disorders

Insensitivity

Inability to communicate or respond to pain

Poor thermal regulation ( e.g. from neuroleptics)

Malignancy

Edema

Ischemia

Atrophic skin

Scar tissue

  

  3). General indications for therapeutic cold

Acute musculoskeletal trauma

  Edema

  Hemorrhage

  Analgesia

Pain

Muscle spasm

Spasticity

Adjunct in muscle reeducation

Reduction of local and systemic metabolic activity

 

  4). General contraindications and precautions for therapeutic cold

Ischemia

Cold intolerance

Raynaudˇs phenomenon and disease

Severe cold pressor responses

Cold allergy

Insensitivity

 

PRESSURE SORE

Pressure sores (decubitus, bed sore, pressure ulcers) are localized areas of tissue necrosis produced by ischemia from excessive external pressure and blockage of capillary direct pressure alone the cause of skin breakdown. Distortion and shear of the skin are two other major mechanisms of tissue trauma in patients with a ¨pressure〃 sore.

 

Pathogenesis

Pallor is the initial response of tissue to local ischemia. When pressure is relieved, signs of erythema, edema, and punctate hemorrhage often are seen. The overlying skin may slough and evolve into a well-circumsribed area of necrosis within 3-5 days. Bacterial infection exacerbates the process and can eventually reach exposed fascia and bone. Sepsis and death may occur.

 

Grading of pressure sore

Grade 1 is superficial redness and induration, which persist 24 hours or more after the

       relief of pressure.

Grade 2 involves blisters or very superficial breaks in the skin. Erythema and

       induration persist.

Grade 3 involves the dermis.

Grade 4 is breakdown of overlying skin, subcutaneous layer, fascia and muscle. Bone

       is spared.

Grade 5 involves frank osteomyelitis

 

Predisposing factors

1.  Immobilization

2.  Spasticity

3.  Sensory impairment

4.  Poor nutrition

5.  Local factor: pressure > 65 mmHg > 2 hours,  wet and cold

Location

Supine: sacrum, scapular, occipital, heel

Prone: chest wall, knee, ant superior iliac spine

Lateral: shoulder, knee, ankle

 

Complication

1. Local infection

2. Osteomyelitis

3. Sepsis

4. Sinus and fistula

Prevention

1.  Relief pressure: supine q2h changing position around the clock sitting q15 min

               push up

2.  Increase tissue resistance: supply Vit C, protein

3.  Skin care: dry and clean

4.  Decrease spasticity: valium, dantrium, baclofen

5.  Early mobilization

Treatment

1.Debridement: Mechanical: hydrotherapy

             Chemical: proteolytic enzyme, H2O2

2.Dressing

3.UV

4.Surgical treatment: skin graft, rotation flap

Prognosis

Grade 1: 3-5 days

Grade 2: 10-14 days

Grade 3: 3-8 weeks

Grade 4 and 5: 3-6 months

 

UV: E1 erythema dose

    E0 <E1 suberythema dose

    E2 2.5xE1 stimulate granulation

    E3 2xE2 tissue destruction and lysis

    E4 2xE3

AUTONOMIC DYSREFLEXIA

 

Autonomic dysreflexia or hyperreflexia can occur in a patient with a spinal cord injury at T4-6 and above. An episode of autonomic dysreflexia can occur suddenly and dramatically. A pound headaches profuse sweating, vague discomfort and skin blotches can result in loss of full conscious, seizure, visual disorder, apnea, and cerebrovascular accidents from subarachnoid or intracerebral hemorrhage.

 

Autonomic dysreflexia is caused by a variety of abnormal stimuli, creating an exaggerated response of the sympathetic nervous system (comprising the thoracolumbar outflow of the nervous system to lack of control from higher centers). This condition occurs mainly when the lesion of level is at the T4‑6 segmental level or higher.

 

The condition of autonomic dysreflexia is precipitated by afferent stimuli from localized areas below the level of lesion, mostly from abdominopelvic region. The most, frequent infection, calculi, or instrumentation are also common offenders.

 

Mechanism

1. Local stimuli (for example, for a distended bladder ) enter the spinal cord and ascend to the level of the lesion where communication to the brain is interrupted. An enormous sympathetic response is activated.

2. The result: blood vessel spasm in the abdominal and pelvic organs and vasculature of the skin. This spasm causes vaso­constriction to an area so rich in blood supply that the body's blood pressure rises quickly.

3. Message indicating this sudden hypertension travel by systemic routes other than spinal cord (Communication from distended receptors in the aortic arch and carotid sinuses) to the vasomotor center in the brain. To compensate, the parasympathetic division of the autonomic nervous system lowers the blood pressure by slowing the heart rate and attempting to dilate all blood vessels. Some impulses may be effective, as normal parasympathetic outflow in the cranial and upper thoracic regions may be preserved, but other im­pulses are blocked by the spinal cord lesion, thus preventing communication with the lower thoracic and sacral autonomic outflow.

4. The result

*Overactive sympathetic vasodilatation above the level of lesion causing flushing of the face, neck, and chest; nasal stuffiness or congestion; profuse sweating of the upper body; possible engorged neck blood vessel; and headache.

*Parasympathetic stimulation (through the cranial outflow to the intact vagus nerve) causing bradycardia.

Acute Management

A.      Sit the patient upright.

B.     Eliminate the noxious stimulus. Palpate the lower abdomen for an enlarged bladder. Careful inspect the catheter for kinks or plugs. If necessary, irrigate an indwelling catheter or catheterize the bladder. Carefully perform a digital examination of the rectum to rule out an impaction.

C.      Monitor blood pressure every 5‑10 minutes.

D.     Antihypertensive drugs. Most cases of autonomic dysreflexia subside spontaneously or an a result of proper action at the bedside. When hypertension appears malignant, however, intravascular or intravenous medication should be considered. Hydralazine (Apresoline) 10‑20 mg can be give by intramuscular or slow‑intravenous push.

 

Significant interruption of the sympathetic nervous system in evident with an injury at the T4‑6 cord segments or above.

(A)    Local stimuli enter the spinal cord; upgoing communication is blocked by lesion at T4‑6 segmental levels (or above); an ex­aggerated sympathetic reflex response is activated.

(B)       Communicating via systemic routes activates the parasympathetic nervous system, but inhibitive downgoing messages are blocked by the T4‑6 lesion; parasympathetic response in the cranial outflow overcompensates., causing a number of symptomsexperienced above the level of the lesion.

 

SPASTICITY: Modified Ashworth Scale

0 = No increase in tone

1 = Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion (ROM) when the affected part(s) is moved in flexion or extension.

1+ = Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (<50%) of the ROM .

2 = More marked increase in muscle tone through most of the ROM: affected part(s) easily moved.

3 = Considerable increase in muscle tone: passive movement is difficult

4 = Affected part(s) rigid in flexion or extension
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

福┦陈肤ㄠ担ぇ禘耞籔獀励

                                             

﹚竡

    福┦陈肤Cerebral Palsy琌パ福诀穕┮ま癬贺笲笆╰参陈肤癐畓ア秸┪诀┦ア盽福穕甡场ぃ硑Θ笲笆毁锚痝ョぃ硂ㄇ痝礚膥尿碿て镣墩穦Τ祘跑笆笲笆墩のψ眎钵盽

    硄盽福┦陈肤痜ぃΤ笲笆毁锚┕┕福端硑Θ闽钵盽跌谋毁锚钮谋穕醇ぃì奉钵盽粂ē炒谋の薄狐拜肈单珿场福┦陈肤常妮毁锚ぃ珹竒笲笆┦Neuromotor毁锚临珹み醇┪み瞶毁锚

 

痜

()ダ克

1.                С甒い

        a.16烦40烦ネ玻35烦玻

        b.筁ネ玻策篋┦瑈玻璏璍Ν玻奉エ捆

        c.С甒ぃタ盽潮笵﹀

        d.С甒稰琕TORCHAIDS挡Э隔稰琕单

        e.С甒瑀媚甮絬钡牟

        f.废皊盽ノ

        g.С甒瑀﹀痝

        h.痝痚痜み登痚縸Э痜のㄤずだ猚痚痜

2.                ネ玻

a.玻祘筁玻禬筁24竒玻禬筁12

b.Ν戳瘆ネ玻玡24玡

c.璍ネ玻

d.璍絃Ν戳瞒玡竚璍絃

e.钵盽ο

f.吕盿钵盽叉钵盽

g.羦┪ㄤぃタ盽璍ネ玻

h.璍絃诀ぃ

 

    ()穝ネㄠ

1.                ネ砰筁ぶ┪筁2.5そょ

2.                璍秅计筁祏┪筁32秅

3.                ネ砰籔璍秅计ぃ癸嘿SFD┪LFD

4.                部Apgar Scoreだ

5.                穝ネㄠ奉

6.                ㊣螟

7.                穝ネㄠ稰琕

8.                蔼義﹀

9.                ネ玻端甡

10.い枷竒钵盽

11.穝ネㄠ﹀砲﹀﹀縸

12.┾輟

13.ぱ┦み纽痜

 

だ摸

()                ㄌ竒ψだ摸(Neuro motor classification)

摸    

ゑ    ㄒ

福    舱    麓

端跋办

羬                        紉

礿潘(Spasticity)

40%-60%

ブ          借

(繞 砰 ╰ 参)

1.         笆墩盽蝴い丁à竚

2.         ψ盽矪蔼眎篈甧玻ネ奉(deformity)

3.         瞷﹠礿潘礿潘(芭墩)

4.         笆篊Τ圾祑稰

5.         Τ皚潘の瞣眎は甮筁瞷禜

6.         讽ǔ硉ユがノ礿潘糤眏

畗笆(Athetosis)

15%-20%

膀    ┏   

(繞砰畖╰参)

1.         玻ネぃ癸嘿ぃ笆

2.         眎礚盽砰礚猭蝴い丁竚(mid-range)┪㏕﹚琘墩

3.         璝礚ㄖ礿潘瞷禜ぃ玻ネ奉

4.         硄盽捧喝紇臫繷繴羪场笲笆盽︸繦ぃ笆糒秨穦瑈睠

5.         硄盽耕腨

6.         Ν戳眎盽瞷硁瓀瓀(floppy)

7.         ぃ癸嘿眎は甮北

8.         紇臫粂ē羪场瞷┣钵薄

笲笆ア秸(Ataxia)

1%-13%

          福

1.         ψ眎秸ろㄎ

2.         Τキ颗の笆⌒稰谋毁锚

3.         繷逻稦瞷笆┦鸥л瞷禜(Intentional tremor)

4.         ︽ǐ絯篊ぃ铆ㄢ竲眎秨筁

5.         泊瞴Τ綺鸥瞷禜(Nystagmus)

礚眎(Atonia)

 

 

1.   ψ眎ψ礚Μ罽瞷禜

2.   パ㊣竟﹛ψ紇臫盽硑Θ┦(Aspiration pneumonia)担痜珿

綺鸥(Tremor)

 

膀    ┏   

1.         ⊿Τ奉瞷禜

2.         瞷滦τΤ竊┦﹠ぃΜ罽瞷禜

圾(Rigidity)

 

膉    憨    ┦

(Diffuse)

パ﹠尿Μ罽ㄏ贺

А瞷い丁闽竊笆竚

睼(Mixed)

 

场А

ㄢ贺┪ㄢ贺竒ψ疭紉盽ǎ礿潘籔畗笆睼

()                ㄌ穕端场だ摸(Disabled classification)

  摸            

疭                  紉

虫陈肤(Monoplegia)

Τ唉も┪唉竲陈肤

ō陈肤(Hemiplegia)

オ凹┪凹Τ腨毁锚

ō陈肤(Paraplegia)

ō┪ㄢ唉竲陈肤

陈肤(Triplegia)

蛮竲の唉も陈肤

陈肤(Quadriplegia)

毁锚祘ぃΤㄇ玥ō陈肤耕腨(嘿Double hemiplegia)Τㄇ玥ō陈肤耕糉甡τ淮稬(嘿Diplegia)

 

()               ㄌ穕甡腨祘ㄓだ(Severity)

1.           淮(Mild)-竒獀励ぃ紇臫ら盽ネ

2.           い(Moderate)-竒獀励斗徊ㄣネ瞶ネ縒ミ

3.           (Severe)-ㄏ琁ぉΝ戳獀励狦ご讽Τ

闽毁锚

()   醇ぃì

福陈肤眞︽笆螟ぶ诀穦籔ㄤㄆ钡牟竒喷珿眞厩策硉瞯盽τ筐絯ぃ玡

   

()   钮拜肈

福┦陈肤眞ぇア钮瞯耕蔼もì畗笆ぇア钮瞯程蔼RH紇臫τ祇ネもì畗笆眞蔼繵瞯ア钮(High-frequency hearing loss)独痭τ祇ネもì畗笆眞い枷┦ア钮(Central hearing loss)

   

()   薄狐拜肈

   福┦陈肤眞︽笆и酚臮籔ユ酵狝叭单よ常Τ

   螟礚猭籔胺眃妓竒菌摸ㄆ薄τㄏ薄狐Τタ盽祇甶τōみ祇

   甶筐絯┪ネ笆诀ネ⊿Τヘ夹ㄏΤョぃち龟悔甡┤

   ア毖籔種端甡磷籔ユ┕玱倪┤﹖縒薄狐拜肈┕┕ゑ

   ō砰炒紇臫

 

()   牟谋の笆稰谋毁锚

   福┦陈肤眞眞礚猭稰谋珇彩灿籔竚Τㄇ眞礚猭

   だ侩竚ㄤず珇ぇ┪竚硂贺的稰谋毁锚穦紇臫

   〤腪都篶籔ず贺笲笆厩策福┦陈肤眞笆稰毁锚

   籔︽笆螟盽硑Θи癸ō砰禜(Body image)耑紇臫

   贺笆┪笲笆厩策

 

(き)   奉拜肈

奉ìぱ琖奉А玒福┦陈肤眞盽ǎ拜肈奉獶琌福┦陈肤挡狦ㄤ祇ネ奉盽琌パψ钵盽τ癬

 

(せ)   跌谋拜肈

福┦陈肤ㄠ蛮泊砿畉紇臫跌谋祇甶籔秸泊氟拜肈珹狡跌畓跌弊跌泊綺单丁﹚ョ穕

 

()   谋拜肈

谋琌稰谋籔σいざ菌祘τ盢稰谋结ぉ種ㄤだ跌谋钮谋籔牟谋贺家Α福┦陈肤眞跌谋拜肈程跌Τㄇ眞螟Τ锣簿ㄤ癸縀猔種τ癸贺縀稰睼睹

 

()   粂ē拜肈

70%福┦陈肤眞Τ粂ē炒ㄤいもì畗笆﹡福┦陈肤眞ぇ粂ē炒珹(Dysarthria)粂ē祇甶筐絯羘钵盽籔ア粂痝单

Spasticity

Spasticity (meaning to draw or tug) is involuntary velocity-dependent increased muscle tone resulting in resistance to movement that may occur secondary to spinal cord injury (SCI), brain injury, tumor, stroke, multiple sclerosis (MS), or a peripheral nerve injury. A lag time may exist between injury and spasticity onset, and severity may wax and wane over time. Spasticity may be static or dynamic in nature. Although many therapeutic and medical interventions can attenuate its effects, spasticity can be severely debilitating. In spite of the fact that spasticity may coexist with other conditions, it should not be confused with any of the following:

   Rigidity - Involuntary bidirectional nonvelocity-dependent resistance to movement

   Clonus - Self-sustaining oscillating movements secondary to hypertonicity

   Dystonia - Involuntary sustained contractions resulting in twisting abnormal postures

   Athetoid movement - Involuntary irregular confluent writhing movements

   Chorea - Involuntary, abrupt, rapid, irregular, and unsustained movements

   Ballisms - Involuntary flinging movements of the limbs or body

   Tremor - Involuntary rhythmic repetitive oscillations, not self-sustaining

Pathophysiology

First described by Little in 1843, spasticity has many postulated causes, most revolving around altered afferent and efferent input to the alpha motor neuron. Spinal, peripheral nerve, or cortical injury can alter inhibitory and excitatory messages to the motor neuron. Alternatively, these injuries might result in denervation supersensitivity, deafferentation, central collateral sprouting, or disinhibition of the nerves.

Polysynaptic responses may be involved in spinal cord-mediated spasticity, while enhanced excitability of monosynaptic pathways is involved in cortically medicated spasticity.


Frequency

Spasticity is present to some degree in most patients with MS, SCI, cerebral palsy (CP), and traumatic brain injury (TBI).

 

Advantages of spasticity

   Substitutes for strength, allowing standing, walking, gripping

   May improve circulation and prevent deep venous thrombosis (DVT) and edema

   May reduce the risk of osteoporosis

 

Morbidity/disadvantages of spasticity

   Orthopedic deformity such as hip dislocation, contractures, or scoliosis

   Impairment of activities of daily living (ADL) (eg, dressing, bathing, toileting)

   Impairment of mobility (eg, inability to walk, roll, sit)

   Skin breakdown secondary to positioning difficulties and shearing pressure

   Pain or abnormal sensory feedback

   Poor weight gain secondary to high caloric expenditure

   Sleep disturbance

   Depression secondary to lack of functional independence

 

Sex/Age

Spasticity is not affected by sex, race, or age group, nor is it more prevalent in any of those groups.


Measurement

Spasticity is difficult to quantify, but clinically useful scales include the following:

Ashworth scale

0-4 (normal to rigid tone)

Physician's rating scale

Gait pattern and range of motion assessed

Spasm scale

0-4 (no spasms to greater than 10 per hour)

 

Functional scales such as the Functional Independence Measure (FIM) or Gross Motor Function Measure (GMFM) also may be valuable, although they do not measure spasticity directly.

 

Research-oriented tools for measurement include surface electromyography (EMG), isokinetic dynamometry, the H reflex, the tonic vibration reflex, F-wave response, flexor reflex response, and transcranial electrical/magnetic stimulation.

ぐ或琌ψ瑀膘颠

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胺玂Τ倒盾ヘ玡胺玂倒兜ヘ度肅泊楼┾輟繴场ψ圾の12烦ぇ玡福┦陈肤眞


 

 

 


 

 

 

 


痜菌糶盽ǎ拜肈のэ到某

 

盽ǎ拜肈

э到某

1.     痜眞膀セ戈皘ら戳フ┪岿粇

斗恶糶Ч俱

2.     皘禘耞ろЧ俱锣痜眞の穦禘虫ぇ禘耞ゼ絋龟癘更皘痜菌篕璶の痜菌(MRO13)

1. Τ禣洛励戈方ぇ痚痜穦禘┪疭浪琩痁ぇ禘耞┪钵盽挡狦А斗恶糶Ч俱

2. 璝痜眞锣皘皘痜菌篕璶の痜菌(MRO13)パ赣皘ЧΘ

3.     禗ゼ癘更祇ネ丁

痜眞―禘ぇ璶拜肈斗糶痝の丁

4.     痜癘更Ω皘ぇ猵

斗翴癘更Ω皘の筁璶矪竚痜も砃砾痝竟﹛簿从.单

5.     皘獀励竒筁糶〃SMOOTH〃

斗翴癘更獀励竒筁璶矪竚(獻┦獀励矪竚の疭浪琩单)の獀励は莱

6.     皘ボ糶〃RTC〃ゼ糶癹禘丁のノ媚ボ

斗癘更皘ノ媚ボ猔種ㄆ兜の禘發萝浪琩丁

7.     浪琩厨挡狦ゼ癘更Ч俱

斗翴篕魁浪琩挡狦璝タ盽斗癘更;璝皘厨ゼ叫糶〃PENDING〃

8.     皘痜菌篕璶兜Ω逆ず盽ǎ〃DITTO〃〃x〃┪〃//〃のフ癘更

﹜冈龟癘更Ч俱

9.     獀洛畍の皘洛畍帽彻ぃЧ┪帽

﹜絋龟帽ЧΘ

 

References 毙厩膟

1.Krusen's handbook of physical medicine and rehabilitation, 4th ed, 1990.

2.Rehabilitation medicine-principles and practice by Joel A. DeLisa 2nd edition, 1993.

3.Rehabilitation medicine by Goodgold 1988.

4.Rehabilitation medicine by Rusk , 4th edition, 1977.

5.Exercise physiology :Energy, nutrition and human performance by William D. McArdle, Frank  I. Katch, Victor L. Katch.

6.Koustuik & Gillleslpie (ED.) : Amputation surgery and rehabilitation, 1981.

7.Electrodiagnosis of neuromuscular disease by William's & Wilkins, Goodgold.

8.Muscles texting and function, 3rd edition by Kendall, Kendall & Wadsworth.

9.Medical neurology by Gilroy & Meyer, 1970.

10.Practical electromyography by Johnson , Williams & Wilkins.

11.Sport Medicine by W.B. Saunders company.

12.Textbook of work physiology- physiological bases of exercise by McGraw-Hill book company.

13.Rehabilitation management of amputees.

14.Therapeutic exercise, 3rd ed.

15.Behavioral problems and the disabled: Assessment and management

16.Rehabilitation services and the social work role : challenge for change

17.Rehabilitaiton in chronic renal failure.

18.Pulmonary therapy and rehabilitation principles and practice.

19.Behavioral psychology in rehabilitation medicine: Clinical Application.

20.Practical electromyography.

21.Management of spasticity with peripheral phenol nerve blocks.

22.Therapeutic heat and cold, 3rd ed.

23.Prevention and rehabilitation in ischemic heart disease.

24.Orthotics etectera, 2nd ed.

25.Manipulation, traction and massage, 2nd ed.

26.Human sexuality in rehabilitation medicine.

27.Rehabilitaiton management of rheumatic conditions.

        (13~27 are all published by Williams & Wilkins)

28.Pain series : Low back pain syndrome

            Neck and agm pain

            Shoulder pain

            Knee pain and disability

            Hand pain and impairment

            Foot and ankle pain

            Soft tissue pain and disability ( all provided by Cailliet)

29.The care and management of spinal cord injuries by Bedbrook, 1981.

30.Cowdry's the care of the geriatric patient , 8th ed, by Steinberg , 1976.

31.Stroke by Wade et al.

32.Behavioral psychology in rehabilitation by Laurence P. Ince.

33.Adult hemiplegia evaluation and treatment by Berta Bofuth.

34.Movement therapy in hemiplgia by Brunnstrom.

35.Stroke and its rehabilitation by Licht.

36.Stroke by Hutchinsono and Hscheson.

37.Language intervention strategies in adult aphasia.

38.Occupational therapy for physical dysfunction by Cathorine Anne Trombly.

39.Functional anatomy of limbs & back by Hollinshead.

40.Muscle testing and function by Henry Otis Kendall.

41.The lumbar spine & back pain by Jayson.

42.Treatment of injuries to athletes by O'Donoghue.

43.Rehabilitaiton of hand by Hunter, Schneider, Mackin.

44.Burn, a team approach by Artz.

45.Fracture treatment and healing by Bruce.

46.Upper extremities orthotics by Adnerson.

47.Physiotherpay in pediatric practice by Scatten and Bilberston.

48.Spinal cord injuries comprehensive management and research by Guttmann.

49.Spinal cord injury by Duiel Ruge.

50.Orchopaedic Medicine by Cyrias and Cyriax.

51.Lower limb amputation : A guide to rehabilitation by Gloria T. Sauders.

52.Amputation surgery and lower limb prosthetics by G. Murdoch.

53.Cash's textbook of neurology for physiotherapists by Patricia A Downie.

54.Cash's textbook of orthopaedics and rheumatology for physiotherapist by Patricia A Dowie.

55.Motor control : Concepts & lssues by John Wiley  & Sons, 1991.

56.Burn management by Carole L. Johnson, R.P.T.

57.Biomechanics of the spine : Clinical &  surgical perspective by Vijay K. Goel & James N. Weinstein ; CRC Press, 1990.

58.Occupational therapy by Willard & Spackman's, 6th ed.

59.Stroke/Head injury - a guide to functional outcomes in physical therapy management by Ann Charness, M.S.P.T.

60.Physical management for the quadriplegic patient. 2nd ed., by Ford & Duckworth, 1987.

61.The physiological basis of rehabilitation medicine, 2nd ed., by Butter Worth- Heinemann.

62.Clinical aspects of lower extremity orthotics by CAOP, 1990.

63.Physical rehabilitation : Assessment & treatment, 2nd ed., by O'sullivan Schnitz, F. A. Davis.

64.Neurological rehabilitation by Mosby.

65.Rehabilitation nursing : Process & application by Sharson S. Dittmar, Mosby.

66.The biomechanics of the foot & ankle by F.A. Davis.

67.Rehabilitation of the foot & ankle by G. James Samnarco, Mosby.

68.Biomechanical & motor control of human movement, 2nd ed., by David a. Winter, John Wiley & Sons, Inc.

69.Manufacture and use of the functional foot orthosis by Raymond J. Anthony, Karger, 1991.

70.Physical therapy of the foot and ankle by Gary C. Hunt, Churchill Living stone., vol 15.

71.Physical medicine & rehabilitation : Clinics of North America by Justus F. Lehmann, M.D..

72.The practical management of spasticity in children & adult by Lea & Febiger, Glenn/Whyte.

73.The orthopedic clinics : Foot & ankle injuries in sports by Saunders 1994.

74.The diabetic foot by Levin O'Neal, Mosby.

75.Gait analysis in cerebral palsy by James R. Gage, CDM.

76.Biomechanics in orthopedic by Niwa Perren Hattori (Eds).

77.Gait analysis : An introduction by Michael Whittle, Butterworth Heinemann.

78.Gait analysis : B/T/S IOS Press.

79.Gait disorders in childhood & adolescence by David H. sutherland, Williams & Wilkins.

80.Human walking, 2nd ed., William & Wilkins, 1994.

81.The functional foot orthosis by J.W. Philps, Churchill Livingstone, 1990.

82.The development of mature walking by Mac Keith press, 1988.

83.Clinics in physical therapy vol. 1-20.

84.Low back pain by Bernard E, 2nd ed., Finneson ,1980.

85.Anatomic guide for the electromyographer 2nd ed., by Edward F. Delagi., M.D.

86.A manual of orthopedic shoe technology by Clyde A. Edwards, 1981.

87.Orthopedic physical assessment by David J. Magee, 1987.

88.Pediatric rehabilitation by Gabriella E. Molnar, MD, 1985.

89.Physical therapy of the cervical and thoracic spine by Ruth Grabt, MappSc, GradDiPAdVMan Ther, 1988.

90.Orthopaedic physical therapy by Donctelli Wooden.

91.Comprehensive rehabilitation of burn by Steven V. Fisher M.D., 1984.

92.Radiology of the foot by Stephen D. Weissman, 1990.

93.Manual of nerve conduction velocity & somatosensory evoked potentials by Joel A. DeLisa, MD, 2nd ed., 1981.

94.Peripheral neurology, case studies in electrodiagnosis by Jay A. Liveson, MD, 2nd ed., 1991.

95.Physical examination of the spine and extremities by Stanley Hoppenfeld, MD., 1976.

96.The electromyographer's hand book by Lowery Lee Thompson, MD.

97.Magnetic stimulation in clinical neurophysiology by Sudhansu Chokroverty, MBBS, FRCP, 1990.

98.The foot in diabetes by James Sammarco, 1991.

99.Biomechanical basis of human movement by Joseph Hamill, Kathleen M. Kuutzen, 1995.

100.  Foot orthoses & other forms of conservative foot care by Thomas C. Michaud, D.C., William & Wilkins.

101.  Physical Medicine & Rehabiliation, Randall L.Braddom 1996

確胺の闽ヘ戳ヘ魁

1.  American Journal of Occupational Therapy.

2.  American Journal of Physical Medicine And Rehabilitation.

3.  American Journal of Sports Medicine.

4.  Archives of Physical Medicine and Rehabilitation.

5.  Brain and Language.

6.  Clinics in Sports Medicine.

7.  Isokinetics and Exercise Science.

8.  Journal of Orthopedic and Sports Physical Therapy.

9.  Journal of Prosthetics and Orthotics.

10.      Journal of Speech Language and Hearing Research.

11.      Physical Therapy.

12.      Movement Disorders.

13.      Muscle and Nerve.

14.      Neurologic Clinics.

15.      Stroke.

16.      Journal of Neurology Neurosurgery and Psychiatry.

17.      Clinical Orthopedics and Related Research.

18.      Orthopedic Clinics of North American.

19.    Spine.

痜┬矪竚砏絛