复健科 物理治疗组

1、復健科 物理治療組壹、 復健科組織架構 病床數: 15 床 佔床率: 100%平均每月門診人次: 7666 平均臨床老師與實習生比例: 1:1-2復健科主任主治醫師 3人¸住院醫師3人謝霖芬物理治療師13人¸物理治療員 3人復健科技術主任職能治療師5人¸職能治療員1人陳麗妃語言治療師2人貳、病人型態 神經系統損傷病患 15% : 如Stroke¸SCI, head injury, PNI, etc 骨骼肌肉系統病患 79% : 如Fracture, knee injury, THR, TKR, LBP, frozen shoulder, sports i

2、njury,etc 小兒疾患5% : 如 CP, MR, brachial plexus injury, torticollis,etc 心肺血管疾患 0.33%: 如 CAD, COPD, etc 其他 1% : 如 Burn, etc參、臨床實習目標 提供大學物理治療學系大四學生將所學能實際應用在臨床上的機會,以便熟悉一般生理殘障患者的評估,制定適當的治療計畫, 並執行一般臨床治療技巧於病患身上。此外了解本院復健醫學各部門工作概況,以增進與其他專業人員的溝通技巧,及培養行政管理之能力,使成獨立作業之物理治療師。肆、實習內容 1.實習分站情形: 本部門大分為兩組巡迴- 神經系統(Neurol

3、ogy)及骨骼肌 肉系統(Musculoskeletal Disorder) 兩組。採上下午制,即半 天神經系統,半天骨骼肌肉系統。三個月後,互換上下午之 時段。 每到一站的前二天是見習期,包括對該站儀器器械的使 用¸保養及放置之介紹,簡介一般評估技巧¸然後才正式開 始實際治療工作。 2. 病歷書寫: A. 初評報告: 應於新接病人三次後繳交。 B. 進度報告: 原則上每週記錄一次,如病情變化快應 每日記錄。 C. 交班報告: 因故無法繼續治療該病患時,除口頭與接 任者交代外,應書寫交班報告,以便治療 能順利進行 D. 結束治療報告: 於結束治療後一周內繳交 3. 復健科內

4、之教學活動週一週二週三週四週五8:00-9:00CaseBookStaffJournalBookConferencereadingSeminarMeetingreading9:00-12:0013:30-16:30臨床實習16:30-18:00BookBookReadingreading伍、 實習學生請假規則 1.請假之最小單位為一小時 2. 請病假者,應於當日八時前以電話通知臨床指導老師。 3. 請公假者,應於事前備妥證明文件向臨床指導老師申請。 4.學生實習遲到時,應儘早與臨床指導老師連絡,並告之何時可 到達,以便安排病患事宜。遲到逾二十分鐘者以一小時論之, 並得就遲到時數請事假。 5.

5、臨床實習週數為20-21週者,請假時數最多為24小時; 而實習週數為14週者,請假時數最多為16小時,超過之時 數,應於實習結束後補之,每超過一小時補二小時。請假總 時數超出應實習時數的三分之一,則不給予實習成績。陸、實習學生服裝儀容 為維護醫療專業形象,實習學生應穿著合宜服裝 1.頭髮 男生: 前髮不得遮住眼睛,後髮以齊髮根為原則 女生: 頭髮過肩者應將其紮成髮束 2. 服裝 男生: 應穿著襯衫及長褲,長褲顏色以素面為原則,不得著牛 仔褲或奇裝異服 女生: 衣裙褲不可過短,以及膝為原則,亦不得著牛仔褲 3. 應穿著整齊清潔之鞋襪,鞋子以能完全包住腳趾為原則 4. 實習時應穿著白色制服,並配戴

6、識別證於左胸前 5. 指甲不可過長及擦有色指甲油,飾物不宜過於華麗且不得妨礙 治療工作之進行柒、教學計劃教學項目教學內容時數教學方法指導老師病歷書寫骨科物理治療3Hr講義及年資二年以上之投影片講解治療師神經科物理治療3Hr講義及年資二年以上之投影片講解治療師考核方式繳交病歷各兩份臨床指導(骨科及神經科)治療師物理治療常用特殊評估手法1Hr實地操作及年資二年以上之評估互相練習治療師關節活動度評估1Hr講義及大學部以上之實際操作治療師肌力測試評估1Hr參考書及大學部以上之實際操作治療師Upright Control1Hr講義及年資二年以上之Test實際操作治療師Brunstrom Stage1Hr

7、講義及年資二年以上之實際操作治療師考核方式跑檯考試1Hr由各授課老師負責步態分析正常步態說明1Hr使用參考書年資二年以上之治療師常見異常步態解說1Hr講義及年資二年以上之投影片講解治療師考核方式筆試由各授課老師負責教學項目教學內容時數教學方法指導老師骨科軟組織特性及1Hr由學生以投大學部以上之物理治療應用影片報告,之治療師讀書會指導老師作總結及補充頸,腰部8Hr由學生以投大學部以上之之物理治療影片報告,之治療師(McKenzie )指導老師作總結及補充個案討論與徒手手法示範四肢各關節之8-12由學生以投大學部以上之物理治療Hr影片報告,之治療師指導老師作總結及補充個案討論與示範各關節之鬆動術筋

8、肌膜炎之2Hr由學生以投大學部以上之物理治療影片報告,之治療師指導老師作總結及補充按摩及拉筋手法考核方式1.由報告學生之表由各授課老師達程度評分負責2. 於各單元讀書會後,舉行筆試教學項目教學內容時數教學方法指導老師神經科基本理論基礎2-3由學生以投大學部以上之物理治療(PNF, Brunstrom,Hr影片報告,之治療師讀書會Bobath, Motor 指導老師作Relearning 等)總結轉位技巧1Hr學生實際操大學部以上之(transfer technique)作並示範之治療師功能活動訓練3-4由學生以投大學部以上之(Functional Hr影片報告,之治療師Mobility)老師作

9、總結並實際演練誘發技巧10由學生以投大學部以上之(Facilitation Hr影片報告,之治療師Technique)老師作總結並實際演練平衡訓練2 Hr由學生以投大學部以上之(Balance training)影片報告,之治療師老師作總結並實際演練擺位方式1Hr由學生以投大學部以上之(Positioning)影片報告,之治療師老師作總結並實際演練考核方式由報告學生之表由各授課老師達程度評分負責病例討論骨科2 Hr投影片說明臨床指導會1次/每一學生X治療師學生數神經科2 Hr投影片說明臨床指導1次/每一學生X及治療師學生實際治療數考核方式由報告學生之表所有臨床指導達程度評分治療師評分捌、教學項

10、目 1. 病歷書寫: 教學內容 骨科物理治療病歷 1. Patient Profile 簡單的病史說明. 應包括年齡,性別,粗略之診斷及何時開始 物理治療. 病史應包含 What, When, How, and Where,及症狀 之發展歷程(Symptom behavior). 未發病前之功能狀態 (functional level)及過去病史與藥物服用亦應詳細詢問,以便 訂定適當之治療目標.病患之Social history(sports,occupation 等)因會影響治療目標也須確認.若為Summary note則須概略 描述治療之反應及目前情形 2.0 Orientation /C

11、ognition 確認病患對時,地,之概念與認知程度,以便目標設定與 治療進行 Orientation : 對時間,地點,人物之概念 Cognition: (認知) No response:對刺激無反應 Generalized response: 對刺激之反應不一致且不具任 何目的 Localized response:對刺激產生固定之局部反應,例如皺 眉頭,手握拳 Confused-agitated: 病患成躁動反應.對環境刺激成 Bizarre反應 Confused-inappropriate:只能對simple command產生反應 Confused-appropriate:病患顯現

12、goal-directed behavior且 可延續學習成果 Automatic-appropriate:大致正常,只是對不熟悉環境反應 會較遲緩 Purposeful and appropriate: 正常 2.1 Communication/Behavior 確認病患有無 說,聽,或語言等之溝通障礙 確認病患之行為表現是否正常適合治療之進行,包括其 mental status, level of alertness, concentration and personality disorder 2.2 Other medical Problems 確認病患有無其他內臟器官疾病是可能與其病

13、症有關或 會影響到治療之療程,應包括Cardiovascular, pulmonary, metabolic, GI/GU 等系統 Cardiovascular: angina, pulse, HR, BP, SOB with activity Pulmonary: COPD, URI, asthma, cystic fibrosis, dyspnea, cyanosis, breathing pattern Metabolic: DM, thyroid dysfunction, oncological problems, anemias, RA, obesity GI/GU: renal d

14、ialysis, GI disorder, Ob/Gyn condition 2.3 Studies 包括各類與此次病症有關之特殊檢查, 例如 X-ray, MRI, CT, EMG study 3.0 Pain and tenderness 應包括疼痛發生之時間( onset), 位置(location), 類型(quality), 強度(intensity) 及頻率(frequency) 最好能用身體圖示圖(body chart)表示之。造成疼痛加劇與和緩之機械因素也須詢問 (aggravating, ease factors, irritatility) 4.0 Skin and Sof

15、t tissue 皮膚: 褥瘡之有無, 溫度, 色澤,毛細孔之狀況, 疤痕等 軟組織: 柔軟度(mobility)如何,有無組織沾粘(adhesion)等 水腫/萎縮現象: circumferential measurement 4.1 Skeletal and Joint condition Bone and joint deformity: varus & valgus Ligamentous integrity: ACL/PCL, MCL/LCL, Ankle ligament integrity Joint play: hypo/hyper mobility Gr I, II,

16、 III, IV and end-feel Leg length discrepancy 之有無 有開刀者應標明開刀日期及開刀與骨頭固定方式(包括 implant 之種類) 4.2 Range of Motion and muscle length 應包括AROM, PROM 等關節活動度, PROM 之 End-Feel 亦應記錄之 Muscle length 主要是測量2-joint muscle, 例如Biceps, Triceps, SCM,Quadratus Lumborum, Rectus femoris, Hamistring, Gastrocnemius 等 4.3 Neuro

17、muscular MMT, Muscle tone, Reflex, Pulse Resisted isometric test 4.4 Sensation Light touch: dermatome, around scar area Pin prick: dermatome Proprioception: joint poistion sense/ joint motion sense 5.0 Balance and equilibrium 在以下幾種狀況下記錄其可完成之時間及動作是否平穩 (timing and movement quality) Both legs parallel

18、Tendem standing: (L) side ahead/(R) side ahead One leg standing: (L) side with eye opening/ eye closing (R) side with eye opening/ eye closing Tendem walking 5.1 Posture/appearance Any deviation from normal posture: standing, sitting or supine 5.2 Functional mobility 包括 bed mobility, transfer activi

19、ties, normal ADL , vocational & recreational activities 上肢: 穿衣/ 脫衣(包含內衣) , 梳頭, 洗澡, 手摸後腦勺, 手摸對側肩膀, 手拿臀部皮夾 下肢: 上下樓梯, 蹲, 跑, 跳 5.3 Endurance 病患是否能正常執行一般日常活動而不會肌肉疲勞或產生不 正常生理反應 5.4 Gait pattern 檢視病患之步態是否正常.包括平地, 跨越障礙,上下樓梯等 承重是否均衡, 各個關節在各步態時期之表現是否有偏差 是否有使用輔助器具, 若有者, 應列出輔助種類及其 Gait pattern(2-, 3-,or 4-p

20、oint, swing-to, swing-through) 6.0 Equipment 描述病患是否有且適當使用輔助器材, 包括prosthesis, orthoses, sling, brace, bandage Problems and Goal 將上述之檢查作一整理, 列出病患之問題.而問題應與動作 失能(movement dysfunction) 有關. 例如 nutrition, length & flexibility, strength, sensation, motor control 等再依據個別問 題訂定一為期2週之治療目標 Assessment 在綜合以上之病史

21、及客觀檢查後,給予該病患一物理治療診 斷,即何種組織受到何種程度之傷害而產生之動作缺損(例 如: chronic inflammation of (R) rotator cuff tendon resulting in shoulder ROM limitation) 而其預後為何?(應列出影響因素) 以及大概之療程規劃Plan 訂定治療計畫神經科物理治療病歷 (Physical Therapy Note for Neurological patients) Impression : CVA /c Rt hemiplegia / Head injury /c bil. Hemiparesis

22、(stage 5 or 6 ) / AVM /c Lt hemiparesis / Recurrent CVA /c bil. Hemiplegia CT or X-ray Finding : Date / Finding :90-1-1 : Infarction/ Hemorrhage over Rt MCA Other medical problems : DM / H.T./ Heart disease C /S regular control Brief History : (1) Age/Sex (2) Impression This 59 y/o female pt is a ca

23、se of Rt MCA infarction with Lt hemiplegia. (3) Reason (T/A, Aneurysm rupture, Cerebral infarction, Putaminal hemorrhage) (4) Date of onset (5) 描述當時發生的情況 He suffered from sudden onset of Rt side weakness. He suffered from weakness over Lt side gradually. (6) Treatment : medical treatment / transfer

24、to ICU / surgery ( date & type ) (7) PT started on / The patient was referred to me on 90-1-1. (8) 之前的健康狀況 尤其是 recurrent stroke之 functional perrformance # Summary Note : treatment effect and main problem : General weakness / Poor trunk control/ Poor cooperation and motivationGeneral condition :

25、Consciousness ( EMV) : Glasgow Coma Scale : Eye Opening : Spontaneous 4 To speech 3 To pain 2 (supraorbital area) Nit 1 Best Motor Response : Obeys6 Localizes5 ( press over supraorbital area , see if pt can raise hand over jaw and pull your hand away ) Withdraws4 ( press finger nail , pt withdraw )

26、Abnormal flexion 3 Extensor response2 Nit1 Verbal Response : Orientated 5 Confused conversation 4 (答非所問) Inappropriate words3 (incomplete sentence) Incomprehensible sounds2 Nit1 Coma score (E+M+V) = 3 to 15 Others : E4M6Va ( aphasia) E4M6VT (Tracheotomy) Mentality (JOMAC) : Judgment : 紅綠燈該做什麼 ? Orie

27、ntation : 人事時地物 Memory : immediate / recent / remote Abstract : 一石二鳥 , 一舉兩得 . Calculation : 100-7 7-7-7-7 ( 生活化 ) Co-operation ( 治療時 ) / Motivation ( 病床或家中 ) : P / F / Gl short attention span Vision / hearing : hemianopsia . hemineglet (聲音) / hard of hearing . deaf Speech / Swallowing : aphasia ( mo

28、tor. Sensory.global ) , dysarthia / Drooling . ChokingFacial palsy : Rt central / peripheral typeShoulder problems : Rt shoulder subluxation 1 FW Rt shoulder pain at terminal ROM of flexionCognitive functionSensorimotor status :Sensation : (1) light touch (localization & quality ) : Hyper/ Hypo

29、/ Intact (2) pin prick (localization & quality ) : Hyper/ Hypo / Intact (3) proprioception (好邊學壞邊動作) : JMS / JPSMuscle Tone : Flaccid / Mild / Moderate / Severe spasticity / nearly normal # mild elbow flexor spasticityMMT : (sound side ) : generally G (affected side ) : Stage 以上才能測ROM : WNL / Li

30、mitation : Rt shoulder flexion 0-150° Muscle tightness : hip flexor tightnessBrunnstrom Stage : UE : P (proximal) / D (distal) : P :Stage : Flaccid Stage : Spasticity Stage : Synergy pattern Stage : Movement deviating from basic synergy Stage : Relative independence of basic synergy Stage : Nea

31、rly normal ( Speed , muscle power ) D : Stage : Flaccid Stage : Spasticity Stage : Mass grasp S voluntary release Stage : Lateral prehension Mass grasp C partial voluntary release : finger ext. Stage : Palmar prehension Mass grasp C full voluntary finger ext. Stage : OppositionCo-ordination : UE : f

32、inger to nose : 10 times /10 sec LE : Heel to shin : 10 times /10 secl test sound side l quality : Dysmetria , tremor Body image : (observation) intact / impairedMotor planning (copy PT movement ) : intact/ impairedUE performance in lying : supine / side-lying What movement can pt perform at what RO

33、M assistance # Shoulder : flexion 0-150°in elbow extension in supine Elbow : extension 90-0°in shoulder flexion 90°in supineFunctional Status : ID ID /c supervision : require someone nearby for verbal cue and /or safety ID /c contact guard : require hands on pt for safety precaution W

34、ithout assistance Min A (25%) Mod A (50%) Max A (75%) D (100%)Performance : 描述病人表現非原因 Sitting balance : P / F /G Standing balance : P/ F /G # 前 : 1/2 range 側 : 1/4 range # G ( more weight bearing on sound side ) Ambulation : (+) /c / /s quadricane C/S AFO C Min A (-)Gait pattern : refer to LE evalua

35、tion noteAssistance Device : Shoulder splint , W/C , quadricane , Regular cane , AFOUp & Down Stairs : (+) C regular cane / Rt hand supported on rail / Min A / step by step or step over step(-) Others : Bladder function : Urinary incontinence /on folly ADL : (1)eating (2)dressing (3)light hygien

36、e (4)heavy hygiene ID/ partial D /partial ID/ D Home environment : 3F C/S elevator Endurance : 至少可完成30 min PT treatment Subjective : complaint ( activity , duration or repetition) Objective : vital sign : BP / HR / RRMajor problems : the most important the least importantGoal : Short term : within 2

37、 week ( 2-3 項) Long term : DC ( in patient) 3 month ( OPD)Program : 現在做的治療計畫. 教學項目 2. Upright Control Test教學內容 Upright Control Test (Flexion) Instructions to Patient for Hip Flexion Test 1.”Stand as straight as you can.” 2.”Bring your knee up toward your chest, as high as you can.” Grading Hip Flexi

38、on (When observed range is borderline between Weak-and Moderate, or Moderate and Strong give the lesser grade). Weak (W) - no motion or actively flexes less than 30o . Moderate (M) - actively accomplishes an are or hip flexion more than 60o. (Base grade on true hip motion and not on substitutions su

39、ch as backward trunk lean or pelvic tilt) Instructions to Patient for Knee Flexion Test 1.”Stand as straight as you can.” 2.”Bring you knee up toward your chest, as high as you can.” Grading Knee Flexion (When observed range is borderline between Weak and Moderate, or Moderate and Strong give lesser

40、 grade). Weak (W) - no motion or knee flexes less than 30o. Weak (M) knee flexes between 30o 60o. Strong (S) knee flexes more than 60o. Instructions to Patient for Ankle Flexion Test 1.”Stand as straight as you can.”2.”Bring your knee and your foot up toward your chest, as high as you can. Grading A

41、nkle Flexion (When observed range is borderline between Weak and Strong give the lesser grade). Weak (W) no motion or actively dorsiflexes to less than a right angle at the joint. Strong (S) actively dorsiflexes to a right angle or greater at the ankle joint. Upright Control Test (EXTENSION) Number

42、of Examiners Two examiners required for testing; testing examiner determines grade, assisting examiner assists in stabilizing or providing hand support as indicated under Pre-test Position and Stabilization. Position for Test Standing with the use of the examiners hand for support (balance support a

43、dequate to maintain single limb stance) Technique for Administering Test for Each Segment1.One demonstration by examiner2.One practice trial by patient (or two trials if needed to help patient understand test) 3.One test trial to determine grade. 4.If patient has bilateral lower extremity involvemen

44、t, assist opposite lower extremity flexion as needed to determine extension control of the stance limb. Pre-Test Positioning and Stabilization for Hip Extension Test 1.Testing examiner positioned beside patient to provide hand support and to assure that patient begins from a position of neutral or m

45、aximum hip extension range. 2.Assisting examiner provides manual stabilization as demonstrated in diagram to maintain neutral knee extension and a stable ankle. 3.If there is a fixed equines contracture greater than neutral, accommodate for the contracture by placing a 30o wedge under the patients h

46、eel. 4.If unable to maintain a stable plantigrade platform for single limb stance either manually or with an AFO, record UT (Unable to test) for hip and knee extension. See “Grading Ankle Extension for testing and recording an appropriate ankle grade. Instructions to Patient for Hip Extension Test 1

47、.”Stand on both legs as straight as you can.”2.”Now stand as straight as you can on just you (R) (Weaker) leg”-“lift this leg up”-“keep standing as straight as you can. Grading Hip Extension (When patient is balanced on weaker leg, testing examiner gradually decreases amount of hand support to determine hip control). Weak (W) uncontrolled trunk flexion on hip (testing examiner must prevent continued forward motion of trunk