医院培训课件：《认知神经复健与职能治疗的应用》

1CognitiveNeurorehabilitationin

OccupationalTherapy

認知神經復健於職能治療的應用2神經復健

(動作復健、認知復健、腦重塑)●腦側化/腦塑性（腦傷側效應與腦復原的潛力）●腦傷所形成的神經與行為失能→神經復健●動作復健：現代任務導向途徑、迫用療法、雙肢復健●認知復健：忽略症復健（例）●個案是學習者，治療師是雕塑者：治療讓個案透過大量練習累積經驗，提供腦重塑的機會(use-dependentplasticity)。3現代動作復健途徑ContemporaryMotorRehabilitationApproaches

Constraint-InducedTherapy(CIT)BilateralArmTraining(BAT)

Robot-AssistedTherapy(RT)4Constraint-InducedTherapy(CIT)

（侷限誘發療法;制動療法;迫用療法）AbehavioralapproachtostrokerehabilitationToovercomethelearnednonusephenomenonTreatmentcomponents:Constraintmitt（侷限健側）Forceduse（迫用患側）Intensivepractice（密集練習）Behavioralshaping（行為雕塑）CITanditsDistributedForms:CITDistributedCITTreatmenthours6h/d,5d/wk,for2wks2h/d,5d/wk,for3wksRestrainthours90%ofwakinghours6hoursperday5EffectsofModifiedConstraint-InducedMovementTherapyonReach-to-GraspMovementsandFunctionalPerformanceAfterChronicStroke:

ARandomizedControlledStudy

Keh-chungLin,Ching-yiWu,Tzu-huiWei,Chia-yiLee,andJung-senLiu

ClinRehabil2007;21:1075–1086.PPV=PercentageofmovementtimewherepeakvelocityoccursAhigherPPVindicatesalongeraccelerationphase,suggestinglessonlineerrorcorrectionandmorepreplannedcontrolofthereachingmovements(i.e.,feedforwardcontrol).6雙肢演練（機械式、活動式）的致效機制：

啟動雙肢偶合效應(BilateralCoupling)(Cauraugh&Summers,2005)Ipsilateralpathways:

10-15%non-decussatingdescendingfibers.

Motorcommandsgeneratefromtheundamagedhemispheremayinfluencethemotoroutputoftheaffectedarm.LeftarmmovementintentionRightarmmovementintentionLeftmotorcortexRightmotorcortexNeuralaverageNeuralaverageCorpuscallosumconnectionsLeftarmoutputRightarmoutputCross-talk7MajorCategoriesofPerceptualDisordersVisualperceptualdeficitsDeficitsinvisualperceptualfunctioningaftercerebralinsult(e.g.,objectagnosia,figure-grounddiscriminationdeficits,deficitsinspatialvision,etc.)ConstructionaldeficitsDeficitsincombining,assembling,orarticulatingpartstoformasinglestructure(e.g.,defectiveblockdesignperformance)UnilateralneglectTheinabilitytoperceiveorrespondto

stimulipresentedtothecontralesionalspace,despitetheabsenceofsignificantsensoryormotordeficits.

89Visualprocessingpathways:theventralstream(the“what”systemforobjectrecognition)andthedorsalstream

(the“where”and“how”systemsforspatialorientationandvisually-guidedaction)10111213UnilateralNeglect

Thedisorderoccursacrossvarioussensorysystems,includingthevisual,somatosensory,andauditorysystems.Thedisorderismorefrequentlyseenfollowingrighthemispheredysfunction.Thedisorderhasimportantimplicationsforrehabilitationandthestudyofbrain-behaviorrelation.

14Attentionaldifferencesinthehemispheresofthebrain.

15RelatedDisordersExtinctionThefailuretoreportthestimuluspresentedtothespacecontralateraltoabrainlesionwhenbilateralsimultaneousstimuliaregiven.HypokinesiaAninabilitytoinitiateanactiontowardormaintainmovementwithinthecontralesionalspace.16RelatedDisorders(Cont’d)NeglectdyslexiaSubstitutions

eatate雅推晴朗清朝Deletions

houseuse俗谷港口巷口Additions(completion)

canscan可何也是他是17RelatedDisorders(Cont’d)Anosognosia

Unawarenessordenialofdisease/disabilities.Pushersyndrome

Theinabilitytobearweightontheless-affectedside(usuallytheright).

Motorimpersistence

Difficultyinsustainingmovementsorpostures.1819TheAnteriorandPosteriorAttentionSystems20AttentionSystemMediatedby

TheAnteriorBrainNetworkAnteriorBrainAttentionSystemPrefrontalcortexandanteriorcingulategyrusComponent:Alternatingattention(theabilitytochangeattentionfocusinaflexibleandadaptivemanner)Rostralmidbrain,reticularformation,andthalamusComponent:Sustainingattention(theabilitytomaintainvigilanceovertime)21AttentionSystemMediatedby

ThePosteriorBrainNetworkPosteriorBrainAttentionSystemInferiorparietallobule,superiortemporallobe,andthestriatalregionsComponents:Alertness

(theabilitytoconcentrateonattentionfocus)Focusedattention(theabilitytoorient,detect,andselect

targetsfromcompetingstimuli)Shiftingattention(theabilitytodisengageandmoveasattentionfocuschanges)22AssessmentofUnilateralNeglectTheLineBisectionTestTheCancellationTestTheDrawingTaskDoubleSimultaneousStimulationsTestMotionAnalysis(e.g.,kinematicanalysisandeyemovementrecording)FunctionalTasks(e.g.,textreading,mobilitydeficits,andtrunkdyscontrol)23WhenAssessingVisualAttentionThebasictoknowfirstisthe

visualfoundationskills(e.g.,visualacuityandocularmovement).24VisualFoundationSkillsVisualacuity

theabilityoftheeyestomakewhatisseensharpandclear20/200vision

Apersonwith20/200visioncanrecognizeat20feetastimulusthatapersonwithnormalvisioncanrecognizeat200feet.Near&FarvisionNearvision:<16inches(shouldbecorrectedto20/70orbetterwhenevaluatingvisualtasks)Farvision:>20feet25VisionScreener26TheLineBisectionTestThepatientplacesthebisectionmarkatthesubjectivemidpointofalinesegmentbetweentherightendofthelineandthe“attentionalhorizon”reachedontheleft.27

RightwardBiasontheLineBisectionTestbyPatientswithLeftVisuospatialNeglect28

Examplesofthe

Eye-FixationPatterns

ontheLineBisectionTest

（忽略症與視野缺損不同，且可區分！）（兩者可合併發生）

29

動作性忽略(motorneglect)：左向性動作的遲滯、偏位

TrajectoriesofReachesforTargetsbyaPatientwithRightStrokeUsingtheRightHand.NoticethePronouncedRightwardHeadingWhenReachingintotheLeft

Hemispace.30NeglectontheCancellationTestTargetdetectionfailuresreflecttwointeractivefactors:DecreasedtendencytoexploretheleftExcessiveattractionexertedbystimuliontheright31VisuospatialNeglectontheShapeCancellationTestShowingOmissionsonBothHemi-SpacesAfterRightHemisphericStroke.32Right-Hand(Top)andLeft-Hand(Bottom)PerformanceontheShapeCancellationTestbya5.5-Year-OldBoywithAttentionDeficit/HyperactivityDisorder(ADHD).

33

“RightNeglect”inaPatientofSchizophreniaontheRandomChineseWordCancellationTestPerformedbytheRightHand(theOmittedTargetsareCircledinRed)

34Performanceofa2-Year-and-3-Month-OldBoywith

TraumaticBrainInjury

toFPTO(R)(R>L)(16DaysPostInjury)ontheTeddyBearCancellationTask.35DistributionofSpatialAttentionIsneglectahemispatialdeficitoradirectionalbias?Whatisthereferenceframeforspatialrepresentationinpatientswithneglect?Fractionationofviewer-centeredneglect（視者為基）andobject-centeredneglect

（物件為基）的忽略可分離呈現）36Leftneglect:“Left”towhat?Viewer-Centered(a)andObject-Centered(b)Neglect.37Whattypeofneglectdidthis53-year-old,right-hemisphericlesioned,femalepatientshowonthecirclecancellationtest?38

NeglectontheMapTest.

EastwardTranspositionoftheIslets,Sea,andCitiesontheWest(Allochiria).39NeglectontheTextReadingTestShownbyOmissionsandDyslexicErrors(e.g.,端

Misreadas瑞).NotethattheErrorsAreNotConfinedtotheLeftHemispace.40NeglectRehabilitationVisualandVisuomotor

Cueing(NONVERBAL!)EyePatchingConstraint-InducedTherapy(CIT)VibrationtotheLeftNeckNonverbalAuditoryStimulation(e.g.,Music)Neuropharmacological(DopamineAgonist)Treatment41NeglectontheUncuedLineBisectionTest.NoticetheGreaterBisectionErrorswithIncreasedLineLengths.42ImprovedLineBisectionPerformance

by

VisualCueing(i.e.,VerbalReportoftheLeft-SidedDigitBeforeBisectingtheLine).43

EnhancedImprovementby

CirclingtheLeft-SidedDigit

(Left-StartCueingbyLimbActivation).

44

Locus

ofTask

LimbActivationToEnhanceGoal-DirectedAttention:Activatingtherighthemispherebydirectingtherighthandleftwardforagoal-directedmotoract.

ThePremotorTheoryofAttention:Attentionandmotorpreparation(theintentiontoact)aresocloselylinkedthatactivationofonesystemwouldleadto“recruitment”oftheother.

LH=lefthemisphere,RH=righthemisphere,CC=corpuscallosum,S-M=sensorimotorprocessors,A-I=attentionalintentionalsystems.45

FurtherImprovementbyVisuomotorCueingInvolvingCirclingtheLeft-SidedDigit(i.e.,LeftStartCueing)PlusFingerTracingoftheLine(I.e.,TactileExploration).46ImprovementontheTextReadingTestbyMeansofDigitCirclingandFingerTracingoftheWordstobeRead.47

(A)GlassesandCompleteRightPatch(Monocularright-eyepatch)(B)GlassesandRightHalf-FieldPatches(Binocularrighthalf-fieldpatches)48Retinalpathwaytothecontralateralsuperio