職能治療介入重度創傷性腦損傷合併右側忽略症候群之個案報告

Occupational Therapy for A Patient With Right Hemispatial Neglect after Severe Traumatic Brain Injury

許世賓(Shih-Pin Hsu) ； 王怡文(I-Wen Wang) ； 李佳靜(Chia-Ching Li)

《臺灣職能治療研究與實務雜誌》 14卷2期 (2018/12) Pp. 111-122

https://doi.org/10.6534/jtotrp.201812_14(2).0005

摘要

忽略症候群（簡稱忽略症）是中樞神經損傷後，對於腦傷對側刺激反應下降的現象，症狀常見於左側忽略。忽略症是眾多功能復原的不利因子，例如平衡、上肢動作、日常生活活動（activity of daily living, ADL）功能，然而右側忽略症容易被疏忽，影響個案復健進度。本報告敘述一名因車禍導致創傷性腦損傷（簡稱腦外傷）的個案，發生日期是2014年1月，雖然持續接受動作復健，左上肢動作正常，其餘肢體僅有部分聯合動作反應。2015年12月評估發現，個案靜態坐姿平衡差，無法穩坐在治療床邊，Rancho Los Amigos認知功能量表分數為V級，功能獨立量表（Functional Independent Measure, FIM）24分，臨床觀察個案並無跨越身體中線碰觸右側身體和肢體，但視線會移動到右方空間和右側肢體。4週後，星星刪除測驗發現個案有右側視空間忽略症，遺漏9顆目標物，其中7顆集中在最右方且靠近身體，視覺消除現象（extinction）測試則發現，個案眼球瞬間轉向右側，但只回答左側有刺激物。職能治療計畫包括身體探索（body exploration）任務和視覺搜尋訓練（visual scanning training）15至30分鐘，另外60至75分鐘治療內容為右上肢被動關節運動、坐姿平衡訓練和ADL訓練，每週安排3到4天職能治療。經20次治療，個案可獨立坐在治療床邊25分鐘以上，靜態平衡為佳，星星刪除測驗遺漏數剩下1顆，FIM總分提升至43分，Rancho Los Amigos認知功能量表則在VI到VII級之間。本篇研究的初步發現，臨床觀察配合標準化測驗可幫助確認重度腦外傷個案是否存在忽略症，此外，慢性期腦外傷個案接受積極職能治療合併忽略症介入，仍可改善功能，此正面結果值得未來研究進一步探討。

關鍵字

忽略症候群 ； 創傷性腦損傷 ； 職能治療 ； 日常生活活動

並列摘要

Hemispatial neglect is defined as a reduction of response to multiple modalities on the contralesional side after damage of central nervous system. The prevalence of left neglect is high. Although neglect has been considered as a negative predictor for different outcomes, impacts of right neglect are frequently ignored in clinical practical and literature. This study reports a male case with right neglect after severe traumatic brain injury (TBI) caused by a vehicle accidence two years ago. The initial evaluation found that the patient had a poor sitting balance, a Rancho Los Amigos (RLA) Scale level V, and a total score of 24 on Functional Independent Measure (FIM). Meanwhile, we noted his sound hand scarcely crossed the body midline to scratch or protect his right limb. Four weeks later, we re-evaluated the neglect syndrome through the star cancellation test and the visual extinction test. The patient omitted 9 targets on the star cancellation test and reported only the left stimulus when presented bilateral, simultaneous stimulation. The occupational therapy program consisted of 15-30 minutes of body exploration and visual scanning training, 30 minutes of range of motion exercise, and 30-45 minutes of balance training and activity of daily living (ADL) training. Treatment frequency was 3-4 sessions per week. After 20 sessions, the number of omitted target on the star cancellation test reduced to 1, and the FIM score increased to 43 points. The patient could sit on bed without physical support for at least 25 minutes. In addition, his RLA level raised to level VI-VII. This case study suggested that a combination of standardized assessments and clinical observation may help clinicians identify right hemispatial neglect among a patient with complicated conditions. Furthermore, integrating neglect intervention into occupational therapy might result in positive changes in a severe TBI patient with neglect in chronic stage. These findings warrant further investigation.

並列關鍵字

Hemispatial neglect ； Traumatic brain injury ； Occupational therapy ； Activity of daily living