• 期刊

透視螢光吞嚥檢查與吞嚥內視鏡檢查在吞嚥障礙評估的角色

吞嚥障礙是許多中樞神經性疾患及口咽腔腫瘤常見的後遺症。一旦發生吞嚥障礙，對於患者生理及心理都會造成影響，進而影響生活品質。如何確實評估吞嚥功能異常並給予適時的治療成為一項重要的課題。透視螢光吞嚥檢查（videofluoroscopic swallowing study）與吞嚥內視鏡檢查（fiberoptic endoscopic evaluation of swallowing）是吞嚥障礙患者常接受的儀器檢查。大部分的學者將透視螢光吞嚥檢查視為吞嚥檢查的黃金準則，但也有學者認為吞嚥內視鏡檢查可提供許多額外的資訊且具足夠的正確性，是優於透視螢光吞嚥檢查的方法，這種討論一直存在。本文藉由完整的文獻回顧作出以下結論：若是要評估局部的咽喉構造，則建議先進行吞嚥內視鏡檢查；若是要評估吞嚥生理變化，則建議先進行透視螢光吞嚥檢查。透視螢光吞嚥檢查與吞嚥內視鏡檢查在吞嚥後咽部殘留物及滲入-吸入量表級數的評估上具有高度一致性，且在治療上不會因為選擇這二項檢查的不同而影響肺炎的發生率。因此，透視螢光吞嚥檢查與吞嚥內視鏡檢查皆可當作吞嚥障礙的客觀評估工具。

• 期刊

以系統性回顧探討住院腦中風病人之出院安置地點

前言：影響住院腦中風病人出院動向的因素是複雜且多元的，本研究利用文獻回顧方式，系統性地分類統整相關研究資料，探討單因子的重要性與多因子（multivariable）的預測效能。方法：本研究透過PubMed及Cochrane Library電子資源，利用stroke、discharge destination 等關鍵字搜尋2005年至2018年相關文章，並限制為原著論文及英文撰寫。結果：經篩選後共19篇納入本研究探討，相關因素歸納為年齡、性別、生活習慣、婚姻家庭、經濟社會、共病症、腦中風型態、認知與生理功能、醫療情況與地理環境，共10類別；所有研究支持年齡較小或生活功能較好者有更大機會返回居家（p＜0.05），大部分研究也顯示女性在出院後入住機構比例較大。多因子預測相關性質研究共9篇符合納入探討，其研究方法均應用羅吉斯迴歸建立模型，預測效能AUC為0.68至0.89；年齡、功能獨立量表（Functional Independence Measure, FIM）及巴氏量表（Barthel Index, BI）為常用且顯著影響之研究變項。結論：出院後不同安置地點對腦中風病人後續之生活功能與照顧花費會有明顯差異，本研究系統性歸納過往實證結果，可以提供醫療單位合宜的決策輔助，在出院準備及長照資源協助下提升病人返回居家的可能性，落實在地老化的健康照護理念。

• 期刊

慢性中風患者使用前葉式足踝支架之平衡效用

目的：探討中風病人長期穿戴前足踝支架後，其前足踝支架在靜態站立平衡的效用。方法：我們邀請穿戴前足踝支架至少5個月的慢性腦中風患者參加此研究。病人會站Tetrax平衡系統在8個不同姿勢下進行評估：1.頭正睜眼站在力板上面（NO）、2.頭正閉眼站在力板上（NC）、3.頭正睜眼站在泡棉上（PO）、4.頭正閉眼站在泡棉上（PC）、5.頭轉向右邊30度閉眼站在力板上（HR）、6.頭轉向左邊30度閉眼站在力板上（HL）、7.頭向上閉眼站在力板上（HB）及8.頭向下且閉眼站在力板上（HF）。病人會完成穿及不穿前足踝支架的評估，而此評估順序是隨機產生。經Tetrax平衡系統軟體運算得到4個姿勢控制的參數：穩定性、重量分佈、同步性和搖晃強度的傅利葉分析。結果：51位中風病人參與本研究，平均年齡為54歲，34位（67%）為男性，平均中風時間為48個月。與裸足站立相比，前足踝支架可顯著地1.促進整體穩定性（p= 0.01）、2.促進雙足後跟的協同性（p＜ 0.01）、3.促進同側前後足的協調性（p＜ 0.01）、4.促使前足承重增加（p＜ 0.01）、5.降低0.75～1Hz的搖晃程度（p＜0.01）。但在無感覺剝奪的情況（NO）或缺乏視覺及本體覺回饋的情況（PC），前足踝支架則不具以上效益。前足踝支架對增加患側腳的承重沒有助益，此外前足踝支架會讓患側的前足承重大於足後跟。結論：長期穿戴前足踝支架的中風患者，處在些許感覺挑戰情況下穿戴支架相較於裸足可以改善身體搖晃的程度、增加體感回饋並促進雙足相關肌肉的協調性收縮。但前足踝支架無法增加患側下肢的承重，也使患側前足承受比後腳跟更多的重量。

• 期刊

Rehabilitation is Associated with Lower Mortality in Patients with Dengue Fever in Intensive Care Units: A Retrospective Study

Objective: The study aimed to examine the effect of rehabilitation on mortality in patients with dengue in intensive care units (ICUs). Design: This was a retrospective cohort study. In this study, 142 patients with dengue from ICUs were enrolled from August to December, 2015. They were divided into two groups: patients with or without rehabilitation. The relationship between rehabilitative therapy and the risk of dengue-related mortality was assessed using a multivariate Cox regression model after adjustment for related variables. Results: Of the 142 patients, 70 (49.3%) were men, and the mean age was 69.97 ± 15.93 years. The average length of stay in the hospital was 14.79 ± 16.14 days. The results of the Cox regression indicated that rehabilitated patients had a lower risk of dengue-related mortality [adjusted hazard ratio (HR) = 0.196; 95% confidence interval (CI) = 0.059-0.656]. Conclusion: Rehabilitation was found to be associated with lower risk of mortality in patients with dengue fever in the ICUs. More randomized control trials are required to consolidate the effect.

• 期刊

Increased Risk of Arrhythmia in Patients with Cervical Spinal Cord Injury: A Nationwide Population-based Matched Cohort Study

Objective: To investigate the risk of cardiac arrhythmias among adults with spinal cord injury (SCI). Methods: This is a retrospective population-based matched cohort study. Data were derived from the National Health Insurance Research Database. This study identified all patients diagnosed with SCI from January 1, 2000 to December 31, 2013. Patients with SCI were categorized into the cervical SCI (C-SCI) and other SCI (O-SCI) groups according to the level of injury. The cumulative incidence of cardiac arrhythmias was compared between patients with C-SCI, those with O-SCI, and those without SCI. Cox proportional hazards regression model was used to assess the differences in the incidence of cardiac arrhythmias between C-SCI and O-SCI groups. Results: The cumulative incidence of arrhythmia was higher in the C-SCI group than the O-SCI group or non-SCI group (log-rank p ＜0.0001). The C-SCI group had a higher risk of arrhythmia than the O-SCI group (adjusted hazard ratio = 1.64(95% CI 1.29-2.08, p ＜ 0.0001). Other factors associated with arrhythmia included age, hyperlipidemia, hypertension, and chronic obstructive pulmonary disease. The incidence rate ratios (IRR) of three different types of cardiac arrhythmia were significantly higher in the C-SCI group than in the O-SCI group (supraventricular arrhythmia IRR = 3.65, 95% CI 2.23-5.99; ventricular arrhythmia IRR = 5.00, 95% CI 1.10-22.82; other arrhythmia IRR = 4.15, 95% CI 3.17-5.45). Conclusions: Patients with C-SCI had a higher risk of cardiac arrhythmia than patients with O-SCI or those without SCI. We should monitor these patients more carefully to detect the occurrence of arrhythmia.

• 期刊

醫師與護理師對巴氏量表評分一致性的研究

巴氏量表為目前台灣地區用來評估日常生活活動功能狀態最廣為運用的評估量表，除了用於評估病人日常生活能力外，並且是聘僱外籍看護工之評估皆以巴氏量表為依據。在臨床住院照護中，醫師及護理師是最常評估患者日常生活的醫護人員，但是綜觀相關之研究卻缺乏了探討醫師與護理師評估巴氏量表一致性之報告，本研究的目的在於探討醫師及護理師評估巴氏量表的一致性及可能影響其一致性的相關因子。本研究以北部某醫學中心之復健科病房進行，以實際上參與病人照護之住院醫師與護理師為量表的評估者。以結構式問卷調查病人與照顧者之基本資料，病人資料包括年齡、診斷、性別、教育程度、簡短智能測驗分數等；照顧者資料包括年齡、照顧病人的時間、性別與教育程度；評估者則收集年齡、性別、本院工作年資、職級與接受過巴氏量表評估在職教育時數等資料進行描述性與推論性之統計。本研究自2014年8月至2014年9月，共收集67對病人與照顧者、評估表含住院醫師15名、護理師20名。結果顯示醫師與護理師利用巴氏量表進行病人日常生活之評估總分具有良好之一致性（ICC=0.95），而分項目中，僅「個人衛生」、「如廁」、「洗澡」與「平地走動」等四個項目屬中等一致性（ICC=0.50-0.70），其餘六項「進食」、「移位」、「上下樓梯」、「穿脫衣褲」、「大便控制」與「小便控制」具有良好的一致性（ICC=0.80-0.95）。評估的一致性和評估的背景及被評估者的生理教育背景無關。我們總結，醫師與護理師使用巴氏量表進行日常生活活動功能評估具有良好的評估者間一致性。

• 期刊

Kienböck's Disease in a Patient with Hemiparetic Stroke: A case report

Kienböck's disease of the wrist is a multifactorial, progressive osteonecrosis of the lunate bone. Patients with this disease often complain of dorsal wrist pain and other wrist dysfunctions. Image studies are usually required for definite diagnosis; however, careful history taking and physical examination are also necessary. Treatment varies according to the stage of the disease; although surgery is needed in most of the cases, rehabilitation after the surgery seems helpful as well. Kienböck's disease is rarely seen in our daily practice, and even though we do recognize the disease, diagnosing it correctly in patients with comorbidities such as stroke is often difficult. We thereby present a case of a patient with hemiparetic stroke in our ward who complained of shoulder and wrist pain. The patient was diagnosed of shoulder-hand syndrome first, but he then turned out to be a victim of Kienböck's disease. This case report provides an important insight for physiatrists to have a second thought of any refractory wrist pain in a patient with stroke even though it is being treated as a more prevalent disease. Furthermore, physiatrist could further instruct the therapists to adjust their rehabilitation program accordingly and collaborate with orthopedic surgeons to provide a more thorough care for the patients.

• 期刊

蜘蛛網膜下腔出血後續發脊髓空洞症：病例報告

背景：腦血管動脈瘤（cerebral artery aneurysm）破裂是導致蜘蛛網膜下腔出血 （subarachnoid hemorrhage, SAH）常見的原因之一，這類腦出血病患可能有相當程度的神經學症狀及日常生活功能（activity of daily living）受損。脊髓空洞症（syringomyelia）是描述在脊髓內部產生空洞的一種疾病，成因可分為先天性及後天性，患者可有肢體疼痛及感覺異常等臨床症狀。根據現有之文獻資料，蜘蛛網膜下腔出血後續發脊髓空洞症之個案並不多見。本篇病例報告將描述這類患者的臨床表現及影像學特色，並回顧關於脊髓空洞症之診斷、治療方式及預後的文獻資料。病例報告：個案為一位35歲男性，初次入住本科病房前半年發生右側椎動脈瘤破裂導致蜘蛛網膜下腔出血併發水腦症並接受腦室腹腔引流管放置手術，因仍有左側肢體無力至本科接受住院復健，並同時有左側肩膀疼痛及麻痛分佈於左上肢等症狀，無明顯加重及緩解因子。理學檢查有左側第二頸椎至第一胸椎皮節之針刺感覺減弱，左上肢深肌腱反射減低。因懷疑感覺異常、無力及疼痛可能和肩頸部肌肉、神經及骨骼等構造異常有關，故安排進一步檢查。頸部X光影像檢查顯示輕度頸椎關節退化，無壓迫性骨折或椎體移位；左肩軟組織超音波顯示棘上肌夾擠伴有部分撕裂傷及慢性肌腱炎；上肢神經傳導檢查顯示可能存有左側頸椎神經根病變（cervical radiculopathy）。初步診斷為左側頸椎神經根病變伴有左肩棘上肌夾擠症及肌腱炎，並安排患者接受復健及藥物治療。其症狀雖稍緩解但仍反覆發生，追蹤腦部電腦斷層亦無發現新的腦內出血或水腦。因懷疑有脊髓內病灶故安排頸部核磁共振檢查，顯示頸椎第一頸椎至第七頸椎之脊髓空洞病灶，診斷為非創傷性脊髓空洞症。個案持續接受復健治療後，追蹤肢體疼痛及無力情形穩定無明顯惡化。結論：脊髓空洞症較常見於創傷性脊髓損傷的患者，於出血性腦中風族群特別是蜘蛛網膜下腔出血於文獻中僅有少數個案報告，可能病理機轉為蜘蛛網膜炎後造成腦脊髓液循環受阻。此個案報告顯示蜘蛛網膜下腔出血可併發脊髓空洞症，因此這類患者若有持續肢體疼痛及感覺異常之症狀，理學檢查顯示為眾多皮節異常而非單一神經病變時，我們建議需接受脊髓核磁共振檢查，以確認病因，作為後續治療計畫擬定之依據。

• 期刊

Role of High Intensity Laser Therapy on a Child with Atlantoaxial Rotatory Fixation-Case Report

After wearing a hairpin for the entire evening during her sleep, 8-year-old girl experienced acute onset of torticollis and neck pain after walking up the next morning. She was brought to our outpatient department. Her head was tilted to the left, with tenderness over the left neck region. Imaging studies revealed atlantoaxial rotatory fixation. She initially received a combination of soft neck collar and medications with muscle relaxants as well as anti-inflammatory agents. However, these treatments had limited effects. Then, she received high-intensity laser therapy on the left posterior deep neck muscles, which greatly improved the range of motion of her neck.

• 期刊

不常見位置之足底筋膜病變：兩病例報告

足底筋膜病變是很常見的疾病，通常是臨床診斷且最常影響到的區域是足底筋膜的跟骨近端處，很少人在探討跟骨遠端的足底筋膜病變，據文獻回顧發生在跟骨遠端的的病灶只佔足底筋膜病變的12％，而本文的兩病例報告是上述遠端病灶之中發生在足底筋膜中段的筋膜病變，此類病灶發生比例顯然會更低。這兩案例位於足弓之足底筋膜病變，是屬於非典型部位的病灶，經過增生治療，均未見明顯效果，接著改為類固醇注射，只經一次注射，病患疼痛症狀都有明顯改善。另外扁平足是其危險因子，所以建議使應該用雙腳足弓支撐墊，以改善足底的生物力學缺陷，預防疾病的再度發生。回顧文獻後發現典型跟骨近端的足底筋膜病變相關的文獻很多，但這類非典型足底筋膜病變及其治療文獻討論則極為少見，本報告完整呈現兩病例報告之臨床療程，以提供臨床醫師參考。