急診科物理治療實例 practice of physical therapy at emergency
TRANSCRIPT
Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-1
Emergency Physical Therapy #06:
急診科物理治療實例Practice of Physical Therapy at
Emergency Department
– Acute Lateral Ankle Sprain
Huei-Ming Chai, PT. PhD
School of Physical Therapy
National Taiwan University
Emergency Physical Therapy
• Pre-hospital– BLS
– AED
• PT department or clinic– Medical emergency
– Trauma emergency
• Emergency department– Femur fracture
– Ankle sprain
• Disaster area– Preparedness phase
– Response phase2
Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-2
Scenario 1
• 一名男性50歲車禍病人;醫師評估左大腿骨折,雙上肢擦傷,意識清醒,等待開刀中。
• 你是急診室的物理治療師,請問下列狀況如何處理?
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• 病患疼痛哀嚎
• 病患沒有哀嚎
Scenario 2
• 32歲女性,在大賣場電梯摔下來,被送至急診室。醫生發現腳踝嚴重扭傷,X光確認無脫臼或骨折,開藥後轉介給物理治療師。
• 你是急診室物理治療師,該如何處置?
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Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-3
Questions to Be Solved
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Questions Courses
How many ligaments around the ankle joint, where
are they attached, and what are their functions?
Anatomy
Surface Anatomy
What mechanism of injury results in lateral ankle
sprain?
Kinesiology
Biomechanics
Orthopedics
In general, what does a physical therapist do for this
patient at the first visit?
PT Assessment,
Orthopedic PT
Clinical Internship
What is the role of physical therapist for this patient
at the acute stage?
Athletic Taping
Elastic Taping
Orthopedic PT
How can a physical therapist help with an ankle
injury at the recovery stage?
Athletic Taping
Elastic Taping
Orthopedic PT
Clinical Internship
Clinical Pictures of Lateral Ankle Sprain
• acute inflammation:紅、腫、熱、痛
• unable to do single-leg heel-rise or – ankle plantarflex + inversion: ATF
– ankle neutral + inversion: CF
• pain during passive ankle plantarflexion
and inversion
• tenderness– ATF
– CF
• DO NOT perform anterior drawer
test at acute stage
patient cares?
PT cares?
pay more attention to?
6For chronic ankle instability only
Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-4
PT Assessment
Physical Therapy Approach
safety checking
self introduction
systemic
approach
decision-making
approach
treatment-based
approach
execute treatment
modified
treatment planevaluate
outcomes
Infection control
environment safety
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First Aid as Acute Ankle Sprain
• Protection (保護)
• Rest (休息)
• Ice (冰敷)
• Compression (壓迫)
• Elevation (抬高)
rest
elevation
ice
protection
+ compression
迷思:1. 停止冰敷時間2. 冰敷時要加水3. 第一時間冰敷控制繼續腫脹,
但已經腫脹時,冰敷無法消腫4. 已經腫漲時,消腫靠壓迫與抬高
繃帶、貼紮、按摩、淋巴引
流8
前4-6個小時,每小時冰敷15-20分鐘
Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-5
PRICE Principle
Protection (保護)
Rest (休息) 或
Ice (冰敷)
Compression (壓迫)
Elevation (抬高)
迷思:1. 第一時間冰敷控制繼續腫脹,但已經腫脹時,冰敷無法消腫
2.已經腫漲時,消腫靠壓迫與抬高
Bleakley CM, Glasgow PD, Phillips N, et al. Guidelines on the management of acute soft tissue
Injury using protection rest ice compression and elevation. London: ACPSM, 2011. 9
POLICE Principle
Protection (保護)
Optimal Loading (適度活動)
主動運動
被動運動
阻力運動(重量訓練)
Ice (冰敷)
Compression (壓迫)
Elevation (抬高)
10Bleakley CM, Glasgow P, MacAuley DC. Price needs updating, should we call the police?
Br J Sports Med 2012;46: 220-1
POLICE需要醫學專業知識否則可能造成二度傷害
Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-6
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https://blogs.bmj.com/bjsm/files/2019/04/
Screen-Shot-2019-04-25-at-2.58.47-PM.png
2019
British
Medical
Journal
Kinesio Taping to
Decrease Swelling of Ankle Sprain• position: knee flexed, ankle neutral, and foot
dorsiflexed and inverted
• type: fork-shaped strips (章魚)– anchor end at the muscle belly or lymph node area
– angle of two strips: ~ 30
– least tension
– tails toward distal end
• remarks– 只能消腫,無法預防二度
傷害,所以要加上白貼
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Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-7
Kinesio Taping on Internet, OK?
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眼皮水腫貼紮一小時後
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Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-8
Lymphatic Massage
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• 利用淋巴引流,加速排除代謝廢物• 以<35Hg的力量對腫脹肢體做向心推動• 先做淋巴結較多的地方(有凹窩處)
• 肢體近端先開始,按摩方向是向心臟方向• 下肢順序:1.鼠蹊2.大腿 3.膝窩 4.小腿5.跟腱6.足底7.足背
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16
3 min later
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Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-9
2018/12/03 Ecchymosis for a Week
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Before
(9:30 am)
Drainage Taping After
(11:30 pm)
Patient Problem
(or Population)
63 athletes who suffered an acute ankle sprain
that had occurred between 48 and 96 hours
before the 1st assessment, with visible swelling of
the ankle
Intervention Kinesio taping for 3 days, which was designed to
treat swelling
Comparison
or Control
sham Kinesio taping for 3 days
Outcome swelling measured via volumetry and perimetry,
which collected immediately after 3-day
intervention and 15 days post intervention
Results NS (no significance) 18
Nunes GS, Vargas Vz, Wageck B et al:
Kiesio taping does not decrease swelling in acute
lateral ankle sprain of athletes: A randomized trial.
J Physiother 2015;61:28-33.Is this study design reasonable?
Please criticize!!
Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-10
浴缸水滿了
• 浴缸水滿了,即將淹水,你會如何處理?
打開底部出水口關掉水龍頭
固定關節促進引流
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Principles of Management
• to enhance external support– acute: athletic taping with compression felt
– recovery: kinesio taping or bandaging
• to keep ligament in a shortening position– in a position of 0 of dorsiflexion and eversion
• PRICE or POLICE– icing + elastic bandage
– 15-20 min each hour for first 4-8 hours
• crutch walking with a toeing-out gait
• exercise under water
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Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-11
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扭傷處理新觀念受傷6小時後別冰敷中央通訊社發稿時間:2017/03/16 16:55
http://www.cna.com.tw/news/firstnews/201703160369-1.aspx
恢復期的肌貼--支撐韌帶
calc.
ATF
CF
PTF
lateral view
AP
calc.
ATF
CF
PTF
lateral view
AP
ATF CF22
Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-12
恢復期的肌貼--鎖跟與支撐肌肉
支撐腓骨長肌
鎖跟
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?
Elastic Bandaging for Ankle Sprain
• Luisana bandaging
• 口訣:腳跟、腳背、腳底、拉
5. 腳跟對側
1. 兩圈固定 2. 往腳跟拉 3. 繞過腳背
4. 繞過腳底24
Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-13
案例一: 亞運選手的大拇指
• 9/17 FB: 大姆指腫的不像話,有三個禮拜了,20號開始比賽
• 有無治療?
-- 冰熱敷、超音波都做了
• 那些動作不能做?-- 無法比「讚」-- 彎、直都會痛
• 你現在用按的,按關節的上、下、左、右,哪一個面比較痛?-- 上面,紅腫地方最痛-- 可以往下用力,但無法往上用力
只剩3天
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我的建議
• 做水中的超音波(選手的手指微彎)
• 關節鬆動術,做distraction
• 肌貼 X固定與黃絲帶限制
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Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-14
結果
• 會感到是肌貼拉住的嗎?
-- ㄧ點點--貼的地方有感到痠痛
• 痛嗎?
-- 還是會
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0917結果
• 會感到是肌貼拉住的嗎?
-- ㄧ點點--貼的地方有感到痠痛
• 痛嗎?
-- 還是會
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Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-15
0918修正
• 老師我剛練習完,今天是其他護員幫我貼的
• 腫起來的地方,貼起來還是很不舒服
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0921
• 9/22晚上比賽
• 還痛嗎?
-- 剛冰敷完
• 我沒想到你做冰敷-- 防護員叫我冰敷
• 那你自己處理好了,可能要一小時
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Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-16
改變計畫
• 將手泡在溫水裡不斷地做抓握的動作
• 如果不會不舒服做10分鐘
• 不要太燙唷
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Exercises Under Water
• contrast bath:cold started and cold ended– cold water for 2 min warm water for 30 s cold
water for 2 min …… cold water for 2 min
• to keep continuously moving– 上、下、左、右、繞圈圈
dorsiflxion/ plantarflexion
inversion/ eversion
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Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-17
肌貼並非是唯一的解決方法
治療前 治療後 治療9小時後33
First Aid of Acute Ankle Sprain
場邊物理治療Sideline PT
隨隊物理治療Team PT
冰不冰 冰 不冰
按不按 不按 按(淋巴按摩)
貼不貼 貼白貼 貼肌貼+白貼
動不動 不動 動(水中運動)
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Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-18
奧運是物理治療師的競技場
35http://ptlog.pt.ntu.edu.tw/ptlog/?vol=117&aid=1879
Physical Therapy Outcomes (I)
• pain– Provocation: aggravating factors/ decreasing factors
– Patient specific functional scale (PSFS)
– Quality: sharp/ dull’ stabbing/ burning/ tingling
– Radiation: peripheralization/ centralization
– Severity: visual analogus scale (VAS)
– Time: continuous vs. intermittent
0 10
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Emergency Physical Therapy 110
Fracture and Sprain at Emergency Station
2021/11/4
06-19
Physical Therapy Outcomes (II)
• swelling– figure of eight method
– water volumetry method
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Physical Therapy Outcomes (III)
• muscle flexibility test– ankle dorsiflexion in knee extended position
– ankle dorsiflexion in knee flexed position
• muscle strength tests– peroneus longus
– peroneus brevis
• one leg stance test– with eye open
– with eye closed
38