🏥 Clinical Grand Rounds | Case Report

Source: 2025-12-14-16_黃O嫦.html

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Department of Physical Therapy & Rehabilitation

Date:

Status: Active Care

Patient Name

Ms. Huang (黃x嫦)

Constitutional Signs

Heat Intolerance / Wind Phobia (Autonomic Dysregulation?)

Key Comorbidity

Pain-induced Auditory/Cognitive Interference

臨床病程與疼痛轉移地圖 (Clinical Course & Pain Migration Map)

{{< mermaid >}} graph TD subgraph Right [右腳: 疼痛轉移路徑 Right Leg Migration] R1[“初始: 小腿痛(Initial: Calf Pain)”] R2[“症狀緩解(Relief)”] R3[“轉移焦點: 膝蓋痛(Knee Pain)”] R4[“轉移焦點: 髖部/大腿外側(Hip/Lateral Thigh)”] R5[“現況: 僅存麻感行走時(Current: Numbness)”]

                    R1 -- "神經鬆動術 + 腳底伸展(Neural Mob + Stretch)" --&gt; R2
                    R2 --&gt; R3
                    R3 -- "膝蓋彎曲運動(Knee Flexion Ex)" --&gt; R4
                    R4 --&gt; R5
                    end

                    subgraph Left [左腳: 新發症狀 Left Leg Onset]
                    L1["無症狀(Asymptomatic)"]
                    L2["疼痛 + 腳趾麻感 1/2趾(Pain + Toe Numbness)"]

                    L1 -- "去遮蔽效應 / 代償解除(Unmasking / Compensation)" --&gt; L2
                    end

                    subgraph ADL [功能性訓練 ADL Training]
                    F1["餐廳情境模擬(Restaurant Scenario)"]
                    F2["減少助行器依賴(Reduce Assistive Device)"]

                    F1 -- "雙重任務訓練(Dual Tasking)" --&gt; F2
                    end

                    style R1 fill:#fecaca,stroke:#ef4444
                    style R5 fill:#dcfce7,stroke:#22c55e
                    style L2 fill:#fef08a,stroke:#eab308
                    style F1 fill:#dbeafe,stroke:#3b82f6

SINSS Analysis (病理特質分析)

Severity (嚴重度): High. 疼痛直接阻斷聽覺認知處理。
Irritability (易激惹性): High. Jump Sign (+) 顯示極高機械敏感度。
Nature (性質): Neuropathic (Moving Shooting Pain) + Autonomic Component (Heat/Wind sensitivity).
Stage (病程): Sub-acute migration phase (Pain moving proximally).
Stability (穩定度): Volatile. 受精神狀態與疲勞顯著影響。

Red Flags / Precautions

Auditory-Cognitive Interference: 疼痛時無法處理語言。治療指令需簡短明確，並於疼痛緩解後再進行衛教。
Sensory Dysregulation: 患者愛冰卻怕風，注意治療環境溫控，避免風口直吹誘發不適。

Subjective (主訴與病史)

Symptom Evolution (症狀演變)

Right Leg (右腳):
- 初始：小腿疼痛 (Calf Pain)。
- 現況：疼痛緩解，轉為麻感 (Numbness) (特別是行走時)。
- 誘發：伸直後突然移動會引發抽痛 (Shooting Pain) (小腿至腳底)。
Left Leg (左腳):
- 現況：新發作疼痛 (New onset pain)。
- 特徵：大拇指與食指麻感 (L4/L5 pattern?)。

Functional Report (功能回報)

Improvement: 氣色改善，行走距離增加。
Left Toe Control: 治療後左腳趾靈活度提升。
Stiffness: "Gel Phenomenon" - 久坐/久伸直後，膝蓋彎曲時有強烈僵硬與抽痛感。

Objective (客觀評估)

Pain Migration Pattern (疼痛轉移模式):

治療足/小腿 -> 緩解 -> 疼痛轉移至 膝蓋 (Knee) -> 治療膝蓋 -> 疼痛轉移至 髖/大腿外側 (Hip/Thigh)。
*Typical proximal migration sign during neural release chain.

Neuro-Dynamic Tests:

LLTT (+): Positive, especially Tibial/Peroneal bias.
Palpation: 沿神經路徑有明顯 Jump Sign (驚嚇反應)。

Functional Task Analysis (Restaurant Scenario):

Able to perform complex tasks (coffee/fruit prep) without walker support under supervision. Balance improved when cognitively engaged (Dual-tasking).

Assessment (臨床診斷與分析)

1. Peripheral Neuropathic Pain with Proximal Migration: 右腳症狀從遠端向近端（髖部）轉移，且痛感轉為麻感，符合神經減壓後的修復過程 (Release Phenomenon)。

2. Sensory Integration Issue: 聽覺、痛覺與溫度覺（怕風愛冰）的交互影響，顯示中樞感覺處理可能處於高負載狀態。

3. Left Sciatic Irritation: 左腳大拇指/食指麻感指向 L4-L5 或腓神經壓迫，需針對坐骨神經路徑介入。

Plan of Care (治療計畫)

Manual Therapy (徒手介入)

Right Leg (右腳):
1. Foot/Toe Stretches (腳底/趾伸展).
2. Knee Flexion Mobs (追蹤痛點).
3. Neural Mobilization (神經鬆動/去敏感).
Left Leg (左腳):
1. Sciatic Muscle Group Stretch (坐骨肌群伸展).
2. Growth Exercises (生長運動/延展).

Functional Training (功能訓練)

Restaurant Scenario (Dual-Task):
- 任務: 泡咖啡 / 處理水果。
- 限制: 不使用助行器/拐杖。
- 目標: 讓身體在認知負載下自動維持平衡 (Dissociate balance from cognitive load)。
ADL Goal: 上下車轉位 & 獨立站立。

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