在重型创伤性脑损伤中应用ICF框架：以功能分析指导多学科康复——一例病例报告

文献信息

中文摘要

背景： 创伤性脑损伤是长期残疾的主要原因，常导致复杂的躯体、认知和社会心理挑战。康复必须个体化并采用多学科方式。本病例报告展示了应用《国际功能、残疾和健康分类》（ICF）框架来制定综合功能分析、促进目标设定并支持重型创伤性脑损伤多学科康复规划。
病例介绍： 一名35岁南印度男性在道路交通事故后遭受重型创伤性脑损伤和多发损伤。入院时，他表现为深昏迷。神经影像学显示双侧额叶和小脑挫伤、硬膜外和硬膜下血肿、蛛网膜下腔出血、脑水肿、颅骨骨折和胸部损伤。临床吞咽评估提示口腔和咽部反射严重受损。他接受了急性神经外科和内科处理，随后接受多学科神经康复项目。使用ICF框架进行的功能评估识别出心理功能、神经肌肉骨骼和运动相关功能、感觉功能、吞咽以及日常生活活动方面的缺陷。ICF限定值指导制定针对觉醒、定向、运动控制、沟通、吞咽和日常功能的个体化康复目标。ICF框架被用于识别与康复规划相关的损伤、活动受限、参与限制和环境因素。由此产生的功能分析指导了多学科团队内的个体化目标设定。在康复过程中，患者从最小意识状态进展到实现基本定向、使用代偿策略经口进食以及功能性沟通。
结论： 本病例突出了ICF框架在全面分析重型创伤性脑损伤后功能和残疾方面的实际应用。该框架促进了多学科康复背景下的结构化评估、跨学科沟通和个体化目标设定。

英文摘要

BACKGROUND: Traumatic brain injury is a leading cause of long-term disability and often results in complex physical, cognitive, and psychosocial challenges. Rehabilitation must be individualized and multidisciplinary. This case report demonstrates the application of the International Classification of Functioning, Disability and Health (ICF) framework in developing a comprehensive functional profile, facilitating goal setting, and supporting multidisciplinary rehabilitation planning in severe traumatic brain injury.
CASE PRESENTATION: A 35-year-old South Indian male sustained severe traumatic brain injury and multiple injuries following a road traffic accident. On admission, he presented with deep coma. Neuroimaging revealed bilateral frontal and cerebellar contusions, extradural and subdural hematomas, subarachnoid hemorrhage, cerebral edema, skull fractures, and thoracic injuries. Clinical swallow evaluation indicated severely impaired oral and pharyngeal reflexes. He underwent acute neurosurgical and medical management, followed by a multidisciplinary neurorehabilitation program. Functional assessment using the ICF framework identified deficits in mental functions, neuromusculoskeletal and movement-related functions, sensory functions, swallowing, and activities of daily living. ICF qualifiers guided the formulation of individualized rehabilitation goals addressing arousal, orientation, motor control, communication, swallowing, and daily function. The ICF framework was used to identify impairments, activity limitations, participation restrictions, and environmental factors relevant to rehabilitation planning. The resulting functional profile guided individualized goal setting within the multidisciplinary team. Over, the course of rehabilitation, the patient progressed from a minimally conscious state to achieving basic orientation, oral feeding with compensatory strategies, and functional communication.
CONCLUSIONS: This case highlights the practical application of the ICF framework in comprehensively profiling functioning and disability following severe traumatic brain injury. The framework facilitated structured assessment, interdisciplinary communication, and individualized goal setting within a multidisciplinary rehabilitation context.