Treatment of Individuals who are Slow to Recover 2/9/01 CMSA

MANAGEMENT of INDIVIDUALS WHO ARE
SLOW TO RECOVER FROM BRAIN INJURY
Jeffrey Englander, MD
Michelle Tipton-Burton, MS OT
Santa Clara Valley Medical Center
Referrals (408) 885-2032
www.tbi-sci.org/rehab
NIDRR, US Department of Education,
TBI Model Systems of Northern California
Objectives
 Know the common etiologies that result in slow recovery
after brain injury
 Identify appropriate medical management strategies to
maximize outcomes
 Incorporate critical aspects of care into comprehensive
treatment plans
 Discuss realistic expectations for progress in acute
rehabilitation vs subacute settings.
 Address cultural/ linguistic issues when incorporating
caregivers into treatment plan
Objectives (part 2)
Visualize useful therapeutic interventions
for this population
Set realistic goals in treating individuals
with severe brain injury
Understand the goals of positioning and
how they pertain to severe brain injury
Familiarization of necessary components
for safe/smooth transition to home and
community
Etiology of Injury: Assess by EMS
ER Reports, acute complications

Hypoxia: overdose, hanging, drowning, aspiration
 Trauma plus high ICP, hypotension, hypoxia
(obstructed airway), recurrent hemorrhage
 Subarachnoid hemorrhage with severe vasospasm
 Any of above with multiple medical problems,
e.g., sepsis, pulmonary embolus
 Cardiopulmonary arrest
Brain perfusion is the critical factor-> prognosis!
PROMPT RESUSCITATION & EVACUATION
TO TRAUMA or SPECIALTY CENTER
Drug overdose
 2nd
most common cause to trauma
 Environmental availability of substances
 Long-term encephalopathy
 Current episode: determines recovery pattern
 Hypoxia from aspiration/ large ingestion
 How long down before found? Intubated in field? Lactic acidosis?

Chronic use: determines intervention plan
 How long abuse occurring?
 Interference with daily functioning
Sudden Cardiac Arrest
 3rd
most common cause of coma after
trauma and drug overdose
 225,000 US
 450,000
deaths before reach hospital
CPR during hospitalizations
 80% survivors
comatose after resuscitation
Predicting outcome is challenging !
Non traumatic coma prognosis
DE Levy et al, Ann Int Med 1981: 94293-301

Metabolic coma best recovery > hypoxia> stroke,
SAH
 Day 1: best recovery: speak, open eyes to noise,
commands, dolls eyes/caloric
 Day 3-7: best: orienting eye movements, obey
 2/3 have good recovery if purposeful by day 3
 Poor recovery: no eye opening or movements,
pupillary/ corneal reaction, extensor posturing
Diego’s story
22 yo LH male fell off moving car/intoxicated
CT scan: SDH/EDH/SAH, herniation requiring
emergent craniectomy. Trach & gastrostomy @ 3
weeks
Rancho level 2-3; diaphoretic without fever,
suctioning 4x/ shift with strong cough.
Dysconjugate gaze, bilat facial weakness.
Intermittently grabs washcloth. Bilat LE extensor
tone, difficult to range ankles; UE flexor tone.
Bilateral hyperreflexia and Babinski reflexes.
Diego (2)

How should we characterize Diego’s
injury?
 What is his cognitive state?
 How are we going to measure his progress?
 How are we going to treat his various
problems?
Diego early film clip
Maria’s Story
18 y/o female, living with boyfriend, unrestrained
passenger in SUV rollover.
EMS GCS 6, flexor posturing, intubated in ER
CT scan: basilar skull fx, subarachnoid, intraventricular
R temporal, putamen, caudate hemorrhages. Ribs, L
clavicle, bilateral pelvic fractures, WBAT
Day 1-10: fever (no infection found), intermittent atrial
flutter, cuffed tracheostomy (30% oxygen),
gastrostomy with continuous feeds, fosphenytoin for
seizure prevention, baclofen for spasticity and
famotidine for ulcer protection. Referred to SCVMC
Maria’s story 2
Admission to rehabilitation 14 days post injury at
request of her insurance carrier
HR 76 rest, 140 with stimulation, BP 98/60, RR 20
30% O2. Awake, did not follow commands,
spontaneously moved R hand, L eye did not move
past midline, no L eye closure. Jaws clenched,
grinding teeth, bilateral decorticate posture L > R
How should we characterize Maria’s injury?
What is her cognitive state?
How are we going to measure her progress?
How are we going to treat her various problems?
Pathophysiology: Severe TBI
TBI: Most common cause of coma
 Diffuse Axonal Injury plus ischemia
History: Look for hypotension, hypoxia
Multiple cortical and white matter lesions
Thalamus and midbrain injuries
 ICP > 20 mm Hg for > 24 hrs
 Craniectomy for severe swelling
 GCS motor 5 (purposeful movement) or 6 (follows
commands): Length of coma is landmark of recovery!
 Is patient pulling tubes, following commands?
 Has person been out of bed? Will enhance alertness.
Coma: Rancho level 1



Plum & Posner: not arousable, responsive or aware
Teasdale & Jennett: Glasgow Coma Scale Verbal 1, Eyes
1, Motor 1-3 (decorticate/ decerebrate)
Brainstem reflexes can be present!
 pupillary reaction: direct and consensual
 oculocephalic reflex: eyes move opposite head turn
 corneal reflex: blink with stimulation
 vestibular reflex: cold water, eyes to stimulus
 cough/ gag with stimulation
Coma rarely lasts > 3-4 weeks unless medication
induced
Vegetative State (PVS): Awake but
unaware, Rancho Level 2


No awareness of self or environment / purposeful behavior
 Cannot attend, follow commands
 No intelligible verbal response/ communication
 No automatic motor response or localizing
 Incontinence bowel and bladder
Positive signs
 Sleep/ Wake cycles
 Brainstem, autonomic functions: gag, swallow, cough,
GI motility, temperature regulation
 Random vocalizations, movements
Vegetative State: Tests

PET scans: regional glucose or O2 metabolism
 Levels “far lower than those locked in”
 Disconnection cortex to cortex/ thalamus visual, auditory, painful
stimuli which improve when awareness improves

Neuropathology
 Severe, diffuse lesions incompatible with awareness

CT/ MRI: non-specific atrophy on serial scans or multiple lesions in
midbrain/ thalamus/ corpus callosum/ grey white matter junction

fMRI: activation of language network loci after stimulation before
clinical signs?
Laboratory evaluation cannot yet distinguish VS from MCS; clinical
evaluation is crucial!
Vegetative State: Differential Diagnosis

Coma: no sleep / wake cycles, not arousable

Brain death: no brainstem reflexes, apneic

Dementia: normal arousal with loss self awareness

Akinetic mutism: impaired movement from
bilateral midbrain, thalamus or frontal injuries

Locked in: Awareness without motor function.
Some breathing preserved. Pons or diffuse
peripheral nerve injury
Vegetative State

Persistent Vegetative State (PVS) = diagnosis
 Describes past and current state
 1 month post event or after 1 month status

Permanent (Irreversible) Vegetative State

12 months after TBI

3 months after non traumatic brain insult
 Determine level of medical support, nutrition
Advanced Directives helpful, but rarely present!
Minimally Conscious State: Guidelines
Rancho Level 3

Some Awareness with wakefulness: Inconsistent

Definite reproducible behavioral evidence of some
awareness of self or environment
 Following commands
 Gestures or verbal responses to question, yes/no signal
 Intelligible sounds
 Crying, laughing, smiling to meaningful stimuli
 Reaching for objects, holding objects
 Visual fixation or tracking (pursuit eye movement)
Emergence from Minimally Conscious State
Guidelines

Reliable and consistent behavior in at least 1 area
 Functional interactive communication. 6/6 accurate
responses for situational questions, “are you standing?”

verbalization

yes/ no signals

written communication

augmentative communication device
 Functional use of 2 different objects

Example: use of brush for grooming
Rating Scales Disorders of Consciousness
(ACRM BI-ISIG, 2010)









Glasgow Coma Scale (GCS)
Coma Recovery Scale-Revised (CRS-R)***
Western Neuro sensory stimulation profile (SSAM)**
Sensory Modality Assessment & Rehabilitation Technique
(SMART)**
Wessex Head Injury Matrix (WHIM)**
Disorders of Consciousness Scale (DOCS)**
Coma-near coma scale*
Full Outline of UnResponsiveness (FOUR), Swedish
reaction level, Comprehensive levels of consciousness,
Innsbruck coma, Lowenstein, Glasgow-Liege scales: not
recommended
Rancho Los Amigos Level of Cognitive Functioning Scale
MCS: Consensus-based approaches to care

Assume person can feel pain, may understand
some conversation

Prevention of complications, maintain body
integrity

Establish functional communication, interaction
with environment

Experienced professionals for establishing
diagnosis, prognosis, coordinating clinical
management
MCS: Consensus-based approaches to care (2)

Critical management decisions: recommend 2nd
opinion
Determining appropriate level of care
Disputed treatment decisions
Withdrawal of life sustaining treatment
Decision point: requires medical stability
SUBACUTE CARE
Respiratory and tracheostomy care: internist plus
respiratory therapist or nurses
Nutrition: gastrostomy and enteral feedings
Therapy: ROM, swallowing, 0-2 hours/day
Less expensive in short run
Variable awareness of secondary complications
How comprehensive does the care need to be to
facilitate optimal recovery?
Subacute care questions

Resources to get patient OOB 1-2 times/ day in
optimal sitting position?
 Establish reliable communication system?
 How will track cognitive/ motor progress?
 How manage common complications?
 Trach or ventilator weaning methods
 Hydrocephalus
 Postttraumatic seizures
 Heterotopic ossification
 Tone and musculoskeletal challenges
 Establish continence of bladder/ bowels
Decision: approaching medical stability
Acute rehabilitation: specialty program

Earlier acceptance: ICU to acute rehabilitation

Experience of team: years, numbers of patients

Maybe more expensive in short run

Prevent morbidity, costly care in the long run

Peer support for patients, families

Holistic approach: better functional outcome
Journey to Recovery Program
Goal: Transition to acute rehabilitation, home
Prevent complications
Optimize alertness, awareness

Family understanding of prognosis and discharge

Payer understanding and acceptance of slower
progress, benefits of the program before arrival

Quantitative progress reporting

Weekly goal-oriented reassessments
Journey to Recovery: Patient Assessment
Goal: Characterize brain injury by thorough
neuromedical evaluation and plans
 Health: respiratory management, complications,
pharmacology
 Behavioral interventions
 Cognition and communication
 Nutrition and swallowing
 Mobility, positioning and tone management
 Self care and toileting
Rehab Trauma Center: RTC

Step-down from ICU/ recovery room
 1:1 or 1:2 nursing care needed
 Acute SCI patients pre and post surgery
 Brain Injury patients with high respiratory care
needs: ventilator or suctioning every 1-2 hours
 Ventilator weaning
 PM&R MDs with consultation from specialists
 Dedicated respiratory therapy staff
 PT, OT, SLP services by rehabilitation teams
Integrated Team: Tracheostomy
Weaning
Initial Goal: smaller diameter tubes to decrease
secretions, plugging to allow vocalization
Long-term goal: discontinue tracheostomy

Deflate cuff 24-48 hrs: assess vocalization, airway
protection, cough efficiency

Metal trach tube: smaller external diameter

Trials: Passey-Muir valve, artificial nose, plug

Maintain longer if used for monitoring dysphagia
Brain Injury Complications
Goal: Characterize brain injury and recovery
pattern
 Seizures: careful observations, EEG monitoring
 Hydrocephalus: deterioration or arrested recovery
Plan with neurosurgeon
CT/MRI
Lumbar puncture or drain with functional
evaluation before and after lowering pressure
1/2-2/3 opening pressure
Weaning Trach: communication
 Tracheostomy types
Shiley, Jackson, Bivona
Suctioning
 Artificial nose
 Trach cuff deflation
 Plugging

 Speaking Valve
Passy Muir
D. Peruzzaro
Integrated Team: Nutrition and Swallowing
Goal: adequate hydration, nutrition-> eat food, drink

Continuous -> bolus feeding

Use of tracheostomy to monitor aspiration

Dysphagia evaluation

Timing of videofluoroscopy: depends on bedside
assessment capability of therapist/ patient

Eating trials with diminishing supervision needs

How long gastrostomy tube?
Nutrition and Swallowing



Swallow Evaluation: was it OOB?
Pre-swallow Program: trach plug may help
Secretion management
Thermal stimulation
Vital Stim
Oral motor exercises
Caregiver training
Positioning
Will FEES or Videofluoroscopy guide compensatory
techniques?
D. Peruzzaro
Medications: slow to recover

Initiation problems
– Quick onset: methylphenidate, atomoxetine, d-
amphetamine
– Medium onset: modafinil
– Long onset: bupropion, venlafaxine, fluoxetine

Test dose avoids adverse side effects: titrate
Targeted Medication Interventions

Consolidation/ simplification of medications:
weaning sedating medications

Key target areas: e.g., arousal/sleep, pain, tone,
secondary complications

Baseline behavioral observations, laboratory,
radiologic evaluations

Adequate trials of interventions with
measurements: A/B/A’ (new baseline)
Initiation and participation:
Medications
Initiation problems
– Baseline behavior 2 days for routine ADLs,
mobility, attention to activity = A
– Medication trial = B
– Medication withdrawal with new behavioral
baseline = A’
Medications: bradykinesia

Bradykinesia, rigidity:
– DC antipsychotics
– L-dopa/carbidopa: best tolerated, fastest onset
– amantadine
– pramipexole: slow build up, GI symptoms
– bromocriptine: narrow therapeutic window
Medications: Arousal

Arousal problems Case reports
– Quick onset: methylphenidate, amantadine,
atamoxetine, d-amphetamine
– zolpidem
– Medium onset: modafinil
– Long onset: bupropion, venlafaxine, fluoxetine

Test dose avoids adverse side effects: titrate
Management of Insomnia

Sleep deprivation typical during acute care

Sleep / wake cycle measurements: by ½ hr observations

Pain management

Restless legs /myoclonus: hypoxic injury

Sleep hygiene
Insomnia

Minimize nighttime interruptions

Out of bed and activity schedules

Short-term, help more with falling asleep:
– zolpidem, zaleplon, eszopiclone up to 5 weeks
– hydroxyzine, diphenhydramine: hangover, urinary
retention
– diazepam, clonazepam for benzo withdrawal
Insomnia

Long-term use, more than several weeks:
– Trazodone, tricylclics, mirtazapine
– Neuropathic pain: gabapentin, TCA
– Spasticity that disturbs sleep: tizanidine
– Restless legs (hypoxia): L-dopa, clonazepam
– Melatonin, valerian: OTC
– Ramelteon (melatonin agonist): newest
Paroxysmal Autonomic Instability
Tachycardia, BP, sweating, hyperthermia
 metabolic/ endocrine work-up
 B-blockers: propranolol
 bromocriptine, morphine, benzodiazepines
 Dystonia: extensor posturing, rigidity
– baclofen
– dantrolene
Bladder Management
Goal: Continence of urine
 Pre-injury: nocturia, prostate, stress incontinence
 Current emptying pattern?: measure PVR after sitting void
 Small capacity with complete emptying: oxybutynin,
tolterodine, imipramine
 Overflow or incomplete emptying (diabetes,
multiparous women): a-blockers
 Dyssynergia = imbalance between detrusor and
sphincter (SCI, MS): needs urodynamic study
 Renal/ bladder status: Ultrasound, VCUG
 Timed voiding, especially if normal emptying
 Condom usage for men
Bowel Management
Goal: continence of bowels
Assess pre-injury bowel habits
Typical interventions:
 Timed evacuation after eating/feeding
 Positioning on commode or toilet using gravity
to facilitate emptying
 Avoid anticholinergic agents
 Motility and softening agents
Wean medications as mobility improves
Bowel Medication Management





Water/CCK release entire bowel/ electrolytes: Mg
citrate, MOM
Colonic mucosa nerve plexus stim/ electrolytes:
cascara, bisacodyl, senna, castor oil
Bulking agents entire bowel: psyllium,
polycarbophil, methlycelluolose
Softeners: DSS, mineral oil
Osmotic agents (colon): lactulose, glycerine
Communication Considerations
 Variability of
communication methods
 Consistent use by family & staff
 Emerging attempts to communicate
 Reliable Yes/no system
Eye blinks
Eye gaze to signs
Head nod/ shakes
Limb movements
D. Peruzzaro
Communication Aids
 Communication Boards
Visual scanning (word/letter)
Eye gaze
 Pointing

D. Peruzzaro
Alternative Augmentative
Communication
Augmentative Devices
Communication buttons
• Big Mac
Talking icons


Tech Talk
Macaw
Computer


Gemini
Vantage
D. Peruzzaro
Musculoskeletal Problems
Goal: allow sitting, standing, bed positioning
 Fractures: clarify
weight bearing plan early
 Heterotopic ossification: severe trauma, burns,
fractures, AVMs, recurrent CNS hemorrhage
Symptoms 2-8 weeks post injury,
usually detected by therapists, nurses, families
X-rays, triple phase bone scan: NSAIDs,
etidronate x 6-9 mos
Avoid costly surgery, radiation, pain, time delays
Case: BS
19 y/o restrained passenger, crash with TBI,
pelvic and transverse process fx T spine.
Acute care 11/1/02 in Trauma center
Sub acute care 12.5.02-3.25.03: severe
spasticity, multiple joint contractures,
elevated alk phos; C diff diarrhea. Trach dc.
Acute rehab 3.25.03: Rancho 4-5; continuous
feeds. Communicates yes/no with fingers.
Spasticity management
GOAL: Normalize tone with minimal daytime sedation
 Positioning in bed, chair
 Sitting/ standing opportunities: 2 people treatment
 Neuromuscular blocks PLUS casting
Phenol: motor points for large muscles,
musculocutaneous nerve (biceps), obturator nerve
(thigh adductors)
Bupivacaine: any nerve, allows immediate casting in
relaxed position
Botulinum toxin: every 3 months, small to medium
sized muscles
Spasticity management

Systemic medications
Dantrolene > tizanidine, baclofen
Intrathecal baclofen after 4-6 months
Positioning and casting consume the most
time and resources: Early treatment
makes a difference by reducing the need!
Positioning
Goal: promote comfort, functional
movement in bed, sitting and standing
Why Should Patients Get Out of Bed ?
 Increases alertness
 Increases endurance
 Increases opportunity for
participation in
functional activities
 Physiology of
breathing, eating,
elimination, blood flow
Wheelchair Seating and Positioning
components
 Head
support
 Cushion
 Backrest
 Lateral supports
 Shoulder straps
 Footrests
 Lap tray
Case Study- Katy
17 y/o RH female restrained passenger in MV crash,
100’ down embankment. Intubated in field and
sent to trauma center. CT scan: subdural
hematoma. ICP monitor: normal pressure.
Tracheostomy at 12 days; PEG at 2.5 weeks
3 weeks post injury: intermitted purposeful
movement on L side. Suctioning 4-6x/shift
3.5 weeks: adm to RTC. Signaled intermittently with
open hand for yes; R gaze preference,
dysconjugate eye movements. Clenched jaw, R
hemiplegia Ashworth 4. L hemiparesis.
Katy
2 months of acute rehab
Out of PTA 2 months post injury
Serial tibial nerve blocks w casting RLE x4; LLE x1.
R musculocutaneous phenol x1
Botulinum toxin: R tib posterior, thumb/ finger
flexors/ pronator teres
DC: Min assist grooming/ upper dressing; bed
mobility/ WC transfers; mod assist tub transfer,
LB dressing. Continent bowel bladder.
Communication-basic needs; assist for complex
money management. Supervised household WC
Consequences to Lack of
Intervention

Contractures

Poor head and trunk control

Increase in caregiver assist

Limited participation in mobility

Transportation difficulties
Risk for prolonged need for SNF care
Consequences to Lack of
Intervention
 Contractures
 Poor
head and trunk control
 Increase in
caregiver assist
 Limited participation in
mobility
 Transportation difficulties
Risk for prolonged need for SNF care
Case: AJ
18 y/o ejected from car. L frontal hemorrhage
and punctate contusions. L wrist and R
femur fx, trach, PEG.
Acute trauma 2.13.02-3.15.02
Sub acute 3.15.02-11.18.02
SCVMC 11.18.02: Alert, oriented with
gestures, 4 ext contractures but able to
move everything with limited range
When do you Cast?
 Splinting has
failed to control severe tone or
contracture developing
 Positional cast
is necessary for continued
use (bivalve)
 Range
of motion is decreased and
prolonged stretch is necessary
Mobility
Goal: head/ trunk control for transfers,
sitting. Reframe patient, family goals for
walking!

Safe transfers allow one to function at home

Standing activities: standing frame, parallel bars
decrease tone, increase upright tolerance

Ambulation with assistance: teaching the team,
including family
Standing Devices
 Tilt
table
 Hydraulic standing
 Manual standing
frame
frame
 Parallel bars
 Standing against
wall/open space
Mobility goal example:
Current status: Pt. Requires max assist for
30 minutes in standing frame with 2 people.
STG: Pt. To require (max) assist for (30)
minutes in standing frame with (1) person.
Mat Mobility
Trunk Mobilizations
Bridging
Tall Kneeling
Jack’s story
19 y/o RH distance runner, HS grad. Rollover crash with
family. GCS 5, non-reactive pupils, hypotension needing
dopamine, IV. CT: R frontal fx, brainstem, midbrain, R
thalamus, frontal, temporal contusions, SAH. C7 spinous
process, L1 burst, L2-4 compression fx. Trach and PEG
3 weeks post TBI: SCVMC for rehab trauma care; Rancho 2;
trach weaned to metal cuffless; flexion/extension neck
cleared; TLSO for 12 weeks; CT head improvement
4 weeks post TBI: acute rehab Rancho 2-3. Pupils, corneals.
Limited eye excursion, tongue weak. Tremor RUE/ LE,
rigidity, some spasticity. Focus on wheelchair positioning,
communication, OOB activity
Jack’s Video
 Jack
transferring from acute rehab to
day treatment program
 Evaluation of function and mobility
 Reassessment of ankle ROM and
AFO’s
 Reassessment of Wheelchair
Length of Stay:
Dictated by achievable goals
4-8 weeks know what direction going
May continue to make steady progress -> continue
traditional acute rehabilitation
May make minimal progress-> transition to less
acute care
Caregiver training for home or alternative
institutional care
Family/Caregiver Participation
VIP Suites
Family training initiated early
Empowers family
Assists in the patient’s recovery
Family/Caregiver Training
Durable Medical Equipment (training/ordering)
 Bed (medical necessity/caregiver assist)
 Bathroom equipment
 Wheelchair (purchase vs Rental)
Home evaluation
 Accessibility
 Safety
When Families Request:
Alternative Interventions
 Special Diets
 Hyperbaric Oxygen
 Nerve Stimulation
 Neurofeedback
 Acupuncture
 Massage
Maria’s Video
Conclusions: Slow to Recover
Pathophysiology: hypoxia, hypotension, high
intracranial pressure, vasospasm
Long-term investment: early comprehensive
management->fewer complications
Neurorehabilitation expertise
Teamwork
Planning care, following trajectory of individual’s
recovery is crucial to optimize outcome
Post Presentation Questions
 What is the most critical early complication that affects
brain injury recovery?
 What is the difference between vegetative state (Rancho 2)
and minimally conscious state (Rancho 3)?
 Name 3 later complications that can prolong LOS and
morbidity
 Name 2 interventions for managing contractures from
increased tone or spasticity?
 What are some crucial capabilities that rehabilitation
programs must target to get a severely disabled person
home?
References
American Congress of Rehabilitation Medicine Brain injury special interest group,
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consciousness: evidenced based recommendations for clinical practice and
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Blackman JA et al, Paroxysmal autonomic instability with dystonia after brain
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Bernat JL, Questions remaining about the minimally conscious state. Neurology
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Booth CM et al, Is this patient dead, vegetative or severely neurologically
impaired? Assessing outcome for comatose survivors of cardiac arrest.
JAMA 2004; 291: 870-879
Brain Injury Association (BIA) : www.biausa.org
Center for Outcome Measurement in Brain Injury (COMBI),
www.tbi-sci.org/combi. Website for outcome measures coordinated by
SCVMC TBI Model System.
Chew E, Zafonte RD. Pharmacological management of neurobehavioral disorders
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389-405
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Englander J and Cifu DX, The older adult with traumatic brain injury in
Rosenthal M et al, Rehabilitation of the adult and child with traumatic
brain injury, 3rd edition. FA Davis Co, Philadelphia, 1999, 453-471
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