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TRANSCRIPT
1/13/2017
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Kelly Betts , PT, DPT, NCS Physical Therapist
Kristen M. Ferguson, M.A. CCC-SLP Speech-Language Pathologist
Disorders of Consciousness:
A Comprehensive Treatment Approach
Disclosure / COI Statement
We have the following relevant relationships in the products or services described, reviewed, evaluated or compared in this presentation.
Relevant Financial Relationship(s)
• TIRR Innovations Grant – Use of the Body Weight Support Treadmill in the Minimally Conscious Patient: Effects on Arousal, the
Cardiopulmonary System, and Response to Multi-Sensory Stimulation
• Principle Investigators: Kelly Betts, PT, DPT and Patrice Perrin, PT, DPT
• TIRR Memorial Hermann Employees – Kelly Betts, PT, DPT, NCS
– Kristen M. Ferguson, M.A. CCC-SLP
Relevant non-financial relationship(s)
• No relevant non-financial relationships to disclose
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Course Objectives
1. Overview of Disorders of Consciousness (DOC)
2. Discuss importance of assessment in this population • Describe the Coma Recovery Scale – Revised (CRS-R) and
its limitations
• Explain the use of Individualized Quantitative Behavior Assessments (IQBAs)
3. Interdisciplinary Goal Planning
4. Interdisciplinary Interventions
5. Discharge Planning
Consciousness
• Conscious behavior is often subtle and inconsistent
in the aftermath of a severe brain injury.
• It must be systematically differentiated from reflexive
or random behaviors
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The Trans-disciplinary Team Approach
• Input from many disciplines regarding patient’s abilities, well-being, and overall care.
• Important to bridge all of the various medical and paramedical disciplines.
• Critical to include the family as part of the team.
• Need multiple observers at different times of day.
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PM&R Physician
Specialized Nursing
Respiratory Therapist
Electrophysiologist
Neuro-Ophthalmologist
Occupational Therapist
Physical Therapist
Speech-Language Pathologist
Clinical Neuropsychologist
Case Manager
Social Worker
Chaplain
Family
Patient
Diagnostic Accuracy
• The literature suggests
that approximately 40%
of patients are
erroneously assigned a
diagnosis of VS.
• Standardized behavioral
assessment is a much
more sensitive means
of establishing a
diagnosis than clinical
consensus. 8
Schnakers et al. BMC Neurology 2009
Standardized Assessment
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Behavioral Assessment
• Behavioral observation constitutes the major tool for
detecting signs of consciousness.
• Distinction between arousal vs. consciousness:
– Arousal is necessary, but insufficient, for
consciousness.
– The repertoire of behaviors available for
assessment of conscious awareness may be
dramatically diminished.
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Neurobehavioral Assessment of Disorders of Consciousness
Scales with acceptable standardized administration
and scoring procedures:
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Coma Recovery Scale-Revised (CRS-R)
Sensory Stimulation Assessment Measure (SSAM)
Wessex Head Injury Matrix (WHIM)
Western Neuro Sensory Stimulation Profile (WNSSP)
Sensory Modality Assessment Technique (SMART)
Disorders of Consciousness Scale (DOCS)
Coma/Near-Coma Scale (CNC)
Moderate reservations
Major reservations
Minor reservations
Coma Recovery Scale – Revised
• The CRS-R was developed
in 1991 and revised in 2004.
• The CRS-R assists with:
– Differential diagnosis.
– Prognostic assessment.
– Treatment planning.
• Contains 23 items that comprise
6 subscales.
• Standardized scoring is based on
the presence or absence of
operationally defined behavioral
responses to specific sensory
stimuli.
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Who is Appropriate?
• Patients who range from Rancho Level II to V:
• Level II: Generalized Response:
– Begin to respond to stimuli but slow, inconsistent, or delayed.
– Responses tend to be similar irrespective of stimulation.
• Level III: Localized Response:
– Increased movements and reacts more specifically to stimuli (e.g., turns toward sound, withdraws from pain).
– May begin to respond inconsistently to commands and yes/no questions.
• Level IV: Confused and Agitated
• Level V: Confused and Inappropriate 13
Coma Recovery Scale-Revised Subscales
Baseline Observation
• Purpose:
– Determine level of arousal.
– Facilitate selection of appropriate commands.
– Help differentiate volitional from random/coincidental movements.
• Observe for one minute and record observations:
– Resting posture of extremities, eye opening status, presence/absence of spontaneous visual fixation or tracking, type/frequency of spontaneous movement.
– If no eye opening, perform the arousal protocol.
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Visual
Function
5: Object Recognition *
4: Object Localization – Reaching *
3: Visual Pursuit *
2: Fixation
1: Visual Startle
0: None
Auditory
Function
4: Consistent Movement to Command *
3: Reproducible Movement to Command *
2: Localization to Sound
1: Auditory Startle
0: None
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Oromotor/Verbal
Function
3: Intelligible Verbalization
2: Vocalization/Oral Movement
1: Oral Reflexive Movement
0: None
Motor
Function
6: Functional Object Use †
5: Automatic Motor Response *
4: Object Manipulation *
3: Localization to Noxious Stimulation *
2: Flexion Withdrawal
1: Abnormal Posturing
0: None/Flaccid
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Arousal
Scale
3: Attention
2: Eye Opening without Stimulation
1: Eye Opening with Stimulation
0: Unarousable
Communication
Scale
2: Functional – Accurate †
1: Non-Functional – Intentional *
0: None
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Limitations and Medical Complications
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Post-traumatic Epilepsy Dysautonomic Storming, tachycardia,
blood pressure changes, fever
Spasticity and Posturing Arousal Deficits
Hydrocephalus Attention Deficits
Tracheostomy and secretion
management
Apraxia
Visual Deficits Aphasia
Hearing Deficits Primary language
Heterotopic Ossification Abulia
Bruxism Pressure sores
Individualized Quantitative Behavioral Assessment (IQBA)
• Due to the variability of this patient
population, individualized
assessments are needed to more
formally assess a patient’s response.
• Complements standard
neurobehavior assessments, such as
the CRS-R
• Advantage is that this address the
particular questions and behaviors of
concern to family members and
clinicians
• Differences in the frequency of the
target behavior can be assessed
statistically to determine if the rate of occurrence is significantly greater in
one condition relative to others.
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IQBA
Command Following Protocol • Establishes a method for consistently and
accurately assessing a patient’s ability to
follow commands.
• General data recording is not sensitive
enough to show if patient is becoming
more consistent over time.
• Ambiguity regarding command-following
responses in DOC patients:
– Voluntary, involuntary, and
reflexive responses.
– Reliability issues (false positive
data recording).
• Important for treatment: a starting point for
communication.
Vision Protocol • Visual functioning is one of many areas
used to assess a patient’s level of
consciousness.
• Clinical questions regarding the status
of the visual system may arise.
• Vision is a critical channel for acquiring
information, especially in the DoC
population because exploring and
manipulating the environment can be
limited.
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Command Following Protocol
• Determine the command
• Setup of IQBA with team collaboration
• Collection of data
• Review of results
• Integrate into treatment plan
VP Methods
• Similar to Command Following Protocol, set-up and assessment are individualized to the particular patient.
• Stimuli:
– Glossy, color, meaningful photo.
– Plain white card the same size as the photo
• Procedure:
– Patient shown unilateral stimulus or bilateral stimuli.
– Yes Response: first lateralized eye movement after presentation.
– No Response: No eye movement within 5 seconds.
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Data Pattern for VP
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Stimulus
(left/right) Looks Left
Looks Right
No Response
1. Photo/____ 9 1 21
2. ____/Photo 1 28 3
3. Card/____ 12 4 16
4. ____/Card 1 12 19
5. Photo/Card 1 25 7
6. Card/Photo 4 19 9
TOTAL 28 89 75
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IQBA Conclusions
• Command Following Protocol and Vision Protocols are examples of IQBAs
• Command-following and vision protocols are aspects used in assessing level of consciousness.
• Command-following is central to ensuring the modality of treatment intervention matches patient’s abilities:
– It can also help to facilitate family members’ understanding of observed behaviors (e.g. volitional versus involuntary/spontaneous)
• Vision protocols assist in helping determine if a patient has gaze preference, field cut, neglect, etc.
• Quantitative data can identify and validate subtle patterns we do not pick up on as clinicians
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Pain Assessment
• Biofeedback
(vitals)
• NCS-R (Chatelle
et al.)
Affective Responding
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Affective Responding
• Often forgotten during assessment but also very powerful.
• Frequently reported by family.
• Environmentally contingent affective responses are a sign of conscious awareness:
– May require an IQBA to assess.
– Standardized neurobehavioral assessments do not quantify this area.
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Therapy Goals
PT/OT Goals
• Assess level of consciousness
• Positioning in wheelchair and bed
• Spasticity Management
• Standing Programs
• Equipment trials
• Establishing a home program
• Initiate intensive mobility program
• Family/Caregiver Training
• Manage medical issues with medical team
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OT/PT Goal Examples
• Positioning Goals:
– Pt will tolerate bed positioning to inhibit abnormal tone, maintain
alignment, and prevent skin breakdown
– Pt will tolerate wheelchair positioning to inhibit abnormal tone,
maintain alignment, and prevent skin breakdown
• Neuromuscular Goals:
– Pt will have increased ROM in ankle via serial casting to improve
alignment in preparation for weight bearing with functional tasks.
– Patient participates in activities to facilitate increased postural
and motor control throughout UEs/LEs/trunk/head in preparation
for participation in functional mobility and ADLs
– Pt will participate in a standing program for…
OT/PT Goal Examples
• Discharge Planning Goals:
– Patient/family will be trained in all aspects of
patient's care,
– Patient/family has necessary equipment and
supplies and/or generated prescriptions prior
to time of discharge.
– Patient will have written and/or verbal home
program prior to discharge.
PT/OT Treatment Options
Pain assessment and management
Spasticity assessment and
management
Head/trunk control
Identifying movement for command
protocols
Surface EMG
Vestibular assessment and
treatment
Positioning programs: bed and w/c
Splinting and Casting for ROM
and/or positioning
Standing program
Trying various positions/activities to
promote increased arousal and
consciousness
Prone, tall kneeling, quadruped,
standing, walking
Responses to multisensory
stimulation
Co-treats with MT and TR to
improve responsiveness
Equipment trials
Caregiver/Family training
Establishing an extensive home
programs and modifying
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Spasticity Management
• Conservative management
– Casting
– Splinting
– w/c and bed positioning
– Stretching
– Inhibitive techniques
• Medical management
– When the above techniques aren’t adequate or are no
longer working
– Oral medications
– Injections/Neurolytics
– Intrathecal Baclofen (ITB) pump
Casting
• Indications for casting:
– Decreased ROM
– To maintain proper alignment
– Reduce motion at joints to counteract effect of
spasticity
– Improve:
• Function
• Hygiene
• Cosmesis
– Skin integrity
Positioning: In Bed
• Goals:
– To maintain neutral alignment
– Minimize the effects of spasticity
– Decrease risk of skin breakdown
• Props: foam, casts/bivalves, splints
• Consider:
– Position: side-lying is considered the most neutral position for spasticity
– How they can be used in more than one position
• They need to roll every 2 hrs
– User friendliness
• Can nursing and/or family implement your program?
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Positioning: In Bed (cont.)
• Specific examples:
– Adductor wedges
– Foam blocks to inhibit extensors spasms of
LEs.
– Pillows between arms and trunk
• If too strong consider foam here as well
– Bivalves vs. PRAFOs vs. custom orthotics
• When to consider ordering custom orthotics
– UE bivalves and splints
Bed Positioning
Bed Positioning
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Positioning
Positioning: In W/C
• Goal: Attempt to achieve neutral midline
alignment while maintaining function
– May not be 100% ideal but what is a good
compromise to allow them to be functional
and prevent skin
breakdown/contracture/compensation.
• Props: lap tray, angle adjustable foot
plates, foam build ups, inserts for trunk or
pelvis, straps
W/C Positioning
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Short term vs. long term
• Short term:
– Foam, straps, bi-valves
• Long term
– Custom orthotics, custom wheelchair
• NOTE: Is their positioning going to change with
spasticity management?
• The patient may not be appropriate for a custom
orthotic if they are receiving Botox or an ITB pump
OT/PT Treatment Options: Proprioceptive Feedback
Developmental positions
• Weight bearing
• Quadruped
• Tall kneeling
• Prone
• Standing
(Co-treats are important)
OT/PT Treatment Options: Electrical Stimulation
• Various uses:
– To prevent atrophy in an acute care setting
• Hirose et al:
– ??30-40mA; 30 min daily; BLEs (flexors and extensors)
– Acute care setting; starting 7 days after admission
– Performed weekly for 6 weeks
– Result: effective in preventing disuse atrophy in pt’s with DOC
– To improve arousal
• Right Median Nerve stimulation:
– Shown to cause earlier arousal from coma
– Inconsistently shown to improve functional and cognitive outcomes
– Cossu 2014
• FES
– Decreases spasticity
– Prevent muscle atrophy
– Provides sensory input
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OT/PT Treatment Options: Standing Program
• Elliott L, Coleman M, Shiel A, et al.
demonstrated Improvement in behavioral
responses in those in vegetative and
minimally conscious states.
• Study states that patient experienced
increased arousal at 85 degrees on a tilt
table vs. supine in bed
– Great reason to co-treat with SLP
OT/PT Treatment Options: Ambulation
• Progression from standing
• Automatic motor activity, thus may see:
– Increased arousal
– Increased muscle activation
– Improved responsiveness to stimuli
• No literature present on use of ambulation in
those with DOC, though is seems a natural
progression from a standing program
• Con: difficult and labor intensive; maintaining
safety while optimizing movement patterns
OT/PT Treatment Options: Body Weight Supported Treadmill Training (BWSTT)
• Benefits:
– Increased repetition of a task-specific activity (motor planning principles)
– Earlier opportunities for weight bearing
– Improve strength
– Reduce spasticity
– Decreased burden on therapist; allowing for focus to be on facilitating various components of gait
• Improve safety when working with those with significant functional impairment
• Allows for improve safety and mechanics when ambulating with the DOC population
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OT/PT Treatment Options: BWSTT (cont)
• VERY limited evidence when studied in the TBI population with inconsistent reports in it’s efficacy
• Lapitskaya, Nielsen, Fuglsang-Frederiksen (2011) – No changes in EEG following robotic gait training in pts with
severe TBI
– Might be an indicator of the severity of the brain injury/dysfunction
• In case studies with TBI, it has shown: – Improve cardiorespiratory capacity
– Improve efficiency of gait
– Increase gait speed
– Decrease use of assistive devices
• Supported in the literature in the those with SCI and CVA (Tefertiller et al 2011)
OT/PT Treatment Options: BWSTT (cont.)
• Research has demonstrated that it is not superior to standard gait/over-ground training
– However, it is shown to be an effective treatment modality
• This suggests it should be used in a progression:
– Transitioning from BWS/robotic gait training to traditional over-ground training as is safe and effective
– Use those clinical reasoning skills: to optimize gait mechanics, weight bearing, repetitions
– Progress from a more restrictive environment to a less restrictive environment when appropriate
OT/PT Treatment Options: BWSTT (cont)
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Caregiver Training
• Importance
– Almost all caregivers of a study stressed the
importance of being informed about their
relatives’ health condition, being able to take
care of them, being involved in decisions that
affect their relatives and easily communicating
with operators of the treating team
(Leonardi, 2012)
Caregiver Considerations
• Interventions should be aimed at minimizing caregiver
burden and developing individualized disability
management programs.
• Therapists working with this patient population should
consider the needs of the individual patient in the
context of their family/care environment and recognize
ease of care-giver burden as a meaningful outcome.
(Wheatley-Smith, 2013)
Caregiver Considerations
• As care-giving is a long-term commitment process, support to the caregiver should be guaranteed throughout the duration of the relative’s disease
• Early involvement of caregivers in a comprehensive process of care should be guaranteed by healthcare supporting programs (Giovannetti, 2012)
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Equipment
• Things to consider ordering:
– Hospital Bed and Mattress (Group 1 and 2)
– Tilt in space w/c and cushion
– Hoyer lift with slings
– Ramps
– Tilt in space shower chair
– Inflatable tub
– Orthotics (solid vs articulated)
– Standers
SLP Goals
•Assess level of consciousness
•Auditory Comprehension
•Verbal Expression and Voice
•Swallowing & Secretion Management
•Attention/Arousal
•Family/Caregiver training and home program
•Manage medical issues with medical team
SLP Goals - Inpatient
• Goals for first 2 weeks (geared more toward the
inpatient setting) – Oral Care Training
– Passive oral motor exercises/swallowing via TTS using lemon
swabs
– Trach Management PMV/Trach cap toleration
– Voicing
– Attend to environmental stimuli
– Understand patient’s visual perceptual ability
– Identify best communication modality for yes/no response
– Possible MBSS if indicated or FEES to assess how patient
is managing secretions and possible PO trial tolerance.
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SLP Goals -Inpatient/Outpatient
• Auditory Comprehension
– Patient will follow 1-step simple commands with 30-50%
accuracy with max cues.
– Patient will establish consistent yes/no communication system
• Verbal Expression
– Patient will voice to command 1-3 times in a 60-minute session
with max cues.
• General Health
– Complete instrumental swallow assessment as appropriate
(FEES/MBSS)
– PMV/Trach occlusion trials
• Attention
– Patient will maintain eye opening for a 60-minute session over 3
consecutive sessions.
SLP Example Goals
• Comprehension/CRS-R Auditory Function
– Long Term Goal:
• Patient will demonstrate consistent movement to
commands.
– Short Term Goals:
• Patient will demonstrate localized response to
auditory stimulation with____ % accuracy given
max cues.
• Patient will follow 1-step commands with ___%
accuracy per session with max cues.
SLP Example Goals
• Comprehension/CRS-R Motor Function – Long Term Goal:
• Patient will demonstrate functional object use.*
– Short Term Goals:
• Patient will respond to/follow 1-step commands with ___%
accuracy per session with max cues.
– Long Term Goal:
• Patient will demonstrate functional communication.*
– Short Term Goals:
• Patient will establish yes/no communication modality with
_________ given max cues and modeling.
• Patient will answer egocentric yes/no questions using
establish yes/no communication modality with ___%
accuracy with max cues.
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SLP Example Goals
• Comprehension/CRS-R Communication – Long Term Goal:
• Patient will demonstrate functional communication.* (via
verbalizations, UE and LE movements, eye gaze, etc.)
– Short Term Goals:
• Patient will answer yes/no egocentric questions with %
accuracy with max cues.
SLP Example Goals
• Expression/CRS-R: Oromotor/Verbal
Function – Long Term Goal:
• Patient will produce intelligible verbalizations for
communication.
– Short Term Goals:
• Patient will demonstrate non-meaningful vocalization with
% accuracy in response to pain/discomfort.
SLP Example Goals
• General Health & Dysphagia/CRS-R:
Oromotor – Long Term Goal:
• Patient will demonstrate reflexive and/or volitional swallow.
• Patient will tolerate PO trials and/or PO diet without s/s of
aspiration.
– Short Term Goals:
• Patient will tolerate oral care via suction swab/suction
toothbrush/standard toothbrush with (min/mod/max) cues for
mouth opening.
• Patient will elicit 10 swallows per 30-minute session using
thermal tactile stimulation and PO trials of ice chips.
• Patient will participate in objective swallow assessment
(FEES and/or MBSS) to determine appropriate consistency
for PO trials.
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SLP Example Goals
• Attention/CRS-R: Visual Function – Long Term Goal:
• Patient will demonstrate object recognition.
– Short Term Goals:
• Patient will follow stimuli visually through left and right visual
fields with % accuracy given max cues in a given
session.
SLP Example Goals
• Attention/CRS-R: Arousal – Long Term Goal:
• Eye opening without stimulation and attention
– Short Term Goals:
• Patient will maintain eye opening for ____ minutes in a given
session with max cues.
• Patient will track visual stimuli in 3 out of 4 trials with max
cues
SLP Example Goals
• Education and Discharge Planning Goals: – Long Term Goal:
• Educate family regarding SLP plan of care
• Patient and/or family will be trained in all aspects of patient’s
care.
• Patient will have written and/or verbal home program prior to
discharge.
– Short Term Goals:
• Utilize quantitative data from visual and command following
IQBA protocols to educate family regarding incidental vs.
intentional behaviors.
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SLP Treatment Options
• Assess level of consciousness via CRS-R bi-weekly with therapy team (PT/SLP and
NP/OT).
• Sensory Stimulation Program
– Auditory stimulation
– Visual Stimulation
– Olfactory Stimulation
– Tactile Stimulation
– Gustatory Stimulation
• Assess swallow function via FEES and/or MBSS for secretion management
• Oral care via suction kits
• Trach care and speaking valve
• Treatment for voicing/verbalizations for functional communication
• Develop consistent command following using IQBA’s
• Develop communication modality via low tech and/or high tech AAC system
• Attend to environmental stimuli
• Co-treatments with PT/OT/MT
• Family training and education
Discharge Planning
• Skilled Nursing Facility vs. Home Health vs. Outpatient
• Appropriate time to discharge
– Medically stable
– Can move on to next level of care
• Often met with resistance (see as giving up)
– Setting clear expectations from the beginning
– Giving family clear expectations from OP
– Giving family goals to work on at home that if pt
meets/progressed then they can set-up a time to be re-evaluated
again for either IP or OP
• Working with Social Worker and Case Manager to help
with realistic length of stay goals
References
• Abbasi M, Mohammadi E, Sheaykh rezayi A. Effect of a regular family visiting program as an affective, auditory, and tactile stimulation on the consciousness level of comatose patients with a head injury. Jpn J Nurs Sci. 2009;6(1):21-6.
• Brown TH, Mount J, Rouland BL, Kautz KA, Barnes RM, Kim J. Body weight-supported treadmill training versus conventional gait training for people with chronic
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