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Traumatic Brain Injury Rehabilitation.
  1. STEPHEN KIRKER

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    Traumatic Brain Injury Rehabilitation. Second edition. Edited by mark ylvisaker. (Pp479, £45.00). Published by Heinemann, Oxford, 1998. ISBN 0-7506-9972-8.

    This book is written mainly by an assistant professor of communication disorders, with contributions from 28 speech therapists, psychologists, doctors, physiotherapists, occupational therapists, and educators from different centres across the United States. It emphasises important principles of multidisciplinary management of patients with brain injuries and their families in general. But of more importance, it is one of only a few books dealing with children and their particular problems, the others being either older, or having much greater emphasis on epidemiology and outcome, or on the educational implications of injury.

    The content can be roughly divided into 25% medical, nursing, speech, and swallowing assessment, 33% cognitive rehabilitation, 25% behavioural management, social reintegration, family support, and education, and 12% re-entry to schooling and work. It is extensively referenced, including papers published in 1997 and several lists of web sites, which will be of less interest outside America.

    The medical chapters explain to a non-medical audience why a patient may have been prescribed a particular drug, but are of rather less help to a doctor seeking advice on how to manage a particular problem. Some of their practices may not be applicable in the United Kingdom: I think that few general practitioners would take on the primary responsibility for managing children with head injury just out of the intensive care unit, and paediatric psychopharmacologists, who base their prescribing on SPECT or PET, may be hard to identify.

    However the cognitive rehabilitation chapters are more valuable and emphasise ways to minimise any progressive deterioration in social skills and intellectual ability relative to the increasing abilities of the injured child’s peers. Since the 1985 edition, it has become clear that retraining discrete cognitive tasks or teaching specific compensatory techniques does not lead to sustained or generalised improvement in functional ability, despite measurable improvements in neuropsychological tests. The authors’ practice has now changed to encourage more generalised strategic thinking by the child, understanding their own limitations, and how to complete a task allowing for those limitations. Hence, instead of training with the decontextualised categorising and sequencing exercises which are often found in cognitive training programmes, they recommend meaningful text comprehension exercises, and production of organised narrative. This has also allowed a shift from intensive inpatient therapy to earlier discharge, with therapists now spending more time training families and school teachers to treat the child at home.

    This book fills an important gap in the rehabilitation literature, but it is not an easy read: its 480 pages are filled with small print, hardly any figures, too many words, and far too few full stops.

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