Leininger physiatric approach to concussion

Not all Bells are Not all Bells are Meant to be RungMeant to be Rung

September 29, 2011September 29, 2011

Kirk Leininger, MDKirk Leininger, MD

Head injuries in the Head injuries in the workplaceworkplace

CDC calls head injury CDC calls head injury

the the “silent “silent epidemic”epidemic”

TRAUMATIC BRAIN INJURYTRAUMATIC BRAIN INJURY

2 million TBI 2 million TBI

annually in USannually in US

80% of all TBI are mild (concussion)80% of all TBI are mild (concussion)

Cost of treatment in US = $17 billion/yrCost of treatment in US = $17 billion/yr

ANNUAL INCIDENCE RATES ANNUAL INCIDENCE RATES OF OF

MEDICAL CONDITIONS IN USMEDICAL CONDITIONS IN US2 million TBI2 million TBI

1.5 million heart attacks1.5 million heart attacks

800 thousand strokes800 thousand strokes

400 thousand deaths from heart attack400 thousand deaths from heart attack

200 thousand new cases of breast 200 thousand new cases of breast cancercancer

48 thousand new cases of AIDS48 thousand new cases of AIDS

Concussion is a Latin word Concussion is a Latin word meaning meaning

“collision.”“collision.”

Also called “bell ringer”, “ding”, “mild TBI”Also called “bell ringer”, “ding”, “mild TBI”

NATURE OF BRAIN INJURYNATURE OF BRAIN INJURY

COUP-CONTRECOUPCOUP-CONTRECOUP

OPEN vs CLOSED OPEN vs CLOSED BRAIN INJURYBRAIN INJURY

Open indicates an object has penetrated the Open indicates an object has penetrated the skull, (e.g. bullet, nail)skull, (e.g. bullet, nail)

Closed head injury results from blunt trauma to Closed head injury results from blunt trauma to skull or severe jarring of brain against the skull or severe jarring of brain against the inside of the skull from shakinginside of the skull from shaking

VISIBLE BRAIN LESIONSVISIBLE BRAIN LESIONS

Specific lesion seen on brain imaging is Specific lesion seen on brain imaging is usually associated with a specific usually associated with a specific neurological deficit seen on exam.neurological deficit seen on exam.

(e.g. Left brain contusion on CT scan in (e.g. Left brain contusion on CT scan in a patient with right hemiplegia and a patient with right hemiplegia and speech difficulty)speech difficulty)

CASE STUDY #1CASE STUDY #1

n 49 year old police officer with gun 49 year old police officer with gun shot wound to head, while on duty.shot wound to head, while on duty.

n + loss of consciousness+ loss of consciousnessn Taken to ED by EMSTaken to ED by EMS

OPEN WOUND BRAIN INJURYOPEN WOUND BRAIN INJURY

CASE STUDY #1 cont.CASE STUDY #1 cont.n Neurosurgery removed the bullet the Neurosurgery removed the bullet the

same day of injury.same day of injury.n Medically stabilized and sent to Medically stabilized and sent to

inpatient rehab.inpatient rehab.n Rapid recovery of physical strength Rapid recovery of physical strength

and balance.and balance.n Severe expressive and receptive Severe expressive and receptive

aphasia, improving with ST.aphasia, improving with ST.

BULLET WOUND 2 YRS BULLET WOUND 2 YRS LATERLATER

CLOSED HEAD INJURY MAY CLOSED HEAD INJURY MAY CAUSE FRACTURE OR CAUSE FRACTURE OR

BLEEDBLEED

1.1. Epidural hematomaEpidural hematoma

2.2. Subdural hematomaSubdural hematoma

3.3. Subarachnoid hemorrhageSubarachnoid hemorrhage

4.4. Intracerebral bleedIntracerebral bleed

5.5. Diffuse axonal injuryDiffuse axonal injury

SKULL FRACTURESKULL FRACTURE

EPIDURAL HEMATOMAEPIDURAL HEMATOMA

SUBDURAL HEMATOMASUBDURAL HEMATOMA

SUBARACHNOID SUBARACHNOID HEMORRHAGEHEMORRHAGE

INTRACEREBRAL BLEEDINTRACEREBRAL BLEED

DIFFUSE AXONAL INJURYDIFFUSE AXONAL INJURY

CONCUSSIONCONCUSSION

YOU CANNOT SEE A YOU CANNOT SEE A CONCUSSIONCONCUSSION

There is NOT a strong There is NOT a strong correlation between imaging correlation between imaging and physical or cognitive and physical or cognitive deficits.deficits.

CONCUSSIONCONCUSSION

Def. - An immediate and transient Def. - An immediate and transient impairment of neural function, including impairment of neural function, including alteration of consciousness, disturbance alteration of consciousness, disturbance of vision and/or other symptoms.of vision and/or other symptoms.

Simply put – altered mental state after Simply put – altered mental state after head trauma with or without loss of head trauma with or without loss of consciousness.consciousness.

PATHOPHYSIOLOGY OF PATHOPHYSIOLOGY OF CONCUSSIONCONCUSSION

- METABOLIC injury more than a - METABOLIC injury more than a structuralstructural

- Release of excitatory amino acids that - Release of excitatory amino acids that induce chemical shifts in the braininduce chemical shifts in the brain

- Reduced cerebral blood flow- Reduced cerebral blood flow- Disruption of brain function- Disruption of brain function- Nerve cell vulnerability- Nerve cell vulnerability

Giza and Hovda, 2001Giza and Hovda, 2001

CONCUSSION CRITERIACONCUSSION CRITERIA

Closed head injury or sudden Closed head injury or sudden acceleration/deceleration injuryacceleration/deceleration injury

Glasgow Coma Scale (GCS) score 13-Glasgow Coma Scale (GCS) score 13-15 within first 24 hours15 within first 24 hours

Normal brain imaging (CT scan)Normal brain imaging (CT scan)

Altered mental statusAltered mental status

GLASGOW COMA SCALEGLASGOW COMA SCALE

CONCUSSION EVALCONCUSSION EVAL

May not have signs of head traumaMay not have signs of head trauma

May not have had LOCMay not have had LOC

Imaging studies are normal (CT brain)Imaging studies are normal (CT brain)

Look for symptoms and signs of brain Look for symptoms and signs of brain injuryinjury

SYMPTOMS OF CONCUSSIONSYMPTOMS OF CONCUSSION- Headache- Headache

- Nausea- Nausea

- Dizzy- Dizzy

- Feels “foggy” or slow- Feels “foggy” or slow

- Blurry or double vision- Blurry or double vision

- Sensitive to light/noise- Sensitive to light/noise

- Fatigue- Fatigue

FREQUENCY OF SYMPTOMSFREQUENCY OF SYMPTOMS

SIGNS OF CONCUSSIONSIGNS OF CONCUSSION

- slow response time (questions/instructions)- slow response time (questions/instructions)

- poor concentration (easily distracted)- poor concentration (easily distracted)

- unsteady on feet (clumsy)- unsteady on feet (clumsy)

- disoriented (confused about the situation)- disoriented (confused about the situation)

- personality change (irritable)- personality change (irritable)

- poor memory (asking questioned recently - poor memory (asking questioned recently answered)answered)

- AMNESIA, retrograde vs. anterograde- AMNESIA, retrograde vs. anterograde

ASSESSMENT OF ASSESSMENT OF CONCUSSIONCONCUSSION

- Ask specific questions. Have someone - Ask specific questions. Have someone verify the information.verify the information.

““How did you get hurt?”How did you get hurt?”

““Who helped you when you first got hurt?”Who helped you when you first got hurt?”

““What did you have for lunch today?”What did you have for lunch today?”

- Ask the same questions every 5 minutes - Ask the same questions every 5 minutes for 20 minutes to see if they remember.for 20 minutes to see if they remember.

ASSESSMENT OF ASSESSMENT OF CONCUSSIONCONCUSSION

PREDICTING OUTCOMES PREDICTING OUTCOMES AFTER CONCUSSIONAFTER CONCUSSION

- First TBI vs. previous TBI - First TBI vs. previous TBI

- Loss of consciousness vs. Amnesia- Loss of consciousness vs. Amnesia

- Age- Age

- Premorbid conditions- Premorbid conditions

PREDICTING OUTCOMESPREDICTING OUTCOMES

Multiple concussions – each Multiple concussions – each subsequent injury has more severe subsequent injury has more severe and longer lasting symptoms.and longer lasting symptoms.

Guskiewicz et al, 2003: Iverson et al, 2004Guskiewicz et al, 2003: Iverson et al, 2004

PREDICTING OUTCOMESPREDICTING OUTCOMES

Presence of amnesia is a more Presence of amnesia is a more important predictor of severity and important predictor of severity and long-term problems than LOC. long-term problems than LOC.

Amnesia on day 3 correlates with long-Amnesia on day 3 correlates with long-term deficits.term deficits.

Collins et al, 2003; Erlanger et al, 2003Collins et al, 2003; Erlanger et al, 2003

PREDICTING OUTCOMESPREDICTING OUTCOMES

Research with TBI suggest that age Research with TBI suggest that age <21 or >45 undergo more prolonged <21 or >45 undergo more prolonged and diffuse cerebral swelling after and diffuse cerebral swelling after TBI and less chance of a good TBI and less chance of a good outcome.outcome.Field et al, 2003Field et al, 2003

PREDICTING OUTCOMESPREDICTING OUTCOMES

Premorbid history of depression, ADD, Premorbid history of depression, ADD, learning disability or substance learning disability or substance abuse usually do worse after abuse usually do worse after traumatic brain injury.traumatic brain injury.

CASE STUDY #2CASE STUDY #2

n 18 yr old man, crashes motorcycle 18 yr old man, crashes motorcycle without a helmet.without a helmet.

n Neighbor witnessed crash, came to Neighbor witnessed crash, came to scene, where victim was having seizure.scene, where victim was having seizure.

n Upon EMS arrival he is awake, Upon EMS arrival he is awake, conversing, but very disoriented.conversing, but very disoriented.

n In ED he was fully oriented. CT brain In ED he was fully oriented. CT brain normal. D/C home. No follow up.normal. D/C home. No follow up.

HEAD CT NORMALHEAD CT NORMAL

CASE STUDY #2CASE STUDY #2

n 3 weeks after TBI he graduated from 3 weeks after TBI he graduated from HS with a 4.0 GPAHS with a 4.0 GPA

n 2 months later he left on an LDS 2 months later he left on an LDS mission –English speakingmission –English speaking

n Post-mission he attended BYU on Post-mission he attended BYU on scholarshipscholarship

n GPA at end of 1GPA at end of 1stst year was 1.6 year was 1.6

CASE STUDY #2CASE STUDY #2n Patient complains of:Patient complains of:

n Difficulty concentratingDifficulty concentratingn ForgetfulForgetfuln Can’t retain any information he studiesCan’t retain any information he studiesn No motivation to do anythingNo motivation to do anythingn Sleeps all daySleeps all dayn Admits that he struggled his whole Admits that he struggled his whole

missionmission

CASE STUDY #2CASE STUDY #2

n Neuropsych eval showed:Neuropsych eval showed:n Severe impairment of auditory Severe impairment of auditory

attentionattentionn Severe impairment of visual Severe impairment of visual

attentionattentionn Slow processing speedSlow processing speedn Low enduranceLow endurance

CASE STUDY #2CASE STUDY #2n Treatment:Treatment:n Speech therapySpeech therapyn Ritalin 10 mg dailyRitalin 10 mg dailyn Change school to UVUChange school to UVUn Limit class load to 2 classes per termLimit class load to 2 classes per termn Apps in iPhone that help with taking Apps in iPhone that help with taking

notes in classnotes in class

Outcome: Keeping up with school work.Outcome: Keeping up with school work.

THE CHALLENGE WITH THE CHALLENGE WITH CONCUSSIONCONCUSSION

Absence of obvious neuro deficitAbsence of obvious neuro deficit

Initial period of confusion may resolve Initial period of confusion may resolve quickly and patient appears “fine”quickly and patient appears “fine”

Common for patient to minimize or deny Common for patient to minimize or deny problemproblem

Patient and family believe everything will Patient and family believe everything will be the same as before the accidentbe the same as before the accident

Often no follow upOften no follow up

VULNERABILITY OF BRAIN VULNERABILITY OF BRAIN AFTER INJURYAFTER INJURY

Brain is in a weakened stateBrain is in a weakened state

It fatigues more easily during everyday It fatigues more easily during everyday lifelife

Extra effort required to do formerly Extra effort required to do formerly routine activityroutine activity

Impaired cognitive performance leads Impaired cognitive performance leads to anger, frustration and depressionto anger, frustration and depression

SECOND IMPACT SECOND IMPACT SYNDROMESYNDROME

- Rapid, massive brain swelling occurs if - Rapid, massive brain swelling occurs if a second concussion happens while a second concussion happens while symptomatic from the first onesymptomatic from the first one

- Less impact required on 2- Less impact required on 2ndnd hit hit- Only found in children/adolescents- Only found in children/adolescents- Intracranial vasodilation- Intracranial vasodilation- Brainstem herniation within 2-5 min- Brainstem herniation within 2-5 min

- Morbidity is 100%, Mortality up to 50%- Morbidity is 100%, Mortality up to 50%Zasler, Katz, Zafonte, Brain Injury Medicine, 2007Zasler, Katz, Zafonte, Brain Injury Medicine, 2007

EXPECTED RECOVERY FROM EXPECTED RECOVERY FROM CONCUSSIONCONCUSSION

Benefit from complete rest for 1Benefit from complete rest for 1stst few few days after TBI to promote brain healingdays after TBI to promote brain healing

Most recover in 1Most recover in 1stst week to 1 month (80%) week to 1 month (80%)

Persistent symptoms at 1 year is reported Persistent symptoms at 1 year is reported as 6-15%as 6-15%

If patients don’t get adequate follow up or If patients don’t get adequate follow up or get advice about future activity, may get advice about future activity, may develop long-term condition (post develop long-term condition (post concussive syndrome)concussive syndrome)

POST CONCUSSIVE POST CONCUSSIVE SYNDROMESYNDROME

When symptoms When symptoms

of head injury of head injury

persist, affecting persist, affecting

other aspects other aspects

of lifeof life

POST CONCUSSIVE POST CONCUSSIVE SYMPTOMSSYMPTOMS

- Headache- Headache

- Dizzy- Dizzy

- Poor memory- Poor memory

- Limited attention- Limited attention

- Poor sleep- Poor sleep

- Slow thinking- Slow thinking

- Moody- Moody

- Feeling overwhelmed- Feeling overwhelmed

PCS – 4 AREAS OF PCS – 4 AREAS OF INVOLVEMENTINVOLVEMENT

- Cognitive SymptomsCognitive Symptoms- Attention, memory, executive functionAttention, memory, executive function

- Somatic SymptomsSomatic Symptoms- Headache, nausea, dizzinessHeadache, nausea, dizziness

- Mood DisruptionMood Disruption- Irritability, depression, anxietyIrritability, depression, anxiety

- Sleep AlterationsSleep Alterations- Too much, too little, general fatigueToo much, too little, general fatigue

COGNITIVECOGNITIVE

Reduced attention and being easily distracted Reduced attention and being easily distracted are common after TBIare common after TBI

- Goal is to improve alertness and focus- Goal is to improve alertness and focus

- Minimize distractions- Minimize distractions

- CNS stimulants increase dopamine and - CNS stimulants increase dopamine and norepinephrine in frontal lobenorepinephrine in frontal lobe

- methyphenidate- methyphenidate

- dextroamph/amphetamine- dextroamph/amphetamine

COGNITIVECOGNITIVEPoor short-term memory/forgetful:Poor short-term memory/forgetful:

- No way to give back memory- No way to give back memory

- Memory aids- Memory aids

Repeat infoRepeat info

Write things downWrite things down

Keep a day planner – written or on Keep a day planner – written or on phonephone

Computer games (lumosity.com) Computer games (lumosity.com)

Word/number gamesWord/number games

- Meds: donepezil may help- Meds: donepezil may help

SOMATICSOMATICHeadachesHeadaches - Caused by: - Caused by:

- muscle tension (cranial or cervical)- muscle tension (cranial or cervical)

- sensitivity of scalp laceration/contusion- sensitivity of scalp laceration/contusion

- vascular- vascular

- occipital neuralgia- occipital neuralgia

- trigeminal neuralgia- trigeminal neuralgia

- cognitive fatigue- cognitive fatigue

- medication rebound- medication rebound

- TMJ dysfunction- TMJ dysfunction

SOMATICSOMATIC

HeadachesHeadaches- Treatment, nonpharmacologic:- Treatment, nonpharmacologic:

- manual therapy- manual therapy

- stretching/exercise- stretching/exercise

- modalities- modalities

- injections- injections

- acupuncture- acupuncture

- supplemental oxygen- supplemental oxygen

SOMATICSOMATICHeadaches - Treament, medication:Headaches - Treament, medication:

- NSAIDs- NSAIDs

- muscle relaxants- muscle relaxants

- antiepilepticts- antiepilepticts

- antidepressant – TCA, SSRI, SNRI- antidepressant – TCA, SSRI, SNRI

- beta blockers/calcium channel blocker- beta blockers/calcium channel blocker

- triptans- triptans

- metaclopramide- metaclopramide

- opioids and butalbital- opioids and butalbital

HEADACHE MEDICATIONSHEADACHE MEDICATIONS

Ibuprofen 600 – 800 mg bid-tid prn HAIbuprofen 600 – 800 mg bid-tid prn HA

Tizanidine 4 mg tid prn tension HATizanidine 4 mg tid prn tension HA

Topiramate 25 – 100 mg qhsTopiramate 25 – 100 mg qhs

Nortriptyline 10 -150 mg qhsNortriptyline 10 -150 mg qhs

Propranolol 20 – 80 mg bidPropranolol 20 – 80 mg bid

Metoclopramide 10 mg q8 hrs, w/an NSAIDMetoclopramide 10 mg q8 hrs, w/an NSAID

Sumatriptan 25 – 50 mg at onset of Sumatriptan 25 – 50 mg at onset of headacheheadache

HEADACHE MEDS CONT.HEADACHE MEDS CONT.

Opioids (hydrocodone or oxycodone) Opioids (hydrocodone or oxycodone) avoid use where possible, limit to avoid use where possible, limit to 2x/wk for severe headache2x/wk for severe headache

Butalbital w/aspirin/caffeine, 1-2x/day Butalbital w/aspirin/caffeine, 1-2x/day prn, commonly used. May help with prn, commonly used. May help with tension HA.tension HA.

Tramadol – cautious use, due to lowering Tramadol – cautious use, due to lowering seizure threshold in patients with TBIseizure threshold in patients with TBI

MOODMOODIrritability, impatience, anger:Irritability, impatience, anger:

- behavioral strategies- behavioral strategies

counseling, relaxation, limit caffeinecounseling, relaxation, limit caffeine

- meds (avoid benzos – delay recovery of TBI)- meds (avoid benzos – delay recovery of TBI)

valproic acid 250-500 mg tidvalproic acid 250-500 mg tid

propranolol 20 -80 mg bid-tidpropranolol 20 -80 mg bid-tid

nortriptyline 25-150 mg qhsnortriptyline 25-150 mg qhs

quetiapine 25-200 mg qhs-bidquetiapine 25-200 mg qhs-bid

methylphenidate 5 – 20 mg bidmethylphenidate 5 – 20 mg bid

MOODMOOD

Depression:Depression:

- SSRI, e.g. citalopram 20-60 mg daily- SSRI, e.g. citalopram 20-60 mg daily

- SNRI, e.g. venlafaxine 75-225 mg daily- SNRI, e.g. venlafaxine 75-225 mg daily

- TCA, e.g. nortriptiline 50-150 mg daily- TCA, e.g. nortriptiline 50-150 mg daily

- antiepileptic, valproic acid 250-500 tid- antiepileptic, valproic acid 250-500 tid

Anxiety:Anxiety:

- buspirone 7.5 – 15 mg bid- buspirone 7.5 – 15 mg bid

SLEEP ALTERATIONSLEEP ALTERATION

- Difficulty falling asleep- Difficulty falling asleep

- Difficulty staying asleep- Difficulty staying asleep

- Too much sleep- Too much sleep

- Too little sleep- Too little sleep

SLEEP ALTERATION: Adverse SLEEP ALTERATION: Adverse effectseffects

- Difficulty concentrating- Difficulty concentrating

- Higher risk of accidents- Higher risk of accidents

- Decreased quality of life- Decreased quality of life

- Higher rates of chronic pain- Higher rates of chronic pain

- Independent risk factor for poor physical - Independent risk factor for poor physical and mental healthand mental health

Morin et al. Therapeutic options for sleep maintenance and sleep-onset insomnia. Morin et al. Therapeutic options for sleep maintenance and sleep-onset insomnia. Pharmacotherapy. 2007; 21(1):89-110Pharmacotherapy. 2007; 21(1):89-110

SLEEP ALTERATION: CausesSLEEP ALTERATION: Causes

- Brain injury itself- Brain injury itself

- Pre-existing sleep disorders- Pre-existing sleep disorders

- Pain- Pain

- Pharmacologic effects- Pharmacologic effects- ““energy drinks” energy drinks” - CNS stimulantsCNS stimulants

- Drug withdrawal- Drug withdrawal

SLEEP ALTERATION: SLEEP ALTERATION: TreatmentTreatment

- Behavioral stratagies- Behavioral stratagies- Sleep hygiene education- Sleep hygiene education

- Relaxation therapies- Relaxation therapies

- Sleep restriction- Sleep restriction

- Pharmacology- Pharmacology- Trazadone 50-200 mg qhs- Trazadone 50-200 mg qhs

- TCA – nortriptyline 50-150 mg qhs- TCA – nortriptyline 50-150 mg qhs

- Non-benzodiazepine hypnotics – zolpidem 10 - Non-benzodiazepine hypnotics – zolpidem 10 mg qhsmg qhs

Morin, et al, 2007.Morin, et al, 2007.

RETURN TO WORK/SCHOOLRETURN TO WORK/SCHOOLMultidisciplinary approach:Multidisciplinary approach:

- speech therapist who is familiar with TBI - speech therapist who is familiar with TBI for cognitive rehabfor cognitive rehab

- OT – community reintegration- OT – community reintegration

- psychology for coping strategies- psychology for coping strategies

- pharmacology – the brain is a chemical - pharmacology – the brain is a chemical machinemachine

- vocational rehab for job - vocational rehab for job evaluation/retrainevaluation/retrain

- family support- family support

- RN case manager- RN case manager

RETURN TO WORK/SCHOOLRETURN TO WORK/SCHOOLBenefit of a few days of complete restBenefit of a few days of complete rest

Most brain recovery occurs in 1Most brain recovery occurs in 1stst month month

Gradual transition back to work/schoolGradual transition back to work/school

Reduced work load to startReduced work load to start

Structured environmentStructured environment

Pacing activitiesPacing activities

Accommodations/accessibilityAccommodations/accessibility

Neuropsych eval to determine problem Neuropsych eval to determine problem areasareas

RETURN TO WORK/SCHOOLRETURN TO WORK/SCHOOLAttempts at returning to normal activities Attempts at returning to normal activities

too quickly can lead to frustration, too quickly can lead to frustration, feeling overwhelmed and depressedfeeling overwhelmed and depressed

Research shows 34% still not back to Research shows 34% still not back to work at 3 months work at 3 months Rimel 1981Rimel 1981

Reschedule events that may be stressful Reschedule events that may be stressful until able to manage everyday life until able to manage everyday life (moving, taking exams, travel – applies (moving, taking exams, travel – applies to work and personal life)to work and personal life)

RETURN TO WORK/SCHOOLRETURN TO WORK/SCHOOLLasting problems can occur:Lasting problems can occur:

- memory - memory

- complex problem solving- complex problem solving

- difficulty handling stress- difficulty handling stress

- feeling overwhelmed- feeling overwhelmed

- social interactions- social interactions

More likely to manifest during fatigue or More likely to manifest during fatigue or stressstress

Important: 1 thing at a time and breaksImportant: 1 thing at a time and breaks

IS POST-CONCUSSIVE IS POST-CONCUSSIVE SYNDROME REAL?SYNDROME REAL?

Many physicians and lay people Many physicians and lay people believe that if you can’t see a lesion believe that if you can’t see a lesion on brain imaging studies, then the on brain imaging studies, then the patient with persistent symptoms patient with persistent symptoms must be malingering.must be malingering.

DTI: Diffusion Tensor DTI: Diffusion Tensor ImagesImages

A diffusion MRI that produces images of A diffusion MRI that produces images of brain tissue by following flow of water brain tissue by following flow of water along functioning axons.   along functioning axons.   

The top two images The top two images represent normal  corpus callosal water represent normal  corpus callosal water diffusion. diffusion.

The bottom two images are following what The bottom two images are following what was classified as a mild TBI.  was classified as a mild TBI. 

YES, POST CONCUSSION YES, POST CONCUSSION SYNDROME IS REALSYNDROME IS REAL

Take these patients Take these patients seriously.seriously.

They can have a successful They can have a successful recovery after brain injury recovery after brain injury

with a little insight into with a little insight into their problem.their problem.