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OTJR (Thorofare N J). Author manuscript; available in PMC 2019 September 06.
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OTJR (Thorofare N J). 2015 January ; 35(1): 5–22. doi:10.1177/1539449214561765.

Evidence – Based Practice for Traumatic Brain Injury A

Cognitive Rehabilitation Reference for Occupational Therapists
Jaclyn A. Stephens, OTR/L, CBIS1, Karen-Nicole C. Williamson, Marian E. Berryhill, Ph.D.
Department of Psychology, Program in Cognitive and Brain Sciences, University of Nevada,
Reno, NV 89557
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Abstract
Traumatic brain injury is a growing public health concern. Nearly 1.7 million people in the United
States sustain a TBI each year (Faul, 2010). Many of these individuals require cognitive
rehabilitation from occupational therapists. We conducted a literature review to identify and
summarize best, evidence-based practice for cognitive rehabilitation for everyday citizens who
have sustained TBI. We excluded articles describing specific populations (pediatric, sports injury,
comorbidities, combat specific), articles specific to a geographical location, and articles validating
assessments. This manuscript describes a systematic review of recent (since 2006) TBI literature
specific to the cognitive rehabilitation of everyday citizens.

We found that there is empirical evidence describing interventions for most cognitive domains
affected in TBI, but much more research is needed. Scientific findings from related fields (e.g.
neuroscience) were infrequently cited in occupational therapy literature but arguably relevant to
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TBI assessment and treatment. We summarized our findings so this manuscript could guide
occupational therapists conducting cognitive rehabilitation. This manuscript was also designed to
help identify the “gaps” in interdisciplinary cognitive rehabilitation literature. We addressed the
concern of limited interdisciplinary research by suggesting potential solutions to this problem.

Keywords
TBI; Evidence-Based Practice; Cognition; Rehabilitation; Occupational Therapy; Interdisciplinary
Systematic Review

Introduction
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Imagine this scenario: an occupational therapist receives her schedule for a day at the
rehabilitation hospital. She sees the list of names and diagnoses. She has thirty minutes to
complete a chart review and make treatment plans. For the patients with physical injuries,
her treatment plan is clear. She will help these patients increase flexibility, strength and
utility of their limbs. She will provide adaptive equipment to compensate for the physical

1
Address correspondence to: Jaclyn A. Stephens, University of Nevada, Mail Stop 296, Reno, NV 89557, Tel: 775-682-8667, Fax:
775-784-1126, jaclynanne09@[Link].
Declaration of Interest
The authors report no declarations of interests
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deficits that cannot be remediated. However, there is also a patient listed with traumatic
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brain injury. He needs cognitive rehabilitation so he can return home safely. She recognizes
that rehabilitation should focus on improving his attention, learning, and memory, but she is
uncertain of the best way to accomplish these goals. His injury is internal and invisible. She
wants to assume that the activities he completes in his environment will make meaningful
improvements to brain function. But how can she be sure? Do improvements during therapy
translate to real-life functionality? At what time point does she assume that remediatory
approaches are futile, and compensatory interventions are best practice? What factors
regarding patient management must be considered to predict optimal cognitive outcomes?
What literatures can be tapped to address unexpected issues?

This vignette depicts some of the challenges facing those involved in the cognitive
rehabilitation of people with traumatic brain injury (TBI). TBI is defined as brain damage
that disrupts function in variable ways with diverse consequences (The Merck Manual of
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Diagnosis and Therapy, 2006). Nearly 1.7 million people in the United States sustain a TBI
each year prompting 275,000 hospitalizations (Faul, 2010). Acutely, TBI severity is assessed
using the Glasgow Coma Scale (GCS) with lower scores reflecting more severe injuries
(Teasdale & Jennett, 1974). GCS scores can be grouped according to TBI severity: mild (1
3+), moderate (8–12), severe (<8) (Decuypere & Klimo, 2012). Perhaps surprisingly, there is
no gold standard for cognitive rehabilitation (Gordon, 2011) and no systematic approach to
cognitive remediation. Therapists, of course, use theoretical models to guide treatment, but
empirical evidence can help expedite treatment and maximize gains. Without a systematic,
evidence-based approach, a patient with TBI may receive varied cognitive interventions until
one works, or until reimbursed rehabilitation ends.

There is no single TBI literature. Instead, physicians, nurses, neuropsychologists, therapists,

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researchers, and other professionals often publish research findings in specialty journals.
This makes it nearly impossible to stay current with the literature(s). The purpose of this
paper is to summarize the TBI literatures for the occupational therapist (OT). In short, this
review is intended as a primer for busy OTs who conduct cognitive rehabilitation. Our
secondary goal is to expand crosstalk between related fields as TBI is inherently
interdisciplinary. In the subsequent sections we review issues that influence and improve
cognitive recovery, such as successful early medical interventions, assessment, and
empirically based cognitive rehabilitation strategies.

For this review, we screened 1200 articles in a PubMed search for recent (since 2006) papers
relevant to TBI rehabilitation. More refined searches were completed for to identify themes
relevant to each discipline (e.g. physicians, nurses, neuropsychologists, clinical
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psychologists, occupational therapists, physical therapist, speech and language pathologists,

cognitive neuroscientists, and bioengineers). To focus on what happens in the general TBI
population, we excluded articles describing specific populations (pediatric, sports injury,
comorbidities, combat specific), articles specific to a geographical location, and articles
validating assessments. Finally, although grant funding and research programs targets TBI in
veterans and athletes, our goal was to highlight the consequences of TBI in civilians. In the
review of these manuscripts, we noticed that the involved disciplines were conducting
similar research but not referencing other fields. In other words, we saw a lack of

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interdisciplinary work. As stated above, this manuscript is designed to integrate knowledge

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from multiple fields to serve as a cognitive rehabilitation reference for OTs. Additionally, we
use this manuscript as a forum to address ways to improve interdisciplinary research and
practice. We also note that to avoid excessive qualification through the manuscript, TBI is
variable and there can be exceptions to the patterns described below.

Early Interventions: Intubation, Diagnosis, Surgical and Pharmaceutical Treatment

Early TBI management can predict the success of later cognitive rehabilitation. Indeed, a
major cause of death and secondary brain injury in TBI is caused by first responders’
difficulty establishing, securing, or maintaining an airway (Bauer, 2012) or performing
resuscitation (Bernard et al., 2010). Air medical crews also have the responsibility of safe
and rapid intubation under difficult, often complicated circumstances (e.g. cervical spine
instabilities) (Bauer, 2012). Efficient endotracheal intubation, such as by video
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laryngoscopy, reduces complications such as hypoxia, hyper- or hypo-capnia, or

hypertension (Bauer, 2012). Consequently, therapists should determine if intubation took
place in pre-emergency settings because complications like hypoxia can exacerbate
cognitive deficits and early intubation predicts better outcomes.

Once in the emergency room, quick and correct diagnosis of TBI is essential. Trauma nurses
and physicians receive specific TBI training (Appleby, 2008). The nursing literature
emphasizes that training should include diagnostic criteria, treatment instructions, and
symptom management at discharge from the ER (Bay & Strong, 2011; Bergman & Bay,
2010). For example, it is easy to overlook pupillary changes that may indicate subdural
bleeding, which can be fatal. Other abnormal pupillary responses should be noted because
they can indicate a range of abnormal brain function (Adoni & McNett, 2007). Once a TBI
diagnosis is established, a range of interventions that may be necessary: craniotomies,
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craniectomies or surgical evacuations (Y. J. Kim, 2011), therapeutic hypothermia (Dietrich

& Bramlett, 2010; McIntyre, Fergusson, Hebert, Moher, & Hutchison, 2003; Wright, 2005),
administration of statins (Rosenfeld et al., 2012), tranexamic acid, nimodipine (Lei, Gao, &
Jiang, 2012), erythropoietin (Rosenfeld, et al., 2012), and progesterone (Lei, et al., 2012). In
the past, interventions had the primary goal of preventing death. Now, providers consider a
patient’s long-term prognosis (Livingston, Tripp, Biggs, & Lavery, 2009). Interventions are
used when they can facilitate both survival and meaningful holistic recovery. This has
significant implications for rehabilitation therapists, as they will now treat patients with less
severe injuries who possess greater potential for recovery.

Cognitive Assessment
Once stabilized, a therapy team evaluates and treats patients with TBI in acute care settings.
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When available, neuropsychologists conduct thorough initial cognitive evaluations to clearly

identify impaired domains. These assessments provide objective normed data that is
essential for monitoring change over time. However these assessments do not always relate
to the ‘real-world’ functioning potential of patients as these tests may not have strong
ecological validity (Gordon, 2011). Speech and language pathologists (SLP) and
occupational therapists (OT) assess cognitive functioning more specifically tailored to real-
world function. These specialists prefer more ecologically valid assessments including: the

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Multiple Errands Test (MET), to test cognitive functioning in community settings

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(Alderman, Burgess, Knight, & Henman, 2003), the Assessment of Motor and Process Skills
(AMPS), to test daily life skills (Merritt & Fisher, 2003), and the Canadian Occupational
Performance Measure (COPM) for assessing self care, productivity (i.e. work), and leisure
(McColl et al., 2005). These assessment tools can be invaluable in rehabilitation settings as
they are designed to pinpoint deficit areas that affect functional performance in daily living.
Therapeutic interventions continue until patients’ gains plateau.

Research in cognitive neuroscience remains underutilized for cognitive rehabilitation.

Neuroscientists seek to understand brain structure-function relationships, often in patient
populations. In the TBI literature, these contributions are often diagnostic or prognostic in
nature. For example, magnetic resolution imaging (MRI) can be used to predict functional
outcomes (Moen et al., 2012). Moen and colleagues used MRI to objectively classify the
degree of traumatic axonal injury (TAI) and repair over time becoming invisible to MRI.
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They found that early (injury – 3 months post-injury) MRI of TAI associated with TBI
predicted the patient’s cognitive outcome (Moen, et al., 2012). A second outcome
consideration involves where the TBI damage is apparent. For instance, bilateral brain stem
lesions are associated with poor long-term outcomes. Early MRI is strongly recommended to
maximize their predictive power and accurately predict a patient’s long-term prognosis. This
can help therapists create realistic expectations for rehabilitative outcomes, and alternatively,
encourage others who to achieve maximal functionality.

Research in cognitive neuroscience is also able to identify new rehabilitation targets. For
example, Hartings and colleagues recorded from patients’ neurons using
electrocorticography and examined spreading mass neuronal depolarizations post-TBI
(Hartings et al., 2011). They found that cortical spreading depolarizations corresponded to
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worse cognitive outcomes. This means that some available tools could be used for diagnosis
and to test the efficacy of interventions. For instance, electrocorticography could be
monitored acutely and subsequently by electroencephalography to monitor changes in
activations pre- and post- interventions. This would be accelerated by with regular
interaction between research and clinical fields.

Cognitive Rehabilitation: Remediation Approaches

Typically, in early stages of recovery remediation approaches are used, with a shift toward
compensation approaches during later stages of recovery. The goal of remediation is to
restore function following the view that early intervention is essential to achieve maximal
rehabilitation. Greater improvement occurs within the first 5 months of recovery when
compared to the subsequent 7 months (Christensen et al., 2008). However, significant gains
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in motor and visual spatial areas can happen beyond the initial window. Importantly, motor
and visual spatial therapy should be remedial in nature for significantly longer than therapy
that targets other domains. This recommendation modifies current practice, where therapists
use remediation approaches in the acute stages (<5 months) of rehabilitation and shift to
compensatory strategies in the later stages. It is clear that extending the use of remediation
strategies may be advantageous in some recovery domains. The following sections describe
existing and emerging interventions to improve cognitive outcomes.

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Self-Awareness
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TBI survivors often have deficits in self-awareness and subjective well-being; they are often
unaware of their acquired deficits. Impaired self-awareness reduces the motivation to
participate in the rehabilitation activities – as they are deemed unnecessary - and this
imposes significant challenges for recovery (Bivona et al., 2013; Carroll & Coetzer, 2011;
Evans, Sherer, Nick, Nakase-Richardson, & Yablon, 2005; Kelley et al., 2012; Spikman et
al., 2013). Improving self-awareness is essential for improving other cognitive domains, as
patients need to recognize their deficits in order to improve them. A combination of video
and verbal feedback can improve self-awareness in patients without increasing emotional
distress (Schmidt, Fleming, Ownsworth, & Lannin, 2013). The TBI literature relating to
emotional state focuses on identifying deficits in self-awareness after TBI, rather than
identifying treatment strategies. Nevertheless, researchers have found that the combined use
of video and verbal feedback is one evidence-based treatment that can be used to improve
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self-awareness in patients with TBI.

Learning and Memory

Individuals with TBI have difficulty with learning and memory due to encoding deficits
(Goverover, Arango-Lasprilla, Hillary, Chiaravalloti, & Deluca, 2009). Here, classic
memory research may be beneficial. Strategies that promote deeper encoding, and slow
information presentation facilitate learning in healthy individuals. One deep encoding
technique, self-generation, asks individuals to create their own examples to better understand
new material. Spacing out information is a technique where small amounts of new
information are presented in multiple short time periods. Researchers applied both of these
strategies in individuals who had sustained a TBI. In this population spacing out information
over a longer amount of time (Goverover, et al., 2009) and self-generation of responses
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facilitated recall (Goverover, Chiaravalloti, & DeLuca, 2010). Another study used the
concept of testing as a remediation approach for learning and memory because it improves
memory performance in healthy adults (Roediger & Karpicke, 2006). Testing helped to
facilitate gains in both learning and memory in survivors of severe TBI (Pastotter, Weber, &
Bauml, 2013). In summary, OTs should encourage individuals with TBI to use established
memory encoding strategies, like self-generation and testing, to enhance encoding and
retention of information.

Individuals with TBI also have deficits in prospective memory, the ability to remember to
perform activities in the future. For example, remembering to take the trash to the curb every
Monday. Researchers investigated why individuals with TBI have difficulty with prospective
memory. Again, encoding difficulties combined with deficits in self-awareness may make
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them less likely to use external memory aids (Roche, Moody, Szabo, Fleming, & Shum,
2007). Individuals with TBI benefit from applying strategies associated with the use visual
imagery to assist with prospective memory. The intervention used graded complexity in
naturalistic settings and improved prospective memory by strengthening the memory trace
and facilitating recall of the intended action (Potvin, Rouleau, Senechal, & Giguere, 2011).
Visual imagery is a useful tool for improving prospective memory following TBI.

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Executive Function
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Executive functioning (EF) is the ability to plan, organize, strategize, and focus attention.
Deficits in EF following TBI can be profound and debilitating. The cognitive orientation to
occupational performance model (CO-OP) encourages individuals who have sustained a TBI
to use metacognitive strategies to identify and strengthen weak areas of cognition.
Metacognition refers to the ability to recognize one’s cognitive capacity. If a patient
recognized, for example, that he had trouble remembering verbally presented information,
he could use a metacognitive strategy of requesting written information (D.R. Dawson et al.,
2009). Telerehabilitation, such as videoconferencing between patients and therapists, can
also support this approach (Ng, Polatajko, Marziali, Hunt, & Dawson, 2013). An
ecologically valid intervention includes using virtual environments to target EF deficits. For
example, Jacoby and colleagues used a virtual supermarket to successfully train executive
functioning in adults with TBI (Jacoby et al., 2013). Deficits in EF are also managed with
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compensatory strategies to improve daily activity performance. These compensatory

strategies are described in more detail in a later section. The remediation approaches for
improving EF include: using metacognitive strategies, providing videoconference support to
patients, and adopting virtual reality environments to prepare for community reintegration.

Attention
Attentional deficits are common after TBI and exist in realms of selective, sustained, and
divided attention. Attention Process Training (APT) is shown to improve selective attention
in individuals with TBI by progressively increasing attentional demands (Pero, Incoccia,
Caracciolo, Zoccolotti, & Formisano, 2006). Recent work in patients with severe TBI has
found success using tactile feedback in a virtual environment to facilitate recovery of
sustained attention on visuo-motor tasks (Dvorkin et al., 2013). Training in divided attention
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tasks can improve performance on them, but this improvement does not transfer to other
cognitive tasks (e.g. executive functioning) (Couillet et al., 2010). Clinicians have found that
attention process training, providing tactile feedback, and training divided attention can
successfully ameliorate attention deficits.

Other experimental techniques, including neurostimulation and neuroimaging hold promise.

For instance, transcranial direct current stimulation (tDCS) applied to the left prefrontal
cortex can improve performance of attention tasks for individuals with TBI (Kang, Kim, &
Paik, 2012). Functional magnetic resolution imaging (fMRI) findings are clarifying the
neural mechanism associated with attentional training (Y. H. Kim et al., 2009). In this study,
all participants completed a visuospatial attention task in conjunction with fMRI. In
comparison to healthy controls, participants with TBI demonstrated greater regions of
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frontal and temporoparietal lobe activity along with reduced evidence of activity in the
anterior cingulate gyrus, supplementary motor area, and temporal occipital regions.
Following the intervention, individuals with TBI demonstrated behavioral improvement, and
more normal cortical patterns of activity. These results support the concept that
rehabilitation progress is made due to neural plasticity. While fMRI cannot feasibly be used
to identify maladaptive cortical patterns in individual patients, it can be used to identify
which types of rehabilitative interventions promote more typical patterns of cortical activity.

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Scientists have found that neurostimulation can improve attentional capacity and fMRI may
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be a viable tool to objectively measure cortical changes after therapeutic intervention.

Daily Cognition
In addition to targeting specific cognitive domains, rehabilitation research examines ways to
improve overall cognitive function, or daily cognition. One daily cognitive activity that is
difficult for individuals with TBI is using technology – including electronic, technical and
mechanical equipment (Engstrom, Lexell, & Lund, 2010). Rehabilitation professionals must
address these difficulties with interventions that promote successful technology use. TBI
literature supports the idea that re-learning of daily tasks in a natural setting leads to greater
functional gains, particularly for patients with cognitive deficits (D.R. Dawson, et al., 2009).
It is often in a naturalistic setting that a patient’s functional potential becomes apparent.
There is emerging data showing that transfer effects is possible between technology and the
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real world. Randomized computer based practice for about an hour per day for 13 days
facilitated transfer effects to everyday skills in adult men with TBI (Giuffrida, Demery,
Reyes, Lebowitz, & Hanlon, 2009). In summary, daily cognition can be improved by
providing therapy in patient’s natural environment and through use of technology to train
skills needed for daily functioning.

The paragraphs above outline empirically based interventions to remediate cognitive deficits
following a TBI. As stated earlier, some of these interventions are not yet available for
clinical use as they are in the research and development stages. Nevertheless, clinicians
should be aware of developing remediatory approaches, as many are likely to reach clinical
settings in the future.

Cognitive Rehabilitation: Compensation Approaches

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With time even the best remediatory approaches fail to promote functional gains and
rehabilitation turns to compensatory approaches. The goal of compensation approaches is to
find ways to offset degrees of impaired functioning. Difficulties performing daily activities
can arise from deficits in any of the cognitive domains listed above. Therefore, most
compensatory strategies attempt to facilitate improvements in daily activities without
specifically targeting a cognitive domain. Typically, compensatory strategies involve the use
of assistive technology (AT). AT can improve daily task performance in adults who have
sustained a TBI and, with training and education, health professionals become more
receptive to use of AT (de Joode, van Boxtel, Verhey, & van Heugten, 2012). Boman and
colleagues conducted a study that used a training apartment to determine where patients
would likely have memory lapses upon discharge from a rehabilitation setting. A computer
registered the number of times they forgot to complete a predefined set of activities. Patients
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made the greatest number of errors when using the refrigerator and the stove. Following this
assessment, all participants received training using electronic memory aids and collectively
demonstrated improvement in their ability to use the aids to complete daily tasks.
Determining which electronic aids will be useful can be facilitated by use of a training
apartment (Boman, Lindberg Stenvall, Hemmingsson, & Bartfai, 2010). Health insurance
reimbursement for AT is limited making widespread use less likely, even though it is an
evidenced based way of improving daily functioning. Health insurance reimbursement for

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AT could be improved with more research supporting the successful use of AT in clinical
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populations and subsequent political campaigning for reimbursement of this technology.

Improving access

Overcoming Barriers to Progress

Cognitive disabilities after TBI are assessed and treated by teams of clinicians using the best
information they have. In general, scientists seek to understand the basic science
surrounding TBI. To expedite translational success better communication between various
disciplines would likely improve cognitive outcomes for people with TBI. The
interdisciplinary nature of TBI means that different groups are targeting different problems
using different techniques, and publishing in field-relevant journals, making communication
across disciplines a real challenge.

There is a clear need for more research in cognitive rehabilitation for the everyday citizen
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who has sustained a TBI. Indeed since 2006 only around 20 empirical articles addressed
remediatory or compensatory approaches in this population(Boman, et al., 2010; Couillet, et
al., 2010; D. R. Dawson et al., 2009; de Joode, et al., 2012; Dvorkin, et al., 2013; Engstrom,
et al., 2010; Giuffrida, et al., 2009; Goverover, et al., 2009; Goverover, et al., 2010; Jacoby,
et al., 2013; Kang, et al., 2012; Y. H. Kim, et al., 2009; Ng, et al., 2013; Pastotter, et al.,
2013; Pero, et al., 2006; Potvin, et al., 2011; Roche, et al., 2007; Roediger & Karpicke,
2006; Schmidt, et al., 2013). Increasing the amount of interdisciplinary work and enhancing
access to these findings is essential and could create the ‘gold standard’ for cognitive
rehabilitation. This would improve clinicians’ abilities to select and tailor an evidence-based
cognitive rehabilitation program for their patient in a time efficient and effective manner. In
seeking ways to promote interdisciplinary work, we spoke to both OTs and researchers to
gather anecdotal information about their experiences with interdisciplinary work. The
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following barriers to effective interdisciplinary work were raised. OTs indicated limited
access to empirical work and difficulty understanding researchers using discipline specific
jargon; see Table 1. Researchers indicated reduced awareness of clinical needs and
problems. These potential solutions could provide a starting point for conversations between
groups engaged in TBI research and treatment. A second aim would be to refine and target
translational researchers to address clinical needs more carefully.

Acknowledgments:
Authors JAS and MEB have received grant support from The National Institute of Health Centers of Biomedical
Research Excellence Grant (1P20GM103650–01, PI Webster, Project Leader MEB). We would also like to thank
Dwight Peterson, Kevin Jones, Filiz Gözenman, Eleanor R. Berryhill Caplovitz, Gabriella Dimotsantos, Hector
Arciniega for assisting with this research endeavor.
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Table 1

Summary of Empirical Articles for Each Cognitive Domain

Domain and # of Articles Citations

Self Awareness (3) Goverover, Johnston, Toglia, & Deluca, 2007; Lundqvist, Linnros, Orlenius, & Samuelsson, 2010; Schmidt, Fleming, Ownsworth, & Lannin, 2013
Stephens et al.

Bourgeois, Lenius, Turkstra, & Camp, 2007; Fish et al., 2007; Goverover, Arango-Lasprilla, Hillary, Chiaravalloti, & Deluca, 2009; Goverover, Chiaravalloti, &
Learning and Memory (12) DeLuca, 2010; Grilli & Glisky, 2011; Grilli & McFarland, 2011; O’Brien, Chiaravalloti, Arango-Lasprilla, Lengenfelder, & DeLuca, 2007; Pastotter, Weber, &
Bauml, 2013; Potvin, Rouleau, Senechal, & Giguere, 2011; Roediger & Karpicke, 2006; Sumowski, Coyne, Cohen, & Deluca, 2014; Yip & Man, 2013

Bertens, Fasotti, Boelen, & Kessels, 2013; Dawson, Binns, Hunt, Lemsky, & Polatajko, 2013; Dawson et al., 2009; Hewitt, Evans, & Dritschel, 2006; Jacoby et al.,
Executive Function (7)
2013; Ng, Polatajko, Marziali, Hunt, & Dawson, 2013; Serino et al., 2007

Attention (4) Bartfai, Markovic, Sargenius Landahl, & Schult, 2014; Couillet et al., 2010; Dvorkin et al., 2013; Pero, Incoccia, Caracciolo, Zoccolotti, & Formisano, 2006

Generalized Strategies &

Hegde, 2014; Lojovich, 2010; McDonnell, Smith, & Mackintosh, 2011
Approaches (3)

Engstrom, Lexell, & Lund, 2010; Fong et al., 2010; Giuffrida, Demery, Reyes, Lebowitz, & Hanlon, 2009; Johansson & Tornmalm, 2012; Kim, 2010; Lundqvist,
Daily Cognition (7)
Grundstrom, Samuelsson, & Ronnberg, 2010; Powell, Letson, Davidoff, Valentine, & Greenwood, 2008

Boman, Lindberg Stenvall, Hemmingsson, & Bartfai, 2010; Boman, Tham, Granqvist, Bartfai, & Hemmingsson, 2007; de Joode, van Boxtel, Verhey, & van Heugten,
Compensatory Strategies (7) 2012; Dry, Colantonio, Cameron, & Mihailidis, 2006; Fager, Hux, Beukelman, & Karantounis, 2006; Fried-Oken, Beukelman, & Hux, 2011; Gentry, Wallace,
Kvarfordt, & Lynch, 2008

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