REHABILITATION AFTER HEAD INJURY - a guide for families and carers
Recovery begins when the patient is moved from the Intensive Care Department to an ordinary hospital ward. They still need expert nursing care. They may not be able to swallow properly and may require the naso-gastric tube that was used for feeding in Intensive Care. They may not have recovered enough strength to hold their head up or sit on their own, and they may not yet say anything that makes sense. They will know, however, even if it is in a confused way, that their family and friends are with them, and this will be a comfort and a great source of strength.
Painstaking help and teaching are needed for the best recovery to occur. To begin with, the people who look after the patient will be the hospital staff, but the time they have is limited and soon the family will need to take over some of this responsibility. They will have to learn from the professionals how to give the treatment that's needed, and to add the support and caring that will get their family member through the tedious and tiring months ahead.
If you, as the family, are going do this, you will need to understand how head injury affects the way people think and act, and to appreciate the difficulties that the patient faces.
The effects of a head injury differ from person to person, depending on how severe the injury was and what parts of the brain were damaged. We will tell you here about the common consequences. Any one patient's condition will be made up of a mixture of one or more of these effects in varying degrees of severity.
People with less severe injuries will spend a short time in coma and will go quickly through the stages of rehabilitation and be back at work in a month or two. Those more severely affected will still need care and treatment two years and more after the accident.
Consciousness and coma
The brain makes us aware of what goes on around us and inside us. Deep in the centre of the brain is an area that is essential to this function, and if it is damaged, coma - loss of consciousness - follows. After a mild injury recovery can be quick, so that coma from concussion may last for only a minute. After a severe injury it can continue for days or weeks. When the damage is very severe, there may be no change for months or even years, a condition called the 'locked-in' or 'persistent vegetative' state.
As the coma lightens, voice and touch will begin to produce a response. The first definite sign of consciousness is when the eyes begin to open. Other responses often return quickly after this, but sometimes they can take days or even weeks to appear. It is important to know that while patients are coming out of a coma they often understand what is being said, though they are unable to respond in any way. You should therefore talk to them sensibly, and in a normal voice, as if they were able to reply. Show them affection and tell them family news. Patients often say, when they are at last able to communicate what a comfort this was to them.
The parts of the brain that control the movement of the arms and legs are often affected by a head injury. Even when someone is unconscious you may be able to see that one arm or leg is not moving like the one on the other side, or is lying in an unnatural position. The muscles may not be working at all, so that the limb is loose and floppy, or all the muscles may be contracting at once so that it is stiff or 'spastic'.
Until movement returns, it is important to make sure that the joints are not allowed to stiffen, either from lying still or being pulled into an abnormal position by the spastic muscles. The physiotherapist will begin by trying to relax the tight muscles, and will then put the joints through a full range of movement. This must be done carefully, because too much stretching can damage the joints and ligaments, and they will end up even more stiff.
When some movement returns, exercises will be done to strengthen it. Coordination is often badly affected, even when movements have got their power back, and much of the effort of treatment will be spent on correcting this.
If a joint is being pulled into a bad position by muscles that are spastic and over-contracting, a splint may be needed to control the movement, worn all the time or just at night. Occasionally anoperation may help to get a joint into a position where it can function better.
Posture, balance and where you are in space
As the patient comes out of coma the staff will begin to sit them up in bed. At this stage they may be unable to hold their head up, and their body may fall to one side if it is not supported. This is because they need to get the strength back in their trunk muscles and to relearn how to use them to control their posture.
Several factors are involved. Normally the balance organs in the ear report what position the head is in so that it can be held level. However, these balance organs are very delicate and are often damaged by a head injury. People who have recovered enough to tell you about it will say that they feel dizzy and have no sense of balance. Next, the muscles of the trunk and limbs have their own reporting system that should tell the brain what position the body is in, but again this system is often working badly after a head injury.
Knowing where you are
Probably the most important thing for the patient to know is where their body is in relation to the things around them. Normally we judge this by adding up what we see, what we can feel, where our balance and posture sense tells us where we are, and what we know from past experience. After a severe head injury all these mechanisms tend to be faulty. As a result the patient may have no idea of what their position is, whether they are sitting safely or about to fall off the edge of their chair, or whether if they stretch their hand out it will meet the bed, the wall or empty space.
Good side and bad side
Usually the trouble in knowing what position their limbs and body are in, and how they relate to things around them, is worse on one side of the body than the other. On their bad side not only may they not use their arm and leg but they may not realise that anything on that side exists - the bed, furniture or people. It's important that you realise that this may make them frightened by even simple actions like getting out of bed into a chair.
As a practical measure, treatment starts with exercises which help the patient to recognise where their arms and legs are in relation to their own body and the space around them. It will help if to begin with you come to them on the 'good' side, so that they know you're there; later on to help them recover you can encourage them to take notice of you on the other one. As they begin to sit up, they are encouraged to hold their head and trunk properly. Using a bed which can be tilted until it is upright, by stages they get used to standing and taking weight on their feet. Being upright also expands their lungs and improves their circulation and the function of their kidneys.
As they become used to standing they start to take steps, at first with the help of a mobile frame, and then, as their balance improves, with less and less support.
Walking and getting around
Moving around by oneself is a basic need, both to get on with the business of living and for keeping up one's self-esteem. However, for some people with severe injuries progress towards walking is slow, or even seems to stop. Usually the reason is that both legs are held stiff by the over-contracting 'spastic' muscles. If getting around on stiff legs is getting too much of a burden, it may be best to concentrate on becoming independent by using a wheelchair, and keeping the effort of walking for getting into and out of the chair and managing short distances around the house.
It's natural that learning to walk again should take up a great deal of the energy available, but it should leave energy for other things, and the rest of recovery should not be deprived.
Speech and swallowing
As consciousness returns, you will soon be able to tell if the patient's speech has been affected.
Speech can be impaired int two main ways. In the first, called 'dysarthria' you will find that though the patient seems to have at least some understanding of what you are telling him and reacts appropriately, he says nothing. The problem here is damage to the deep central part of the brain that controls the movements of the vocal cords and voice production.
As they recover the first speech to return will probably be a whisper. This will strengthen with time, but if the injury has been severe speech may remain clumsy and monotonous and without much expression. However the way words are used and the meaning of what they say are likely to be normal.
When there is this sort of problem with speech, it is probable that swallowing is also not working properly, so that there is danger that food will get into the lungs and cause pneumonia. Normally people cough violently if food goes down the wrong way, but this reflex may be lost after a head injury. The only way to tell may be to use special X-ray tests. Until it is certain that swallowing is safe, feeding will have to continue through a naso-gastric tube, as was done in Intensive Care.
The second way in which speech may be affected is called 'dysphasia'. The voice can be produced normally, but the patient is unable to find the right words, or perhaps any words at all. Sometimes they may not be able to understand what is said to them. Dysphasia is usually due to damage to the left side of the brain. Swallowing is unlikely to be much affected.
Dealing with these problems is the work of the speech therapists. When speech is clumsy and weak - dysarthria - they will teach exercises for breathing control and voice production, and to help safe swallowing. If the dysarthria remains severe, alternative methods of communication may be needed, such as boards with letters and pictures to point to, or in the long run more complicated equipment such as computers and voice synthesisers.
When there is difficulty in producing the right words or in understanding them - dysphasia - the therapists will start programmes which help the patient to communicate and to overcome the block.
Sight can be affected in several ways. Fractures of the skull or the bones of the face can damage the nerves that run back from the eyes to the brain, and sight can be partly or completely lost. This sort of injury can also result in double vision, either by damaging the nerves that control eye movement or by distorting the eye sockets, so that the eyes cannot move freely.
The part of the brain responsible for interpreting what we see can also be damaged. When one side of the brain is injured, vision towards the other side of the body is affected. The patient may not be able to see anything in this direction, or may see things but ignore them.
Thinking and behaving
When head injury upsets so many simple and automatic activities such as balance and movement, it is not surprising that it can also result in drastic changes in the way people think and behave.
One of the first things that you will notice when the patient has come out of coma and begins to respond to you is that they can only concentrate on what you are saying for a very short time. They soon forget what you tell them and ask the same question again and again. They tire very quickly and when they get tired their concentration and memory are even worse. If you come to see them after they have been working at a treatment session they may be too tired to respond to you at all.
The first things to recover are familiar and automatic activities, like repeating the days of the week and mental arithmetic, and their memory for their past before the accident may be quite good. However, dealing with any new situation is likely to confuse them, and because their memory for what has just happened is often the last thing to recover, they may not be able to learn from experience.
It will help to get their thinking going again if you talk about the things they can cope with, such as family history, their friends or their work. Find them the sorts of things they liked to read before the accident, even if to begin with they only read a few lines and then forget them. If they like music, bring them a cassette recorder and some of their old tapes.
At this stage as they become tired their ability will fall right off. This is a signal that they need to rest straight away. It's best if they can stop short of becoming more than a little tired, and it's never any good to push them to do more, which will only exhaust them so that they will need more rest than ever. You will find that managing fatigue is one of the most important points in helping people with head injury.
The hospital staff will start them on the familiar routines of everyday life. They will be taken through the simple activities needed to survive - washing, dressing, getting out of bed (into a chair first, then walking or a wheelchair if it's needed), and eating. These will be repeated until they can manage them by themselves, and as they become used to them, more of their normal routine will be added.
As soon as it's practical the psychologist will do tests to see which areas of thinking have been particularly affected by the injury. They may need special help, as we mentioned before, if they are having difficulty with words and their meaning. There may be problems with recognising where things are and what their shape means, particularly if they are neglecting one side of the body.
Treatment by the staff will consist of patient explanation, working with spoken and written words, with drawing and with putting parts of objects together - relearning as they did when they were children. Family as well as staff need to take part in this. Puzzles and games will be used as much as possible so that it is fun as well as hard work. All the time fatigue and its effect on performance are watched carefully.
Progress will depend on their remembering what they learned the day before, but memory is often the slowest thing to return, and this limits the speed of recovery. So that they can keep their life organised they will use a notebook, to remind them what they should be doing at each time of the day (some people are afraid that relying on a notebook may slow down the recovery of memory, but this is not so). Later on computer programmes can help them to develop their memory further.
To behave properly we need insight and self control. Insight is being able to see ourselves and how we relate to other people and to situations as they really are. Insight is often affected after a head injury, both because quite high-level thinking is needed for it, and because some areas of the brain that seem to be specially concerned with insight have been damaged.
In everyday life, if you don't have insight, you won't realise how you affect other people. This may lead you to say or do inappropriate things, and you may not see that you need to change your behaviour according to the way people react to you. This is quite often the situation with someone who has had a head injury, and it may make it difficult for them to be accepted by the people they meet socially or at work. In the long run, loss of insight can become one of the most important practical problems faced by the injured person and their family.
Self-control is needed when your emotions are stirred up and pushing you to do something that is inappropriate or dangerous, or that you will be sorry for later. In this situation people who have had head injury are at risk of losing their control. In the same way that their insight is affected, their emotions are less stable, they are irritable and it is easy to upset them. As well, because they are thinking more slowly, they may not have time to work out the consequences before they act.
For someone who has had a head injury, the minor annoyances of everyday life are likely to be enough to cause an outburst. Because of this, family members often bear the brunt of anger and loss of control. It's sometimes very difficult for them to realise that this is a direct consequence of the injury and not anyone's 'fault'.
Behaving - how to help
Helping a patient with poor insight is difficult because they may not realise that they are acting inappropriately, and so will deny that they need any help. They must be told clearly what they have done and why it was wrong. It mustn't sound like judgement or punishment, so a lot of tact is needed as well as firmness. The only way of getting the message through is to deal with each situation as soon as it occurs. If you delay, the patient will probably have forgotten the details, or will only remember their idea of what happened.
Recognising what's wrong
To begin with it will usually be the staff who will have to correct them. As part of treatment it is often useful to have them act out situations and show them what their reactions to other people ought to be. This can be videotaped so that they can see for themselves how they behaved. Because of their poor memory they may need to be taken over the situations again and again.
Many of the problems will occur when the patient is with their family, who will often find it embarrassing to correct their behaviour, or even be afraid of violence if they attempt to do so. The therapists will be able to help with ways of dealing with this sort of problem. It is important that both the family and the therapists work in the same way, or the message will be confused and will not get through.
As the patient regains some insight they will be able to exercise more self control. They will need help to recognise when they are becoming irritable and in danger of losing their temper. They must learn take 'time out', turn away or to go out of the room. When they are able to profit from it formal teaching about anger control and relaxation may be a help.
It becomes particularly difficult when patients refuse to accept their limitations, and insist on doing things that are dangerous to themselves or other people. They may leave hospital before they are fit to do so, or insist on driving their car or going out drinking. They may become aggressive and even physically violent.
The right thing to do needs to be worked out with the rehabilitation team as a matter of urgency. It may be possible to impress them with the dangers by further counselling. The family may be able to cope with the situation if they have outside help. Medication may make them less agitated and aggressive. Sometimes the problem is too difficult to manage at home and then they may need to return to hospital, perhaps under psychiatric care, for a time.
This is a time when families often find that they need help and support to cope with their own stress and the problems that looking after their family member creates. We have made suggestions about this later.
People with special needs
Men, and especially younger men, make up the majority of people who suffer severe head injuries. Women, children and older people are affected in much the same way, but have some special needs which have to be understood.
Women often have special problems when they leave hospital. They may find that they are expected to return to looking after the family much earlier than they would go back to work outside the home. Though easily tired, their need for rest may not be understood. It is often forgotten that emotional outbursts and tears are the effect of injury. Younger members of the family may find it difficult to understand why Mum is so different.
Special care must be taken to counsel all the family, so that even the youngest members understand the situation and what mother needs.
Help in the house can usually be arranged through the hospital Social Work service, and funding may be available from ACC or other agencies.
As they get into middle age, people do not recover as well after a head injury. The brain seems to be more sensitive to injury, and there may be less reserves of brain function. When an older head injury patient is able to think of returning to work, this must be carefully planned so that the effects of tiredness and any reduction of the ability to learn and remember and to react to new situations is allowed for.
If the patient has reached retirement age they may have become partly dependent on the people around them, and even a little extra loss of function may mean that they can't cope on their own. They may be unwilling to admit this, and special care is needed to make sure they have the help they need.
A child often seems to recover from a severe head injury better than an adult would. This may be because their brain hasn't yet become set in its pattern of working and can change to compensate for damage.
Children also have special problems, mostly because childhood is a time of learning, and their memory is often affected by injury. Behaviour patterns are still forming, and the irritability and lack of insight that we described in adults can distort development and create serious problems later on.
When a child won't obey the ordinary family rules or loses their temper, it's very difficult for parents to know how much of this is due to the head injury and how much to ordinary growing up, and what sort of discipline is right. As is usual with children, firm control with the least punishment and always dealing with them in the same way is best, but this is rarely easy.
When a child is ready to start back at school, to begin with they should usually go for only half a day, or even less. If they stay long enough to get tired, they will not learn and often behave badly and become disruptive. The teachers must be made aware of the problems so that they can help. Some children will need special teaching; how this is arranged will depend on where you live.
Until the child is safely back on a normal pattern of development, families should keep in touch with the rehabilitation team. They will help to make sure that the child is settling back to school and, if it is needed, will be able to get help from people expert in the problems of child development and psychology.
Less severe injuries
Up to now we have talked mostly about people whose recovery will take many months, and where a serious long-term disability is possible.
Many people have head injuries which threaten their lives in the early stages, but then recover quite quickly. They may be left with little or no physical disability, perhaps just some weakness of one arm or leg, or poor balance. The effects on thinking and behaviour may not recover so well, and in the satisfaction about the physical recovery their significance may not be appreciated. Lack of insight can look like self-confidence. Concentration and memory may seem normal in someone taking it easy after an illness, until they get back to school or start work.
It is important therefore that during recovery the brain function and practical ability should be checked by a psychologist and an occupational therapist. This is especially important when the time has come to consider returning to work.
We have seen the difficulties which people with head injury face, and the problems that their families have to deal with. How is rehabilitation arranged, how are the problems solved, and who are the people who can help?
Recovery from coma
When a patient leaves Intensive Care, for a time they will need to be in an acute ward of a hospital, where there is expert nursing. As they get better the emphasis changes from nursing to rehabilitation, and they will spend most of their time with the occupational, speech and physiotherapists. They then need different facilities and surroundings. How these are provided depends on how much they have recovered and what services are provided in the area they live in.
Some patients may be well enough to go home and come up for treatment as an outpatient, either to a hospital department or to a separate rehabilitation centre. This may be best for those who are well on the way to recovery. For others it may not be so suitable, either because treatment becomes limited by the need to fit in with whatever transport is available, or because travelling tires them so much.
In some areas, as an alternative to going home, a patient may be offered a place in a unit which provides accommodation and basic nursing care together with full time rehabilitation. Though getting back home can be a tremendous boost to morale, the best way to a quick recovery may be to live in at a centre like this for five days a week and then to relax at home in the weekend.
Going home - what's needed and how to get help
Before it's decided that your family member could go home and continue with rehabilitation from there, the rehabilitation team will look at your house to make sure it's a practical move. If the patient is not walking and still needs a wheel chair, a ramp may be needed to lead up to the front door, and other doors may need to be widened. Baths are difficult to get into and out of, so a shower, perhaps one that will take a special chair, may be needed. The cost of these alterations may be met by the ACC.
The team will make sure that there is enough help at home to cope with the heavy work of looking after the patient, if they are not yet able to help themselves. The cost of 'attendant care' for some part of the week and some help with the housework may be met by ACC.
Patients in the slow stream
Some patients may progress very slowly, and after some months are still badly disabled and need much individual care. There is often pressure for them to move out of the acute ward. Because even the most severely injured patient may continue to make useful progress, however slowly, it is important that rehabilitation is not cut short. Occasionally it is possible for such patients to be looked after at home, but the heavy nursing care needed often makes this impractical, and adequate rehabilitation at home is difficult to arrange. In some areas special units have been set up to meet this need, but in others it may be difficult to find suitable accommodation. Families of people with these problems should insist that their local authorities make suitable arrangements.
Rehabilitation for independence
When the patient has reached the stage where they can look after their personal needs, can get around and can manage social contacts reasonably well, the next stage is to think about returning to work.
Plans for this will depend on the amount of recovery he has made, what his job was before the accident, and what work is now likely to be available.
Someone who has recovered well may aim to go back to their old work. They may need a period of retraining, and sometimes special working conditions have to be set up. If more help is needed they may have to transfer to a specialised training centre. What is available varies from place to place. Case Managers at ACC and the Government agency Workbridge will play an important part at this stage. Others may need to consider a less demanding job, and similar preparation will be needed.
When the injury has been severe many will not be able to return to economic employment. It is important that a plan is worked out for them that gives them a regular satisfying occupation. This is essential to provide a structure for their life, a sense of purpose and achievement, and personal dignity. What can be done varies from place to place. It may be organised by the hospital services, or by voluntary organisations such as the Head Injury Society.
In the first month or two after a severe injury it's only possible to guess how long recovery will take and what the outcome will be. What is certain is that it is a slow process and that it will take months where other injuries take weeks.
Six months after the injury there will be more to go on, but it's best to wait until a year after the accident before making any important decisions on the future. People usually then fall into one of the three groups: those who will eventually go back to paid employment, those who will need a sheltered job, and those who will remain with a disability that prevents them from working.
This doesn't mean that after a year progress stops or that rehabilitation is no longer useful. People in each of the groups will continue to improve for a number of years, though the rate of progress becomes slower. The gains may not make the difference between employment and sheltered work, but they will reduce the amount of dependence on other people and will improve the quality of their lives. The rehabilitation programme must therefore go on.
It is important to realise that as time goes by, recovery can be affected by factors other than the patient's disability. Grief for what has been lost will be experienced by both the patient and his family, and it can grow to the stage where there seems to be no point in struggling on. Depression may become severe. The family may become worn out from dealing with behaviour problems and from trying to cope with social or financial difficulties, and be unable to continue with the support that is needed.
Recovery in the long term therefore depends not only on getting the right help for the direct consequences of the brain injury, but also on the care that's given to the whole person and their family. Studies of the families of people who have had head injuries show that problems may grow to a crisis point as much as five years after the injury, and that support and counselling are needed not only in the early days but for long afterwards.
The early days
It's great when your family member begins to respond and you can show them your love and concern, but you may find that they don't react as you expected, and that they seem to be a different person. This can be very distressing, but you will have to realise that the way they are seeing the world may have been changed by what happened to their brain. It will take time for them to readjust to this and you can best help them by treating them just as you did before, however difficult this may be.
This is the stage when you will probably have to do a good deal of reorganisation in your everyday life. You will have to find time to visit the hospital and help with rehabilitation, on top of your usual commitments, such as holding down a job, or running the house and looking after the children. You will also have to deal with the extra tasks of dealing with compensation and insurance.
Don't run yourself into the ground. Accept help from family and the professionals. If you have not seen one of the hospital social workers before, now is the time to do so. You will find that your problems will be familiar to them, and they will be able to suggest how you can get the help you need.
When trial weekends out of hospital have been successful, the time may come when your family member can move back home. This will bring a new series of things to organise. Transport to hospital for treatment may be needed. You may need to find someone to be at home when you have to be out.
When there has been a change of personality and behaviour, things can be particularly hard. Irritability and loss of temper are difficult to deal with, especially when there are children in the family. As we said earlier, insistence on driving or drinking, or refusal to obey safety rules may make the carer's task seem almost impossible.
Try first to share the burden with other members of your family. The Head Injury Society will be able to put you in touch with other families who have gone through this stage themselves. They may have practical solutions, and will certainly offer you support. If the problem seems to be getting out of hand, go back to the hospital team and get their help.
The long term
Many people who have had a severe head injury will recover steadily with the help of their family and find their way back into a good life. There may be times when the strain of coping may be more than the caregivers can take. Next we list some of the things you should think of and protect yourself against.
If the person injured was the wage-earner for the family, money will be tight in spite of income maintenance by ACC. Hospital social workers will show you how to apply for supplementary benefits and, if you need it, help with advice on ways of budgeting. If it is the caregiver that is the wage earner, loss of income from time taken off work for hospital visits, and later for caring for the family member at home, may be compensated by ACC.
Caregivers often find themselves isolated. Sometimes friends support them to begin with, but then drop away, especially if there are behaviour problems. Interests that were once shared with friends become impractical. Sometimes family members resent the concentration of attention on the disabled member and become estranged as a result.
You can find yourself overcome by your loss - loss - of the person you knew who seems to have become someone else, loss of a way of life and loss of prospects for the future.
You may find yourself still going through the grieving process long afterwards, when, if the accident had been fatal, there would have been a period of intense grief and mourning and then in time adjustment to the loss.
Grieving is natural, and the best way to cope with it is to face the sorrow rather than try to escape. To be whole again you will need to live through your grief, learn to let go of the past and accept the losses. Only then will it be possible to get on with the new life.
As you grieve, remember that the victim too, will be grieving for what he has lost, and will be needing your support and care. Involving yourself in this caring will help to make your own grief easier to bear.
Things can get to the point where you feel you can't cope any longer. A crisis of this sort can sometimes be forestalled by temporary relief. Families can often deal with difficulties for three or four days a week but not for seven, and either day care during the week or living in a rehabilitation centre may make the weekend an enjoyable holiday rather than a burden. Respite care - providing care and accommodation for a period in a private or health board facility - may enable the family to go away for a holiday and recover their strength. The social worker will know how to arrange this.
Change of role
When the person injured has been the wage earner, the family member who has become the caregiver may find that they have to take over the job of earning, and that as well as looking after the patient they have to provide for the family and be both mother and father to the children.
Adult sons and daughters who have been injured may become dependent on their parents, who would not have expected to take on this responsibility again, and who may feel themselves to be too old to provide the necessary care.
A head injury service should anticipate all the problems we have outlined in this book, offer you help and direct you to the support that is available.
Counselling should be available as a hospital service from social workers and psychologists. It will be able to help you both with personal problems, dealing with stress and grief, and practical ones, such as finance and compensation. They will be able to put you in touch with community based organisation if this is likely to be helpful. Remember that these services are completely confidential.
ACC is there to help you too. You should make a claim as soon as possible after the accident. The hospital staff will have a "Claim for Cover" form to fill in. They will show you how to do this.
After the claim has been accepted, a "Case Manager" will be assigned to the patient. Their role is to help manage the patient's claim and recovery. They will be your personal contact at ACC and will help ensure the patient receives the right treatment, compensation and rehabilitation.
The patient and family may be entitled to several different types of assistance from ACC including weekly compensation, independence allowance, transport, attendant care, housing modification, and aids and appliances.
The Head Injury Society
This society was started by people who had suffered head injuries, and by their families, to help others in the same situation to cope.
Get in touch with them; the hospital staff or the ACC Case Manager will be able to give you a telephone number to call, and you will be able to find out what support is available in your area. If you have any difficulty with this, write or phone the Neurological Foundation.
The Neurological Foundation
The Neurological Foundation, PO Box 68 402, Newton, Auckland 1. Ph (09) 379 8470bjects%3A%??