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Injury prevention for people with disabilities

Injury prevention for people with disabilities

For example, a promotional campaign developed in Australia to increase use of Quinoa soup recipes helmets has Injury prevention for people with disabilities peevention a documented Injury prevention for people with disabilities percent reduction in gor injuries among bicyclists. Links with this icon indicate that rpevention are leaving the CDC website. Although economic costs do not reflect the pain and suffering associated with injury or the burden placed on family and friends, they do provide a quantifiable measure of the public health significance of injuries and can be useful in guiding choices among competing programs of primary, secondary, and tertiary prevention. Learning disabilities can be lifelong conditions and some people can have several overlapping learning disabilities. Injury prevention for people with disabilities


Injury Prevention Research

Injury prevention for people with disabilities -

Deep vein thrombosis, pulmonary embolus, and orthostatic hypotension are seldom a problem postdischarge. Cardiovascular deconditioning needs to be studied in SCI and TBI individuals who are sedentary postdischarge. Bowel training is effective in producing continence.

Renal management can result in significant decrease in morbidity and mortality in SCI. Clinical trials on the benefit of intermittent catheterization are needed.

The value of drugs and electrical stimulation in the management of the neurogenic bladder should be determined. Long-term use of drugs and penile implants should be evaluated for treatment of impotence in SCI.

Renal scans are an effective method to follow renal function and screen for complications in SCI. Complications of the urinary tract in SCI need to be monitored postdischarge. Studies are needed as to the best methods of urinary tract prophylaxis for infection in SCI postdischarge.

Pressure sores are preventable with proper attention to weight relief. Effective types of cushions and beds are available for longer-term prevention.

Education of emergency medical services and trauma personnel is needed to apply known effective measures. New devices and electrical stimulation for prevention of pressure sores need further investigation.

Pressure sores can be effectively prevented in the hospital and postdischarge with adequate nursing care, patient education, and use of appropriate equipment.

Factors that contribute to pressure sores postdischarge need further study to identify effective interventions. I MPAIRMENT AND F UNCTIONAL L IMITATION. Recovery of motor power distal to the zone of injury is known in large groups, and recent information on recovery at the zone of injury is available in SCI.

Recovery of motor power in TBI is not well appreciated. More precise information on the extent and duration of motor recovery is needed to determine effectiveness of various interventions such as surgery, functional electrical stimulation, and other interventions on recovery and function.

Motor recovery in TBI should be studied. Strength and fatigue studies should be correlated with upper and lower extremity function. Some information exists on cognitive remediation in stroke patients but little in TBI. Clusters of cognitive disorders: attention, concept formation, executive functions, self-regulation of affect, and memory have been identified.

Standardization of tests, categorization of patients, and potential interventions such as cognitive retraining devices need to be developed and evaluated. Training of patients with SCI is effective, and large studies show significant gains in function from admission to discharge.

Training of patients with hemiplegia has been shown to be effective, but studies in TBI are limited. Various self-help devices and environmental control systems need to be evaluated. Precise relationship of strength to function in quadriplegic patients needs study.

Effect of self-care retraining with various categories of cognitive deficits in TBI needs evaluation. Mobility can be achieved in virtually all SCI individuals with training, orthotics, and manual or powered wheelchairs. New developments in orthoses and functional electrical stimulation to assist ambulation in SCI need further refinement and evaluation.

Centers for the development of advanced technology need to be identified to facilitate investigative interaction between rehabilitation professionals and engineers.

Cognitive and behavioral factors limit function in self-care and community living. Coma stimulation programs, day care, and transitional living programs have proliferated in recent years in response to the needs of a large TBI population.

Recent studies identify recovery from the persistent vegetative state PVS based on duration. D ISABILITY AND Q UALITY OF L IFE. The disparity in capacity and actual return to work requires measurement and factor analysis in SCI and TBI. Barriers to employment have been identified, such as loss of health benefits and inadequate evaluation of retraining limits.

Legislative authority for employment of people with disabilities was recently enacted. The effect of legislative action should be evaluated in return to employment by people with SCI and TBI.

Severe depression is uncommon in SCI in the hospital and early discharge period. The incidence of depression, suicide, and other self-destructive behaviors over time is not known in SCI and TBI. Disruptive behavior that is disabling is common in TBI in the early discharge period. The natural course of recovery from behavioral dysfunction in TBI requires study.

Frustration and hopelessness are felt to contribute to medical complication in SCI and disability. Interventions based on careful monitoring of psychological adjustment postinjury require study.

Some behaviors that are disruptive to function are controlled with psychotropic agents. The effects of psychotropic agents and other interventions require evaluation in TBI. Most individuals with SCI are quite active.

High quadriplegic individuals on respirators may achieve a significant quality of life. Normative data are needed for quality of life in SCI and TBI based on severity of impairment and disability. Severe SCI and TBI individuals are a significant burden of care for the family. The longitudinal needs of attendant care and respite care based on severity of disability require study.

A great proportion of TBI individuals require alternative placement from the rehabilitation hospital. Quality of life and cost differences for attentive placement in SCI need to be determined. Peer counseling through independent living centers has perceived value to individual adjustments.

Standards development and effectiveness measurement need to be carried out in TBI alternative care settings. Factors such as assertiveness training, education, and advocacy which result in effective interventions should be studied.

Limitation of various categories of insurance for essential services and equipment should be determined. lesion into a complete lesion, which not only increases impairment but also diminishes the prognosis for recovery National Research Council, Associated Injury Persons with central nervous system trauma often have multiple injuries to other organs, and these associated injuries can contribute to further complications and impairment.

For example, recent studies indicate that as many as 82 percent of patients with TBI sustain associated injuries Bontke, These associated injuries include fractures of long bones, skull, and spine; chest and abdominal injuries; and peripheral nerve damage Stover and Fine, The high incidence of associated injuries is related to the major role that motor vehicle crashes play in causing central nervous system trauma.

Finally, about 10 percent of TBI patients have associated SCI, and 10 percent of SCI patients have associated severe TBI. Compared with those who damage only one organ of the central nervous system, both groups sustain greater impairment and subsequent disability.

A recent report indicates that up to half of SCI patients may have a mild head injury, but the incidence of long-term impairment in these cases is not known Davidoff et al. A reduction in overall impairment and mortality may be achievable by improving the skill with which TBI and SCI patients are managed National Research Council, Complications Secondary Conditions The effect of medical complications on individual function is significant.

Patients with SCI and TBI often have similar complications that contribute to impairment and functional limitation, including complications to the cardiopulmonary-vascular, neuromusculoskeletal, and genitourinary-gastrointestinal systems; however, considerably more is known about the incidence and potential for intervention.

in patients with SCI than in those with TBI Young et al. In large part, this lack of information on TBI is attributable to a more mature system of neurological classification and data collection on SCI Stover and Fine, For TBI, classification and data collection are relatively new and present more complicated problems Bachy-Rita, Consequently, efforts to quantify the effectiveness of various intervention strategies in TBI lag behind similar efforts in SCI.

On closer inspection, certain types of complications that appear to be similar are substantially different in the SCI and TBI patient. For example, heterotopic ossification, a cause of contractures, occurs predominantly in the upper extremities in TBI, whereas it occurs predominantly in the lower extremities in SCI Venier and Ditunno, Spasticity during the acute phase of TBI may frequently require casting to prevent contracture Weintraub and Opat, , but this is seldom required in SCI.

Other complications are seen exclusively in TBI, such as cognitive dysfunction, linguistic and cranial nerve deficits, personality change, hydrocephalus, and seizures. Disseminated vascular clotting and neuroendocrine disorders are also prominent in TBI Bontke, ; National Research Council, Deep vein thrombosis is a very common medical complication and occurs in 80 percent to percent of completely paralyzed SCI patients, leading to pulmonary embolism, one of the most frequent causes of early death.

Recent studies provide evidence of effective methods of prevention, and these methods should be used more widely Merli et al. Occurring in 60 percent to 80 percent of high-level quadriplegic patients, pulmonary complications such as atelectasis and pneumonia are another major cause of mortality and morbidity.

Improved understanding of the underlying mechanisms could point the way to more effective interventions Fishburn et al. Infection of the urinary tract is another common complication in SCI and TBI patients who use indwelling Foley catheters. However, advances in the use of intermittent catheterization and improved measures of follow-up in persons with SCI have been reported to reduce renal disease as a major cause of death in the long-term patient Stover and Fine, Recurrent urinary tract infection and complications, however, continue to be a source of functional limitation and, at times, are associated with autonomic hypertension and increased spasticity.

Impaired bowel function is common in both groups of patients because of immobility. Contractures associated with muscle weakness and imbalance, spasticity, and heterotopic ossification constitute a type of medical complication that can lead to significant impairment and functional limitation.

Limited shoulder motion resulting from contractures, for example, may make it impossible for an individual to put on a shirt or reach overhead; walking is severely compromised if strength recovers but the knees and hips are permanently.

fused in flexion, not allowing proper standing and ambulation. A recent study Yarkony and Sahgal, reported an 85 percent incidence of contractures in craniocerebral trauma cases transferred to a rehabilitation unit; frequency was related to duration of coma. In SCI and TBI patients, contractures are most effectively prevented when bed positioning and therapies to maintain motion are instituted early and are continued throughout all phases of recovery.

Pressure sores are perhaps the most commonly cited medical complication associated with SCI. Nutritional deficiency, which may be prevalent early in the conditions of TBI and SCI patients, contributes to tissue breakdown and has been found to correlate with outcome Ragnarsson, in press.

Recurrent pressure sores do occur in a small proportion of patients after discharge, and improved strategies for prevention during this phase are needed.

However, proper education and training in combination with assistive equipment can be effective in preventing this condition. SCI patients suffer severe pressure sores almost twice as often before arriving at a model system care facility as after entry into the facility Young et al.

Basic and clinical research is needed in conjunction with improved surveillance data to develop and improve effective interventions for the prevention, management, and reduction of injury-related damage to the central nervous system.

In particular, emphasis should be given to the reduction of medical complications that contribute to short- and long-term disability in persons with SCI and TBI. Beginning a course of rehabilitation necessitates the assessment of a person's physical and mental status.

In terms of the committee's disability model, it is important to establish the stage in the progression, the risk factors, and the relevant preventive interventions. Depending on the type of impairment, for example, different interventions can be used during rehabilitation to help prevent the development of functional limitations.

In persons with SCI, reduced motor power is the major cause of functional limitation. Among persons with TBI, acute weakness of one side occurs in 18 percent of cases Eisenberg, and usually improves without contributing to significant limitation.

Most functional limitations associated with severe head injury are attributable to neurobehavioral impairments Levin, ; Bleiberg et al. Virtually all studies of rehabilitation in SCI patients are concerned with the capacity for self-care and mobility and how they relate to the severity of the neurological deficit Ditunno et al.

Strengthening exercises have been shown to increase motor. power in partially paralyzed muscles and are therefore important in preventing certain SCI impairments from progressing to functional limitations.

In addition, recent studies Ditunno et al. Recently reported research Bracken et al. Because most people with acute SCI are admitted to a hospital within the critical 8-hour period, this intervention has great potential for reducing disabling conditions.

The study, however, did not measure functional improvement. Improved cardiovascular conditioning of paraplegic individuals is an important part of rehabilitation and can be achieved through aerobic exercises, especially in young people.

Such conditioning enables many to participate in wheelchair sports and to walk in braces with crutches. Functional electrical stimulation FES has been promoted as having several potential applications. These include increasing strength and endurance and preventing osteoporosis in paraplegic and quadriplegic individuals, although these claims have not been evaluated rigorously Ragnarsson et al.

Another application of FES is in implantable electrodes to enable upper extremity grasping and thus self-feeding by persons with high-level quadriplegia Peckham et al. Applications of FES in ambulation Marsolais and Kobetic, and prevention of pressure sores Davidoff et al.

Individuals with complete paralysis of leg muscles can learn to get in and out of bed, bathe, dress, use the toilet, and dress without assistance by learning certain skillful maneuvers and using adaptive equipment.

A high level of independence can be achieved with the aid of adaptive equipment and training in feeding, dressing, bathing, using a wheelchair, and driving a car. Even people with paralysis in all limbs can reduce dependency through the use of technology that permits such individuals to unlock doors, turn on lights, and operate a phone or a computer.

The opportunity for enhancing functional capacity and independence in people with paralysis is great, meriting an expanded research and development effort on new assistive technologies. Educational programs that help individuals perform self-care activities are an integral part of the rehabilitation process, which begins in the acute phase of injury and continues throughout the life course.

Modification of procedures, tasks, and schedules according to the needs of the individual facilitates functioning on the job and in other social contexts. Eventually, these modifications should become the exclusive responsibility of the person with the potentially disabling condition.

Another example is learning to. control bladder and bowel dysfunction, which occurs in most individuals with injury to the spinal cord. Control of these functions is an important aspect of rehabilitation.

With skillful training, more than 90 percent of SCI patients are capable of bladder and bowel continence. Training also includes education on how to avoid bladder infection and prevent other potentially disabling conditions. People with TBI often have more extensive impairment of the nervous system than do people with SCI because TBI can result in focal or diffuse lesions in any part of the brain.

Paralysis, spasticity and rigidity, ataxia, and other disorders affecting coordination in the hands or legs can lead to functional limitation. Posttraumatic involvement of the sensory, labyrinth, or cerebellar-mediated systems results in ataxia in 20 percent to 30 percent of people sustaining diffuse brain injury Weintraub and Opat, In these cases, functional limitation is common because of difficulties in hand performance of fine motor skills and in gross motor skills such as walking.

Although the true incidence of cranial nerve involvement is unknown, loss of the sense of smell occurs in 7 percent to 25 percent of all head injury patients Berrol, Because any of the cranial nerves may be involved, impairments caused by head injury include defective smell, vision, taste, and hearing and thus often limit the amount of information available from the environment; however, the effects of these impairments on function are unclear.

As many as 40 percent of all people with TBI experience problems in communication due to partial aphasia. Other linguistic limitations such as naming, sentence repetition, and word fluency occur in an additional 30 percent or more of cases Levin and Goldstein, Because little is known about the natural course of these limitations, interventions that might improve function are lacking.

Assessment of the neurobehavioral impairments that contribute to the greatest functional limitations in TBI is a considerable research need. Cognitive impairments, which may be grouped into problems with attention, concept formation, executive function, self-regulation of affect, and memory, have been identified and occur in the majority of patients with head injury Diller and Ben-Yishay, However, information on how these impairments affect function, particularly self-care, is very limited.

Finally, when motor impairment occurs along with neurobehavioral dysfunction, traditional instruments for evaluating function and the results of intervention may be of limited value.

For example, the reason why some individuals do not dress themselves may not be because of paralysis but because they sit on the bed without initiating any movement Diller and Ben-Yishay, Although training individuals with cognitive deficits to become more functional has yielded some encouraging results, better tests to measure.

executive function, process function, and acceptance and awareness need to be developed Diller and Ben-Yishay, In summary, acute medical rehabilitation is an important component of the systems approach to acute care and rehabilitation.

However, because impairments in strength, tone, coordination, and information transmission may be superimposed on cognitive and behavioral impairments, better indexes that integrate impairment, functional limitation, and disability need to be developed to determine the effectiveness of rehabilitation interventions.

These assessments must be applied to the proliferating alternative treatment e environments in TBI care, such as day treatment and cognitive rehabilitation.

Basic and clinical rehabilitation research is needed in the prevention, management, and reduction of the motor impairment associated with SCI and the neurobehavioral impairment associated with TBI.

In particular, more thorough study is needed of motor recovery in SCI patients and the effectiveness of various interventions such as surgery, drugs, and rehabilitation in reducing impairment and improving function.

Future research should focus on potential applications of functional electrical stimulation, development and testing of new assistive technologies, and the causal relationships between TBI and the senses of smell, vision, taste, and hearing, as well as the causal relationship between TBI and aphasia.

Better tests to measure higher cortical function e. These indexes should integrate measures of impairment, functional limitation, and disability. An obvious need is for consistent classification and categorization of TBI severity.

Such classification can serve as a basis for prognosis and permit reliable assessments of the effectiveness of therapeutic interventions in reducing impairments.

Psychosocial and vocational interventions during acute and rehabilitation phases are directed at helping the individual and family members cope with the sudden and potentially devastating effects of the affected person's altered self-image and self-esteem.

Prior to the patient being discharged into the community, the goal of such interventions is to offer vocational opportunities, with early assessment, and prepare the individual and family members for the adjustment to the affected person's altered but possibly independent lifestyle.

As functional recovery improves during the first year or more after the injury, the focus of rehabilitation shifts from medical intervention and physical restoration to psychosocial and vocational adaptation. The ultimate goal of psychosocial and vocational rehabilitation is community reintegration.

For children and adolescents, this may mean returning to school. For adults, returning to work is an important component of reintegration.

It is important to emphasize that services aimed at community reintegration must consider not only attributes and limitations of the injured individual, but also the social, educational, and vocational systems in which the individual will function.

It has long been recognized that individuals vary greatly in their ability to adapt to a functional limitation. As discussed in Chapter 3 , variability in outcome depends on a host of personal and environmental factors, some of which are mutable.

Although a comprehensive review of the necessary components of an integrated, coordinated approach to community reintegration is beyond the scope of this report, a brief summary of some of the more important elements follows.

The reader is referred to Chapters of Traumatic Brain Injury Bach-y-Rita, for a more complete discussion of the issues. Transitional living centers offer community-based residential programs that provide an opportunity for individuals to relearn and practice, in a protected but real-life environment, the skills necessary for living independently and productively.

Although most individuals who sustain SCI return home following inpatient rehabilitation, the individual with severe TBI often requires the services of a transitional living center after discharge from an acute rehabilitation center. When the structure of a residential program e.

For individuals who continue to require assistance with activities of daily living, in-home services may be required. Vocational services are crucial for ensuring that return-to-work goals are achieved.

These services may include counseling and work readiness evaluations, job training, job placement, work-site modification, and postemployment services intended to ensure satisfactory adjustment to employment.

Independent living centers offer valuable resources throughout the process of recovery from TBI and SCI. These centers are primarily staffed by individuals with disabling conditions and provide a supportive network for individuals who want to achieve an independent lifestyle.

The importance of independent living centers to the welfare of people with disabling conditions cannot be overemphasized. Independent living centers are described in more detail in Chapter 7. Providers and consumers alike express concerns that existing psychosocial and vocational services do not adequately meet the needs of clients National Council on the Handicapped, This is particularly true for services required by individuals with TBI.

Special education, for example, often focuses on the needs of children with developmental disabilities. The child coping with the effects of a head injury is thought to have needs different from those of the child with a developmental disability.

Yet school systems often do not recognize these special needs and do not have the necessary resources to address them. Similarly, vocational rehabilitation specialists often are not trained to specifically respond to the needs of the head-injured adult who may have no physical limitations but, because of inappropriate behavior or memory problems, has difficulty keeping a job.

Existing and alternative strategies for psychosocial and vocational rehabilitation of individuals with SCI and TBI need to be developed and assessed for their effectiveness. This will require longitudinal studies to measure both outcome and program costs.

Research on outcomes of psychosocial and vocational rehabilitation should include measures of quality of life and not limit the definition of successful outcome solely to return to work, school, or household maintenance. Community-based programs, independent living centers, projects with industry, and alternative programs should be considered in research and evaluation projects.

Despite some questions about the efficacy of the increasing number of alternative strategies for rehabilitating people with SCI or TBI, it is clear that a wide range of community services are needed. It is also clear that many people who need these services do not receive them, and that quality psychosocial and vocational rehabilitation services aimed at reintegrating persons with disabling conditions into the community and back to work should be available to those who need them.

The number of day programs is increasing but is still insufficient to meet the more rapidly increasing demand for such services Jacobs, A major conclusion of the Los Angeles Head Injury Survey was that the rehabilitation needs of many persons with traumatic brain injury go unmet because of the geographic and financial inaccessibility of services.

The shortage of services is even more acute in rural areas of the country. Rehabilitation, especially neurobehavioral rehabilitation and psychosocial services, is rarely covered by private health insurance.

The extent of coverage under Medicaid varies greatly from state to state, but, generally, Medicaid funding is restricted to inpatient medical rehabilitation and physical therapy.

Financial support for transitional living centers and vocational. rehabilitation is more limited. Strict and often confusing eligibility requirements for vocational rehabilitation programs further limit accessibility to these services, especially for those with TBI.

Means for removing financial barriers that limit accessibility to rehabilitation services need to be studied. Such studies should evaluate the extent to which current public and private compensation programs create nonproductive disincentives for rehabilitation and resumption of a productive role in society.

In addition, the lack of public and private insurance coverage for neurobehavioral rehabilitation and psychosocial and vocational services should be examined.

Multidisciplinary research is needed to develop a better understanding of the multiple factors, both medical and nonmedical, that contribute to disability and the overall quality of life following TBI and SCI. Given the problems associated with the availability and accessibility of services, the family often assumes the major responsibility for providing care and support to individuals with SCI or TBI Jacobs, This responsibility, often lifelong, may have a major impact on members of the family, as well as on the family unit as a whole Bach-y-Rita, Separation and divorce and financial difficulties are among the problems commonly reported by families of persons who have sustained major trauma.

These problems are especially acute for families of persons with TBI Brooks, Additional problems arise when the primary caregiver dies. Society must face the challenge of providing appropriate and adequate support to individuals with major physical and neurobehavioral disabling conditions.

Addressing this need will require educating employers of the rights and capabilities of people with disabling conditions associated with TBI and SCI. Expanded education programs are needed to inform the public about the legal rights of people with disabling conditions, including their rights to work and their guarantees of full participation in society, as is consistent with provisions of the Americans with Disabilities Act.

Education programs are also needed to instruct employers in the special capabilities and needs of persons with TBI and SCI. In summary, there is a growing consensus that universal access to coordinated systems of care that integrate treatment from the site of injury through long-term community follow-up is essential for mitigating the short-term effects of SCI and TBI and for reducing long-term disability.

However, the establishment of national and regional networks of SCI and TBI systems of care that link state and local systems will need to be tested. TBI, testing of the entire system, its components, and overall effectiveness is needed; for SCI, more rigorous control is required.

Closer working relationships between industry and vocational rehabilitation programs should also be fostered. Coordinated systems of care that integrate treatment from the site of injury through long-term community follow-up are needed for mitigating the short-term effects of SCI and TBI and for reducing long-term disability.

Several studies have underscored the lack of adequate funding for injury prevention research and practice National Research Council, ; Rice et al. Although considerable progress has been made in accurately describing and establishing injury as a major public health concern, greater resources must be directed to the prevention of injuries by applying existing knowledge and by developing new intervention strategies.

At night, wear reflective tape on your shoes, cap or jacket to reflect the headlights of the cars coming towards you. Safety checklist. Make sure your kitchen knives are kept sharp. A dull knife can slip and cause injury, and can also cause a worse cut.

Charge up. Check the batteries in your smoke detectors at least once a year. Face first. Always walk on the sidewalk. If there is no sidewalk and you have to walk on the side of the road, always walk FACING traffic. Take your time. Whether you are changing a tire, painting a house, or moving furniture, taking your time can prevent injury.

Rushing leads to carelessness and errors. Buckle up! Everyone should wear seat belts. Make sure children are in size and age appropriate certified car seats or booster seats. Working together, the groups aimed to promote health and prevent secondary conditions.

A secondary condition can be any medical, social, emotional, family, or community problem that a person with a primary disabling condition likely experiences.

The Disability Health Project was coordinated by the MDH Injury and Violence Prevention Section and funded by a planning grant through the CDC Division on Birth Defects and Developmental Disabilities.

Minnesota was one of 16 state grantees, and CDC also funded related research projects and national disability organizations. The Disability Health Project Advisory Work Group included agencies and organizations that work with people with disabilities. Members include persons with disabilities and parents of children and adults with disabilities.

Contact Info Injury and Violence Prevention Section. injuryprevention state. Injury and Violence Prevention Disability Health Project People with disabilities often have more health care problems or issues than people without disabilities. These disparities have many causes; they may occur because health care is not accessible physical barriers, financial barriers, lack of information, etc.

Disbilities federal programs are designed to help prevent falls or Injury prevention for people with disabilities accessibility for older adults or adults with disabilities by providing evidence-based disahilities prevention e. Four agencies oversee these programs: Administration on Prevenntion Living RorOrganic anti-inflammatory supplements for Disease Control and Prevention CDCthe Department of Housing and Urban Development, and the Department of Veterans Affairs. These programs serve limited numbers of individuals, based on agency survey responses. Officials from national stakeholder organizations GAO spoke with said that not all populations at risk of falls may be served, including adults with disabilities under age GAO's analysis of national data on self-reported falls from found that adults with disabilities aged 45 to 59 reported rates of falls and fall-related injuries that were higher than those reported by individuals 60 and over. Disabilitoes FAQ Contact Us. Peer reviewed only Full text available on ERIC. Include Synonyms Include Dead terms. Peer reviewed Direct link. ERIC Number: EJ

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