Ontario Neurotrauma Foundation

Clinical Practice Guideline

For the rehabilitation of Adults with Moderate to Severe TBI

Ontario Neurotrauma Foundation INESSS
SECTION 2: Assessment and Rehabilitation of Brain Injury Sequelae > M. Motor Function and Control

M. Motor Function and Control

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Traumatic brain injury (TBI) can result in a wide range of motor/physical limitations including changes in muscle tone, disturbed balance and gait, contractures and reduced aerobic fitness. Moreover, many persons with TBI sustain orthopaedic or musculoskeletal injuries that need to be taken into account when providing interventions to improve motor function. Recommended treatment approaches emphasize balance/gait training, positioning, and exercise training for improved strength and endurance. Treatment approaches should encourage practice and repetition of functional tasks in and outside of formal therapy to optimize motor recovery and function. Positioning and use of medications can be helpful for the treatment of spasticity and contractures.

A trained health care professional with neurological expertise should assess, design, implement and supervise therapy to improve the motor functions of individuals with TBI. The interdisciplinary team should also include professionals with expertise in seating, orthotics and the prescription and fitting of assistive technology and devices as well as equipment to address the range of potential motor impairments/limitations. Persons with TBI should be treated in environments providing them the opportunity to experience upright positions early in their recovery (in the absence of refractory intracranial hypertension).

 

Indicators exemples

  • Proportion of individuals with TBI for whom exercise training is included as an objective in the rehabilitation plan.

Motor Function Control. When motor impairment is present post injury, the extent and timing of an individual’s symptoms and injuries should be considered when determining a course of action. Motor impairment can result from the independent effects of prolonged immobilization and bed rest in the acute period. Prolonged immobility affects multiple body systems, although it is the direct effects on the musculoskeletal system and the cardiovascular system that impact motor function the most (Bushbacher, 2000).

For select patients, constraint-induced therapy has been shown to improve upper extremity use but it requires a high level of adherence (Shaw et al., 2005). Constraint-induced therapy has been shown to improve the amount and quality of use of the upper limb (Motor Activity Log), as well as some functional improvements of the upper limb (Page & Levine, 2003; Shaw et al., 2005).

In order to improve fine motor control, there are retraining activities that should be considered after TBI. In a RCT byNeistadt (1994), fine motor coordination was examined in a group of adult men with brain injury using two types of coordination retraining activities: tabletop activities (i.e. peg board activities, puzzles etc.) and functional activities (i.e. meal preparation). Results indicated that functional activities were more effective than table top activities in promoting fine motor coordination.

To increase task specific performance post TBI, a number of repetitive training interventions have been studied. A RCT conducted by Canning et al. (2003) used intensive sit-to-stand training as an intervention, demonstrating increased ability to perform sit-to stand within a defined time frame. In a prospective study looking at balance training, Dault and Dugas (2002) noted a significant improvement in balance and coordination for a group that participated in a more specific balance and coordination training program rather than traditional muscular training. Virtual reality interventions have also been shown to be beneficial in improving balance. Ustinova, Perkins, Leonard, and Hausbeck (2014) had participants complete 15 sessions of virtual reality therapy and found that this intervention targeted the recovery of postural and coordination abnormalities, with significant improvements shown for balance and dynamic stability, as measured by the Berg Balance Scale, Functional Gait Assessment and Functional Reaching Test. Cuthbert et al. (2014) also demonstrated a significant improvement on balance using virtual reality therapy; however, the gains made using this intervention were not significantly different than those made with standard therapy. Finally, during static balance tasks, visual feedback provided using a Wii Balance board helped reduce weight-bearing asymmetry (Foo, Paterson, Williams, & Clark, 2013).

Based on the results of several RCTs, partial body weight supported treadmill training does not provide any added benefit over conventional training (Brown et al., 2005; Esquenazi, Lee, Packel, & Braitman, 2013;Wilson, Powell, Gorham, & Childers, 2006).

For individuals where contracture and deformity are progressive, casts, splints and passive stretching may be beneficial. For the upper extremities, Moseley et al. (2008) found patients receiving elbow serial casting showed a greater reduction in elbow contractures post treatment than individuals who received passive stretching; however, this improvement diminished quickly (mean reduction was 22░, then 11░ one day later). Follow up assessments found no significant difference in improvements between the groups (Moseley et al., 2008). Range of motion has also been shown to improve with casting (Hill, 1994; Moseley, 1997; Pohl et al., 2002; Verplancke, Snape, Salisbury, Jones, & Ward, 2005). Preservation of functional range of motion is important to allow for future motor recovery.

Cardiorespiratory fitness should be promoted in the TBI population using exercise training. In a RCT, Hassett et al. (2009) found individuals assigned to exercise programs showed significant improvement in their cardiorespiratory levels regardless of where they worked out (in a gym or at home) or how often (2.4 sessions per week vs 0.5 sessions per week). However, adherence to the program was higher among those attending a fitness center. In a case-series study, when comparing individuals with TBI who exercised to those who did not, the exercisers were less depressed, had less symptoms and better self-reported health status than non-exercising brain injury survivors (Gordon et al., 1998).  Furthermore, Bateman et al. (2001) compared cycling training (experimental group) to relaxation training (control group) and found significant improvement in exercise capacity for the experimental group.

Spasticity. A number of pharmacological therapies have been suggested to address the issue of spasticity in TBI. Intiso et al. (2014) examined the effects of Botulinum Neurotoxin-A (BoNT-A) and showed a reduction in spasticity for the upper extremity (elbow, wrist, and hand), as well as ankle joints at one and four months post treatment. These findings were similar to those found by Yablon, Agana, Ivanhoe, and Boake (1996) who reported that BoNT-A injections into the upper extremities improved range of motion and spasticity in 21 patients with ABI.

Meythaler, DeVivo, and Hadley (1996) confirmed the effectiveness of intrathecal baclofen in decreasing upper and lower extremity spasticity in a RCT cross-over trial. In subsequent studies, the same investigators went on to demonstrate the effectiveness of intrathecal baclofen for decreasing spasticity for up to three months (Meythaler, McCary, & Hadley, 1997) and 1 year (Meythaler, Guin-Renfroe, Grabb, & Hadley, 1999). Investigations carried out by other research groups have reported similar findings (Becker, Alberti, & Bauer, 1997; Dario, Di Stefano, Grossi, Casagrande, & Bono, 2002; Francisco, Hu, Boake, & Ivanhoe, 2005; Hoarau, Richer, Dehail, & Cuny, 2012; Posteraro et al., 2013; Stokic, Yablon, & Hayes, 2005). However, a common limitation of these studies is the lack of a control group.

Meythaler et al. (2001) completed a RCT cross-over trial examining tizanidine for the management of spasticity. This study evaluated both stroke (53%) and TBI (47%) survivors. For both upper and lower extremity, there was a significant decrease in the Ashworth scores on the affected side with the active drug compared to placebo. However, significant differences between treatments were not found for upper and lower extremity spasm and reflex scores ((Meythaler et al., 2001). In another mixed population study (brain injury and stroke), Meythaler, Clayton, Davis, Guin-Renfroe, and Brunner (2004) completed a retrospective study evaluating the use of oral baclofen to manage spasticity and found that it improved spasticity in the lower extremity assessed using the Ashworth Rigidity Scale and Spasm Frequency Scale; however, no changes for tone, spasm frequency or reflexes were found for the upper extremity (Meythaler et al., 2004).

REFERENCES
Bateman, A., Culpan, F. J., Pickering, A. D., Powell, J. H., Scott, O. M., & Greenwood, R. J. (2001). The effect of aerobic training on rehabilitation outcomes after recent severe brain injury: a randomized controlled evaluation. Arch Phys Med Rehabil, 82(2), 174-182.

Becker, R., Alberti, O., & Bauer, B. L. (1997). Continuous intrathecal baclofen infusion in severe spasticity after traumatic or hypoxic brain injury. J Neurol, 244(3), 160-166.

Brown, T. H., Mount, J., Rouland, B. L., Kautz, K. A., Barnes, R. M., & Kim, J. (2005). Body weight-supported treadmill training versus conventional gait training for people with chronic traumatic brain injury. J Head Trauma Rehabil, 20(5), 402-415.

Bushbacher, R. M., & Porter, C. D. (2000). Deconditioning, conditioning, and the benefits of exercise. Toronto Saunders Company.

Canning, C. G., Shepherd, R. B., Carr, J. H., Alison, J. A., Wade, L., & White, A. (2003). A randomized controlled trial of the effects of intensive sit-to-stand training after recent traumatic brain injury on sit-to-stand performance. Clin Rehabil, 17(4), 355-362.

Cuthbert, J. P., Staniszewski, K., Hays, K., Gerber, D., Natale, A., & O'Dell, D. (2014). Virtual reality-based therapy for the treatment of balance deficits in patients receiving inpatient rehabilitation for traumatic brain injury. Brain Inj, 28(2), 181-188.

Dario, A., Di Stefano, M. G., Grossi, A., Casagrande, F., & Bono, G. (2002). Long-term intrathecal Baclofen infusion in supraspinal spasticity of adulthood. Acta Neurol Scand, 105(2), 83-87.

Dault, M. C., & Dugas, C. (2002). Evaluation of a specific balance and coordination programme for individuals with a traumatic brain injury. Brain Inj, 16(3), 231-244.

Esquenazi, A., Lee, S., Packel, A. T., & Braitman, L. (2013). A randomized comparative study of manually assisted versus robotic-assisted body weight supported treadmill training in persons with a traumatic brain injury. Pm r, 5(4), 280-290.

Evidence-Based Review of Moderate To Severe Acquired Brain Injury (ERABI). (2016). http://www.abiebr.com/.  

Foo, J., Paterson, K., Williams, G., & Clark, R. (2013). Low-cost evaluation and real-time feedback of static and dynamic weight bearing asymmetry in patients undergoing in-patient physiotherapy rehabilitation for neurological conditions. J Neuroeng Rehabil, 10, 74.

Francisco, G. E., Hu, M. M., Boake, C., & Ivanhoe, C. B. (2005). Efficacy of early use of intrathecal baclofen therapy for treating spastic hypertonia due to acquired brain injury. Brain Inj, 19(5), 359-364.

Gordon, W. A., Sliwinski, M., Echo, J., McLoughlin, M., Sheerer, M., & Meili, T. E. (1998). The benefits of exercise in individuals with traumatic brain injury: A retrospective study. Journal of Head Trauma Rehabilitation, 13(4), 58-67.

Hassett, L. M., Moseley, A. M., Tate, R. L., Harmer, A. R., Fairbairn, T. J., & Leung, J. (2009). Efficacy of a fitness centre-based exercise programme compared with a home-based exercise programme in traumatic brain injury: a randomized controlled trial. Journal of Rehabilitation Medicine, 41(4), 247-255.

Hill, J. (1994). The effects of casting on upper extremity motor disorders after brain injury. Am J Occup Ther, 48(3), 219-224.

Hoarau, X., Richer, E., Dehail, P., & Cuny, E. (2012). Comparison of long-term outcomes of patients with severe traumatic or hypoxic brain injuries treated with intrathecal baclofen therapy for dysautonomia. Brain Injury, 26(12), 1451-1463.

Intiso, D., Simone, V., Di Rienzo, F., Iarossi, A., Pazienza, L., Santamato, A., . . . Basciani, M. (2014). High doses of a new botulinum toxin type A (NT-201) in adult patients with severe spasticity following brain injury and cerebral palsy. NeuroRehabilitation, 34(3), 515-522.

Meythaler, J. M., Clayton, W., Davis, L. K., Guin-Renfroe, S., & Brunner, R. C. (2004). Orally delivered baclofen to control spastic hypertonia in acquired brain injury. J Head Trauma Rehabil, 19(2), 101-108.

Meythaler, J. M., DeVivo, M. J., & Hadley, M. (1996). Prospective study on the use of bolus intrathecal baclofen for spastic hypertonia due to acquired brain injury. Arch Phys Med Rehabil, 77(5), 461-466.

Meythaler, J. M., Guin-Renfroe, S., Grabb, P., & Hadley, M. N. (1999). Long-term continuously infused intrathecal baclofen for spastic-dystonic hypertonia in traumatic brain injury: 1-year experience. Arch Phys Med Rehabil, 80(1), 13-19.

Meythaler, J. M., Guin-Renfroe, S., Johnson, A., & Brunner, R. M. (2001). Prospective assessment of tizanidine for spasticity due to acquired brain injury. Arch Phys Med Rehabil, 82(9), 1155-1163.

Meythaler, J. M., McCary, A., & Hadley, M. N. (1997). Prospective assessment of continuous intrathecal infusion of baclofen for spasticity caused by acquired brain injury: a preliminary report. J Neurosurg, 87(3), 415-419.

Moseley, A. M. (1997). The effect of casting combined with stretching on passive ankle dorsiflexion in adults with traumatic head injuries. Phys Ther, 77(3), 240-247; discussion 248-259.

Moseley, A. M., Hassett, L. M., Leung, J., Clare, J. S., Herbert, R. D., & Harvey, L. A. (2008). Serial casting versus positioning for the treatment of elbow contractures in adults with traumatic brain injury: a randomized controlled trial. Clin Rehabil, 22(5), 406-417.

Neistadt, M. E. (1994). The effects of different treatment activities on functional fine motor coordination in adults with brain injury. Am J Occup Ther, 48(10), 877-882.

Page, S., & Levine, P. (2003). Forced use after TBI: promoting plasticity and function through practice. Brain Inj, 17(8), 675-684.

Pohl, M., Ruckriem, S., Mehrholz, J., Ritschel, C., Strik, H., & Pause, M. R. (2002). Effectiveness of serial casting in patients with severe cerebral spasticity: a comparison study. Arch Phys Med Rehabil, 83(6), 784-790.

Posteraro, F., Calandriello, B., Galli, R., Logi, F., Iardella, L., & Bordi, L. (2013). Timing of intrathecal baclofen therapy in persons with acquired brain injury: influence on outcome. Brain Inj, 27(13-14), 1671-1675.

Shaw, S. E., Morris, D. M., Uswatte, G., McKay, S., Meythaler, J. M., & Taub, E. (2005). Constraint-induced movement therapy for recovery of upper-limb function following traumatic brain injury. J Rehabil Res Dev, 42(6), 769-778.

Stokic, D. S., Yablon, S. A., & Hayes, A. (2005). Comparison of clinical and neurophysiologic responses to intrathecal baclofen bolus administration in moderate-to-severe spasticity after acquired brain injury. Arch Phys Med Rehabil, 86(9), 1801-1806.

Ustinova, K. I., Perkins, J., Leonard, W. A., & Hausbeck, C. J. (2014). Virtual reality game-based therapy for treatment of postural and co-ordination abnormalities secondary to TBI: a pilot study. Brain Inj, 28(4), 486-495.

Verplancke, D., Snape, S., Salisbury, C. F., Jones, P. W., & Ward, A. B. (2005). A randomized controlled trial of botulinum toxin on lower limb spasticity following acute acquired severe brain injury. Clin Rehabil, 19(2), 117-125.

Wilson, D. J., Powell, M., Gorham, J. L., & Childers, M. K. (2006). Ambulation training with and without partial weightbearing after traumatic brain injury: results of a randomized, controlled trial. Am J Phys Med Rehabil, 85(1), 68-74.

Yablon, S. A., Agana, B. T., Ivanhoe, C. B., & Boake, C. (1996). Botulinum toxin in severe upper extremity spasticity among patients with traumatic brain injury: an open-labeled trial. Neurology, 47(4), 939-944.

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M1. Motor Function and Control Assessment

P Priority F Fundamental New Level of evidence A B C
M 1.1 C

A trained professional with neurological expertise should assess, design, implement and supervise therapy to improve the motor functions of individuals with traumatic brain injury.

(Adapted from NZGG 2006, 6.1, p. 88)

M2. Motor Function and Control Rehabilitation

P Priority F Fundamental New Level of evidence A B C
M 2.1 C

Any physical treatment approaches provided following traumatic brain injury should take into account any associated orthopaedic or musculoskeletal injuries.

(Adapted from NZGG 2006, 6.1, p. 88)

M 2.2 P C

Motor therapy programs for individuals with TBI should target the preservation of functional range of motion (ROM) in all phases of care post traumatic brain injury (in the absence of refractory intracranial hypertension), but particularly in the acute and subacute phases, to allow for future motor recovery, functional activities and positioning. Regardless of prognosis, potential for recovery may be adversely affected if contractures are allowed to develop.

(INESSS-ONF, 2015)

REFERENCE:

- ERABI Module 4- Motor & Sensory Impairment Remediation

M 2.3 C

Motor therapy programs should be adapted to accommodate the normal environment and activities of the person with traumatic brain injury as much as possible.

(Adapted from NZGG 2006, 6.1, p. 88)

M 2.4 C

Strength and endurance training with the person with traumatic brain injury should be performed, within the context of functional tasks when possible.

(Adapted from ABIKUS 2007, G54, p. 24)

M 2.5 P A

Individuals with traumatic brain injury should be given opportunities to practise their motor skills outside of formal therapy.

(ABIKUS 2007, G53, p. 24)

M 2.6 C

As postural control is an essential component of mobility and motor function, individuals with traumatic brain injury should be given the opportunity to experience upright positions regardless of their level of responsiveness or level of severity and recovery, provided they are medically stable. For example, progressive upright sitting or supported standing for head, neck and trunk control should be a part of the postural control interventions.

(INESSS-ONF, 2015)

M 2.7 C

Individuals with traumatic brain injury with complex postural/seating needs should be referred to a specialized interdisciplinary team with expertise in specialized seating.

(Adapted from ABIKUS 2007, G54, p. 24 and NZGG 2006, 6.1.1, p. 90)

M 2.8 P B

Specific repetitive training interventions to increase functions post traumatic brain injury are recommended, such as sit-to-stand, functional reaching and balance, and gross motor coordination of the lower extremities.

(INESSS-ONF, 2015)

REFERENCE:

-ERABI Module 4- Motor & Sensory Impairment Remediation, p.32, 4.4.2

M 2.9 P B

Either virtual-reality-based balance retraining program or a conventional balance retraining program can be used to improve balance post traumatic brain injury.

(INESSS-ONF, 2015)

REFERENCE:

-ERABI Module 4- Motor & Sensory Impairment Remediation, p.32, 4.4.2

M 2.10 C

Gait re-education is recommended to improve mobility after traumatic brain injury.

(Adapted from ABIKUS 2007, G54, p. 24)

M 2.11 B

Partial body weight supported gait training does NOT provide any added benefit over conventional gait training in ambulation, mobility or balance following traumatic brain injury.

(INESSS-ONF, 2015)

REFERENCE:

-ERABI Module 4- Motor & Sensory Impairment Remediation, p.29, 4.4.1

M 2.12 C

For individuals with traumatic brain injury who are unable to ambulate over ground, gait training with partial support with a harness and/or hydrotherapy should be considered.

(INESSS-ONF, 2015)

M 2.13 P B

Functional fine motor control retraining activities should be considered to improve fine motor coordination after traumatic brain injury.

(Adapted from AOTA 2009, p. 82)

M 2.14 C

Constraint-induced therapy should be considered for individuals with traumatic brain injury who have upper extremity motor impairments with some active wrist and finger movements and can cognitively engage in the therapy.

(Adapted from AOTA 2009, p. 82)

M 2.15 C

The following therapies could be considered to improve upper and lower extremity motor and sensory impairments following traumatic brain injury:

  • Functional electrical stimulation

  • Contrast baths

  • Mirror therapy

  • Cycle ergometry with or without motor assistance depending on the person’s level of functioning.

(INESSS-ONF, 2015)

M 2.16 C

A program must be in place to prevent shoulder trauma for individuals with traumatic brain injury with flaccid upper extremities. This includes bed positioning, arm support in sitting and use of a hemi arm sling for standing and transfers.

(INESSS-ONF, 2015)

M 2.17 C

Orthoses should be individually fitted by a health professional or orthotist with expertise in traumatic brain injury.

(Adapted from NZGG 2006, 6.1.1, p. 90)

M 2.18 B

Casts, splints and passive stretching may be considered for individuals with traumatic brain injury in cases where contracture and deformity are progressive.

(SIGN 2013, 4.2.1, p. 17)

M 2.19 P A

Exercise training is recommended to promote cardiorespiratory fitness in individuals with traumatic brain injury.

(Adapted from ABIKUS 2007, G54, p. 24)

M3. Assessment of Spasticity

P Priority F Fundamental New Level of evidence A B C
M 3.1 C

Individuals with traumatic brain injury with spasticity should be assessed and provided with a coordinated plan for interdisciplinary management including:

  • Identification and management of aggravating factors such as pain, bladder or bowel distention, skin irritation and infection

  • Use of specific treatment modalities such as serial casting or removable splints

  • Use of anti-spasticity medications (See section M4 for more details)

  • Rehabilitation interventions that consider a range of motion, flexibility and positioning routine

(Adapted from ABIKUS 2007, G63, p. 26)

M4. Management of Spasticity

Medications should only be prescribed by qualified physicians, and guideline users should consult the section on "Principles of medication management" before prescribing.
P Priority F Fundamental New Level of evidence A B C
M 4.1 P B

Botulinum neurotoxin therapy (BoNT) may be considered to reduce tone and deformity in individuals with traumatic brain injury with focal spasticity.

(Adapted from SIGN 2013, 4.2.2, p. 17)


Suggested tool: Health Canada Indications of Use

M 4.2 C

Botulinum neurotoxin therapy (BoNT) for individuals with traumatic brain injury should be used in an interdisciplinary setting with physiotherapist / occupational therapist and orthotist inputs where appropriate.

(Adapted from SIGN 2013, 4.2.2, p. 17)


Suggested tool: Health Canada Indications of Use

M 4.3 C

Oral baclofen, tizanidine or dantrolene sodium may be considered for treatment of spasticity in individuals with traumatic brain injury.

(Adapted from SIGN 2013, 4.2.3, p. 18)

Note: Physicians should consider and monitor the sedative and cognitive side effects when prescribing these medications.


Suggested tool: Health Canada Indications of Use

M 4.4 C

A trial of intrathecal baclofen for the treatment of severe spasticity in individuals with traumatic brain injury may be considered after other treatment options have been exhausted, i.e. antispasticity medications (e.g. baclofen, dantrolene, tizanidine, botulinum toxin), casting, splinting or stretching. The trial should be carefully monitored for possible complications, including pump malfunction. Consideration must also be given to the individual’s ability to access ongoing follow-up, for example to get refills, in case of a malfunction or for troubleshooting.

(Adapted from NZGG 2006, 6.1.1, p. 90)


Suggested tool: Health Canada Indications of Use

M5. Assessment for Assistive Technology

P Priority F Fundamental New Level of evidence A B C
M 5.1 P C

Individuals with traumatic brain injury (TBI) should be assessed to determine whether equipment or adaptations could increase their safety, independence, communication and quality of life. This assessment should:

  • Be conducted by professionals with expertise in these areas (TBI and assistive devices and technology)

  • Be conducted on an individual basis and in the environment in which the equipment will be used

(Adapted from NZGG 2006, 6.2, p. 107)

M6. Prescription of Assistive Technology

P Priority F Fundamental New Level of evidence A B C
M 6.1 P C

The prescription of equipment for individuals with traumatic brain injury should take into account cognitive, communicative and behavioural deficits and how these may constrain the person’s ability, or their family/caregivers’ ability, to use the equipment safely and appropriately. Where this is in doubt, arrangements should be in place for regular review.

(Adapted from ABIKUS 2007, G88, p. 31 and NZGG 2006, 6.2, p. 107)

M 6.2 C

When an item of equipment has been identified as required for a person with traumatic brain injury, it should be provided as quickly as possible. If safety is at issue, it should be provided before the person is discharged to the community.

(NZGG 2006, 6.2, p. 107)

M 6.3 C

The person with traumatic brain injury and their family or caregivers should be trained in the safe and effective use of equipment.

(NZGG 2006, 6.2, p. 107)

M 6.4 C

The person with traumatic brain injury and their family or caregivers should be given clear written information on who to contact for repairs, replacement or future help and advice regarding the equipment. The ongoing effectiveness of the equipment should be reviewed on a regular basis and in accordance with the manufacturers’ guidelines.

(Adapted from ABIKUS 2007, G89, p. 31 and NZGG 2006, 6.2, p. 107)

M 6.5 C

Individuals with traumatic brain injury should have timely provision of an appropriate wheelchair and suitable supportive seating package, with regular review of the seating system as their needs change.

(Adapted from NZGG 2006, 6.1.1, p. 90)

M 6.6 C

Walking or standing aids for individuals with traumatic brain injury should be considered only after a full assessment of the potential benefits and harms of the walking aid in relation to the individual’s physical status and cognitive ability.

(Adapted from SIGN 2013, 4.1.6, p. 16)

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