Clinical Rehabilitation

27(7) 638 645

The Author(s) 2013
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0269215512473136
cre.sagepub.com
CLINICAL
REHABILITATION
473136CRE27710.1177/0269215512473136Clinical RehabilitationHoshii et al.
2013
1
Department of Rehabilitation Science, Kobe University
Graduate School of Health Sciences, Japan
2
Higashikakogawa Hospital, Japan
Subject-chosen activities in
occupational therapy for the
improvement of psychiatric
symptoms of inpatients
with chronic schizophrenia:
a controlled trial
Junko Hoshii
1
, Kayano Yotsumoto
1
, Eri Tatsumi
1
,
Chito Tanaka
1
, Takashi Mori
2
and Takeshi Hashimoto
1
Abstract
Objective: To compare the therapeutic effects of subject-chosen and therapist-chosen activities in
occupational therapy for inpatients with chronic schizophrenia.
Design: Prospective comparative study.
Setting: A psychiatric hospital in Japan.
Subjects: Fifty-nine patients with chronic schizophrenia who had been hospitalized for many years.
Interventions: The subjects received six-months occupational therapy, participating in either activities
of their choice (subject-chosen activity group, n = 30) or activities chosen by occupational therapists
based on treatment recommendations and patient consent (therapist-chosen activity group, n = 29).
Main measures: The Positive and Negative Syndrome Scale and the Global Assessment of Functioning
(GAF) Scale were used to evaluate psychiatric symptoms and psychosocial function, respectively.
Results: After six-months occupational therapy, suspiciousness and hostility scores of the positive scale
and preoccupation scores of the general psychopathology scale significantly improved in the subject-
chosen activity group compared with the therapist-chosen activity group, with 2(2) (median (interquartile
range)) and 3(1.25), 2(1) and 2.5(1), and 2(1) and 3(1), respectively. There were no significant differences
in psychosocial functions between the two groups. In within-group comparisons before and after
occupational therapy, suspiciousness scores of the positive scale, preoccupation scores of the general
psychopathology scale, and psychosocial function significantly improved only in the subject-chosen activity
group, with 3(1) to 2(2), 3(1) to 2(1), and 40(9) to 40(16) respectively, but not in the therapist-chosen
activity group.
Article
Corresponding author:
Takeshi Hashimoto, Department of Rehabilitation Science,
Kobe University Graduate School of Health Sciences,
Tomogaoka 7-10-2, Suma-ku, Kobe 654-0142, Japan.
Email: hashimo@kobe-u.ac.jp
Hoshii et al. 639
Conclusions: The results suggested that the subject-chosen activities in occupational therapy could
improve the psychiatric symptoms, suspiciousness, and preoccupation of the inpatients with chronic
schizophrenia.
Keywords
Occupational therapy, client-centered, schizophrenia, controlled trial
Received: 16 April 2012; accepted: 9 December 2012
Introduction
Beginning in the 1960s, many countries began shift-
ing from a hospital-based system of mental health
treatment to one centered on the community. After
1980, the number of hospital beds and length of
hospital stays reduced sharply. In Organization for
Economic Co-operation and Development (OECD)
countries, the average length of stay in 2005 for
patients with schizophrenia was 38 days.
1
In con-
trast, the number of psychiatric beds in Japanese
hospitals increased suddenly in the 1960s, and the
average length of stay in 2008 for patients with
schizophrenia was 601 days.
2
Mental health care in
Japan has historically been hospital-centered, char-
acterized by long hospital stays and insufficient
support services to allow people with mental disor-
ders to live in the community.
3
Long-term hospitaliza-
tion can cause institutionalization.
4,5
Patients with
institutional syndrome restrain themselves, live a
passive life, and lose their individuality and initiative.
4,5

The 2009 interim report of Visions in Reform of
Mental Health and Medical Welfare noted that
patients with schizophrenia who had stayed in a
hospital for more than one year were more likely to
be subsequently hospitalized for a long period.
6

Some patients with schizophrenia continue to expe-
rience a chronic course of symptoms followed by
long-term hospitalization.
The symptoms of schizophrenia include positive
symptoms, negative symptoms, cognitive dysfunc-
tions, and nonspecific psychological symptoms, such
as anxiousness/depression.
7
Psychopharmacological
treatments, which are the basic treatment, are not
highly effective.
8,9
The effect of psychosocial
therapies, which are provided as add-on therapies
to psychopharmacological treatments, is also
insufficient.
9
Therefore, it is necessary to establish
an effective treatment that minimizes prolonged
hospitalizations and promotes the transfer of patients
back to the community.
Psychiatric rehabilitation, including occupational
therapy, has been a client-centered practice since
the 1990s.
1013
Corring et al.
10
emphasize that it is
important to focus on client perspectives. It is also
important for the clients to work on activities based
on their preferences and choices. Following the
introduction of client-centered occupational therapy
in Japan, it quickly became common in most psychi-
atric hospitals. However, little research has been
done studying the effects of client-centered occupa-
tional therapy in psychiatric hospitals in Japan.
The aim of this study was to compare the effects
of subject-chosen and therapist-chosen activities in
the occupational therapy on the psychiatric symp-
toms and psychosocial functions of patients with
schizophrenia.
The hospital ethics committee approved this
study on 19 January 2010.
Method
The study was conducted at a private psychiatric
hospital located in an urban area. We assessed all
inpatients for eligibility; 209 of them were diag-
nosed with schizophrenia, as defined by the
International Statistical Classification of Diseases
(10th Revision), and had been hospitalized for more
than a year as of January 2010. A total of 59 patients
were included in the study after excluding patients
who had difficulty communicating owing to their
640 Clinical Rehabilitation 27(7)
symptoms, those who were going to be discharged
in a few day, and those who declined to participate
in the study.
The allocation for males and females was inde-
pendent. Each male subjects data were consecu-
tively listed in a row on an excel spreadsheet. The
Global Assessment of Functioning (GAF) Scale
scores were in the first column. All dates were
sorted according to the GAF score (from the high-
est to the lowest). Subjects on odd numbered rows
were allocated to a subject-chosen activity group
and those on even numbered rows were allocated
to a therapist-chosen activity group. The same pro-
cedure was followed for females. The data for
males and females were unified as a subject-chosen
group and a therapist-chosen group.
For the subject-chosen activity group, at the
first interview, the subjects were asked to choose
activities. The Canadian Occupational Performance
Measure (COPM)
14
was used in the process of
extraction of the chosen activities so that the occu-
pational therapists could understand the subjects
choices, regardless of their years of experience.
After subjects had determined the set of activities
that they would take part in, the subjects performed
these activities.
For the therapist-chosen activity group, the first
series of interviews was conducted without using
the COPM, and the occupational therapists chose
activities for patients based on treatment recom-
mendations. The therapists then had their patients
perform these activities under patients consent.
The therapist-chosen activity is often employed
in the occupational therapy for chronic inpatients
with severe symptoms of schizophrenia in Japan.
In both groups, when a patient completed the
first activity that had been chosen, the next activity
was chosen and performed via the same process.
Patients took part in occupational therapy for up to
two hours, once a week, for six months (March to
September 2010). The interviews and interven-
tions were conducted by different therapists so that
differences in the relationship between subjects
and occupational therapists owing to interview
methods could be avoided.
Psychiatric symptoms were measured using
the Japanese version of the Positive and Negative
Syndrome Scale (PANSS).
15
Psychosocial function
was measured using the Japanese version of the
GAF scale.
7
The GAF rates psychological, social,
and occupational function on a scale of 1 to 100.
7

To minimize evaluator bias, subject psychiatric
symptoms and psychosocial function was evaluated
before and after occupational therapy by a psy-
chiatrist who was blind to the group allocation of
patients.
The differences between the two groups in sub-
ject characteristics, including age of onset, amount
of drug, and duration (months) of occupational
therapy before the study, were examined using the
Student t-test. The other factors; age, duration of
illness, number of hospital admission, and length of
current stay were examined using the Mann-Whitney
U test, as the data were not normally distributed. For
the PANSS and GAF Scale, the differences before
and after the occupational therapies were tested
using the Mann-Whitney U test, and differences
within each group before and after the therapies
were tested using the Wilcoxon signed-rank test.
The statistical analyses were performed using
Statcel2 for excel 2007 (The Publisher OMS,
Saitama, Japan), and statistical significance was set
at p < 0.05 for all analyses.
Results
The flow of patients is shown in Figure 1. In each
group, one patient dropped out the study owing to
worsening symptoms. At the beginning of the study,
no significant differences were found between the
subject-chosen activity group and the therapist-
chosen activity group in any of the factors (Table 1).
Also, no significant differences in all item scores
of PANSS and GAF were demonstrated between
the two groups before the occupational therapies
(Table 2).
After the six-months occupational therapies,
suspiciousness and hostility scores of the positive
scale, and preoccupation scores of the general psy-
chopathology scale for the subject-chosen activity
group and therapist-chosen activity group were 2(2)
(median (interquartile range)) and 3(1.25), 2(1) and
2.5(1), and 2(1) and 3(1), respectively. The other
Hoshii et al. 641
items in PANSS and GAF Scores were not signifi-
cantly different between the two groups (Table 2).
These results show that the suspiciousness, hos-
tility, and preoccupation items were significantly
improved more in the subject-chosen activity group
as compared with the therapist-chosen activity
group (p < 0.05).
In the comparisons within the groups between
before and after the occupational therapies, the
scores in the suspiciousness item of the positive
scale and the preoccupation of the general psy-
chopathology scale were significantly improved
in the subject-chosen activity group from 3(1)
(median (interquartile range)) and 3(1) before the
occupational therapies to 2(2) and 2(1), respec-
tively, after the occupational therapies (p < 0.05).
In contrast, no significant changes were found for
any of the PANSS items in the therapist-chosen
group. The GAF Scores in the subject-chosen
activity group significantly improved after occu-
pational therapy, from 40(9) (median (interquar-
tile range)) to 40(16), respectively (p < 0.05).
This improvement was not found in the therapist-
chosen group.
Eligible for the study
(n = 209)
Excluded (n = 150)
scheduled for discharge in a few
days (n = 8)
difficulty communicating (n = 62)
declined to participate (n = 80)
Subject-chosen activity group
(n = 30)
Therapist-chosen activity group
(n = 29)
Received allocated intervention
(n = 30)
Received allocated intervention
(n = 29)
Loss (n=1)
drop-out for worsening
symptoms (n = 1)
Analyzed
(n = 28)
Analyzed
(n = 29)
Loss (n=1)
drop-out for worsening
symptoms (n = 1)
Consecutive alternative allocation by gender and GAF
(n = 59)
Figure 1. Study flowchart.
642 Clinical Rehabilitation 27(7)
Table 1. Characteristics of the patients in this study.
Subject-chosen activity Therapist-chosen activity p-value
(n = 29) (n = 28)
Gender male/female 14/15 14/14
Mean age (years)
a
57.1 9.8 55.9 10.5 n.s.
Age of onset (years)
b
23.6 8.5 24.3 8.0 n.s.
Duration of illness (years)
a
33.1 11.6 31.6 11.8 n.s.
Number of hospital admissions
a
5.4 4.3 4.5 2.9 n.s.
Length of current stay (months)
a
159.1 123.4 151.8 152.9 n.s.
Chlorpromazine equivalent (mg)
b
1329.3 851.8 1197.8 897.7 n.s.
Duration of occupational therapy
before this study (months)
b
97.2 46.2 75.3 57.1 n.s.
Mean SD; n.s., no significance.
a
Mann-Whitney U test.
b
Student t- test.
Table 2. Comparisons of PANSS and GAF scores between subject-chosen activity and therapist-chosen activity.
Sub-C (n = 29) The-C (n = 28) Difference
Pre Post Pre Post Pre Post Sub-C The-C
Median (IQR) Two groups
a
Pre and post
b
Positive and negative syndrome scale (PANSS)
Positive Scale
Delusion 4(2) 4(2) 3(2) 4(2.25) n.s. n.s. n.s. n.s.
Conceptual disorganization 4(1) 4(2) 4(1) 4(1.25) n.s. n.s. n.s. n.s.
Hallucinatory behavior 3(3) 3(2) 3.5(2) 4(2) n.s. n.s. n.s. n.s.
Excitement 3(1) 2(1) 3(1) 3(1) n.s. n.s. n.s. n.s.
Grandiosity 2(2) 2(2) 3(1.25) 3(1) n.s. n.s. n.s. n.s.
Suspiciousness 3(1) 2(2) 3(1.25) 3(1.25) n.s. p<0.05 p<0.05 n.s.
Hostility 2(1) 2(1) 3(1) 2.5(1) n.s. p<0.05 n.s. n.s.
Scale total 20(5) 19(8) 22.5(7.5) 21(8.25) n.s. n.s. n.s. n.s.
Negative Scale
Blunted affect 4(1) 3(1) 3(1) 3(1) n.s. n.s. n.s. n.s.
Emotional withdrawal 3(1) 4(2) 3.5(1) 3.5(1) n.s. n.s. n.s. n.s.
Poor rapport 3(1) 3(2) 3(2) 3(0.5) n.s. n.s. n.s. n.s.
Passive apathetic social
withdrawal
3(2) 3(3) 3(1) 3(1) n.s. n.s. n.s. n.s.
Difficulty in abstract thinking 3(2) 4(2) 3(1) 3(2) n.s. n.s. n.s. n.s.
Lack of spontaneity and flow
of conversation
3(1) 3(2) 3(2) 3(1.25) n.s. n.s. n.s. n.s.
Stereotyped thinking 3(1) 3(1) 3(0.25) 3(0.25) n.s. n.s. n.s. n.s.
Scale total 23(10) 25(11) 22(7) 23(8) n.s. n.s. n.s. n.s.
General Psychopathology Scale
Somatic concern 2(1) 2(2) 3(2.25) 2(2) n.s. n.s. n.s. n.s.
Anxiety 2(1) 2(1) 3(1) 2(1) n.s. n.s. n.s. n.s.
(Continued)
Hoshii et al. 643
Discussion
We adopted only the item that improved in both
group and prepost comparisons as an improvement
item. The subject-chosen activity in occupational
therapy consisted of patients choosing and per-
forming activities and being supported in perform-
ing it by occupational therapists. This might result
in improvements on the suspiciousness item of the
positive scale and the preoccupation item of the
general psychopathology scale of PANSS.
The suspiciousness item of the PANSS positive
scale is defined as unrealistic or exaggerated ideas of
persecution.
15
In the subject-chosen activity group,
the occupational therapists accepted the activities
that the subjects chose and coordinated the environ-
ments in order to support the subjects in performing
their activities satisfactorily. This relationship
between the subject and the occupational therapist is
called a partnership. This is one of the important
concepts constituting client-centered occupational
therapy.
1618
Partnership leads to the subjects trust in
their occupational therapists
16
and comfortable per-
formance of activities. This experience is considered
to relieve patient suspiciousness. This characteristic
symptom, which is often observed in the acute stage,
makes it difficult to attain stable and smooth human
relationships. Ikebuchi
19
also reported that schizo-
phrenia symptoms, such as hostility, excitement, and
suspiciousness, which destroy patients relationships
with those around them, could be factors that prevent
them from being discharged from the hospital.
Therefore, it is suggested that subject-chosen
activities improve psychiatric symptoms, such as
suspiciousness, making it easier to build a stable
relationship between inpatients with chronic schizo-
phrenia and their therapists, and helping patients
recover enough to return to the community.
The preoccupation item of the PANSS general
psychopathology scale refers to absorption with
internally generated thoughts and feelings and
an autistic experience. This comprehensive psy-
chopathological symptom, encompassing both
positive and negative symptoms, is detrimental to
Sub-C (n = 29) The-C (n = 28) Difference
Pre Post Pre Post Pre Post Sub-C The-C
Median (IQR) Two groups
a
Pre and post
b
Guilt feeling 2(0) 2(1) 2(1) 2(0.25) n.s. n.s. n.s. n.s.
Tension 2(1) 2(2) 2(1.25) 2(1) n.s. n.s. n.s. n.s.
Mannerisms and posturing 2(1) 3(1) 3(1) 3(1) n.s. n.s. n.s. n.s.
Depression 2(2) 2(2) 2(1) 2(1) n.s. n.s. n.s. n.s.
Motor retardation 2(2) 3(2) 3(1.25) 3(1) n.s. n.s. n.s. n.s.
Uncooperativeness 3(1) 2(2) 3(2) 3(1) n.s. n.s. n.s. n.s.
Unusual thought content 3(2) 3(1) 3.5(1) 3.5(2) n.s. n.s. n.s. n.s.
Disorientation 2(1) 2(2) 2(2) 3(1) n.s. n.s. n.s. n.s.
Poor attention 3(1) 2(1) 3(2) 3(1) n.s. n.s. n.s. n.s.
Lack of judgment and insight 4(2) 4(1) 4(2) 4(2) n.s. n.s. n.s. n.s.
Disturbance of volition 3(2) 3(2) 3(2) 3(2) n.s. n.s. n.s. n.s.
Poor impulse control 3(1) 3(1) 3(1) 3(1) n.s. n.s. n.s. n.s.
Preoccupation 3(1) 2(1) 3(1) 3(1) n.s. p<0.05 p<0.05 n.s.
Active social avoidance 3(1) 2(3) 3(1.25) 3(2) n.s. n.s. n.s. n.s.
Scale total 43(15) 43(18) 48(13.75) 42(17.25) n.s. n.s. n.s. n.s.
Global Assessment of
Functioning (GAF)
40(9) 40(16) 39(8.25) 37.5(6.75) n.s. n.s. p<0.05 n.s.
a
Comparison between two groups (Mann-Whitney U test).
b
Comparison between pre and post within group (Wilcoxon signed-rank test).
Sub-C, subject-chosen activity group; The-C, therapist-chosen activity group; n.s., no significance.
Table 2. (Continued)
644 Clinical Rehabilitation 27(7)
reality orientation and adaptive behavior.
15
In the
subject-chosen activity group, the subjects chose and
performed activities with the support of occupational
therapists. Choosing and performing the activities
might enable the subjects, who are deeply involved
in an autistic experience, to act realistically and
autonomously, and might improve preoccupation of
the general psychopathological symptoms.
When they are experiencing strong suspicion,
patients with schizophrenia often avoid relationships
with others and their surroundings, and immerse
themselves in their own experiences. Therefore, the
results of this study also suggest the possibility that
the improvement of positive symptoms, such as
suspiciousness, may improve the preoccupation of
general psychopathological symptoms.
Negative symptoms improved neither in the ther-
apist-chosen nor subject-chosen activity groups.
This suggests that occupational therapy did not
directly improve the negative symptoms of schizo-
phrenia. This finding is consistent with the previous
finding that the negative symptoms of schizophrenia
are notoriously difficult to treat.
20
However, preoc-
cupation, the general psychopathological symptom
encompassing both positive and negative symptoms,
was improved in the subject-chosen activity group.
This finding suggests that clinical conditions associ-
ated with negative symptoms could be improved
through client-centered occupational therapy, even if
it were difficult to improve the negative symptoms
themselves.
Client-centered occupational therapy, in this study,
consisted of interviews and interventions. The inter-
view was conducted less than five times, for 10 min-
utes each. Since the total interview time was so short,
the authors suggest that the influence of the interview
itself can be ignored. Therefore, the effects of the
client-centered occupational therapy would be owing
to the client-centered approach regarding patient
choices and performance in occupational therapy.
In this study, social function was also explored
using the GAF Scale. There was a slight improve-
ment in GAF scores in the subject-chosen group,
while no difference in GAF score was observed
between the subject-chosen and therapist-chosen
activity groups. Improvement in PANSS items, such
as suspiciousness and preoccupation in the subject-
chosen group, might have partially affected the
psychological functioning area of the GAF Scale
and led to a slight improvement in GAF scores.
Our findings suggest that the subject-chosen
activity in the occupational therapy could improve
the psychiatric symptoms of the inpatients with
chronic schizophrenia. In the therapist-chosen activ-
ity group, no effect of the occupational therapy was
found for any examined items. These results suggest
the possibility that the subject-chosen activities in
the occupational therapy break the cycle of long-
term hospitalization of the patients with intractable
schizophrenia who experience failed therapies by
various types of professionals and have long-term
chronic conditions. Currently, an effective treatment
is necessary to help patients return to the commu-
nity. The effects of the client-centered occupational
therapy in this study can be highly significant.
This study was limited by the fact that it was only
conducted with a small group of subjects at one hos-
pital. Less than one-third of eligible participants actu-
ally took part in the study. In light of the fact that
many patients with schizophrenia had disease periods
of more than 30 years, and hospitalization periods of
more than 10 years, the intervention period may have
been too brief to be effective. The authors recom-
mend conducting future studies in this area using lon-
ger and more frequent intervention periods. Increasing
the number of subjects and the participating institu-
tions may contribute to the establishment of the
client-centered occupational therapy as an effective
treatment for inpatients with chronic schizophrenia.
Clinical messages
Client-centered occupational therapy in
which patients chose and performed activi-
ties with support of occupational therapists
was feasible for inpatients with chronic
schizophrenia.
Subject-chosen activities in the occupational
therapy were more effective in improving
the suspiciousness and preoccupation of
inpatients with chronic schizophrenia.
Further investigation of the effect of the
subject-chosen activity may contribute
to the establishment of the occupational
therapy as an effective treatment toward
inpatients with chronic schizophrenia.
Hoshii et al. 645
Acknowledgements
The authors are grateful to all of the patients, occupa-
tional therapists, and psychiatrists who contributed to
the study.
Funding
This study was supported by the Kobe University
Graduate School of Health Sciences research fund.
References
1. Organization for economic co-operation and development
(OECD). Mental health in OECD countries. Policy brief,
Paris, France, November 2008.
2. Ministry of Health, Labour and Welfare. Table 59 in the
first volume, Patient survey 2008. Statics and Information
Department, Ministers Secretariat, Ministry of Health,
Labour and Welfare, Tokyo, Japan, December 2009 (in
Japanese).
3. Kuno E and Asukai N. Efforts toward building a commu-
nity-based mental health system in Japan. Int J Law Psy-
chiatry 2000; 23: 361373.
4. Martin DV. Institutionalisation. Lancet 1955; 269: 1188
1190.
5. Johnstone EC, Owens DG, Gold A, et al. Institutionaliza-
tion and the defects of schizophrenia. Br J Psychiatry 1981;
139: 195203.
6. Ministry of Health, Labour and Welfare of Japan. An
interim report of Visions in Reform of Mental Health and
Medical Welfare in 2009. Report, Tokyo Japan, September
2009 (in Japanese).
7. American Psychiatric Association. Diagnostic and statisti-
cal manual of mental disorders: DSM-IV. 4th ed. Washington,
DC: American Psychiatric Association, 1994.
8. Lindenmayer JP. Treatment refractory schizophrenia.
Psychiatr Q 2000; 71: 373384.
9. Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The
schizophrenia patient outcomes research team (PORT):
updated treatment recommendations 2009. Schizophr Bull
2010; 36: 94103.
10. Corring DJ and Cook JV. Client-centred care means that
I am a valued human being. Can J Occup Ther 1999; 66:
7182.
11. Legault E and Rebeiro KL. Occupation as means to men-
tal health: a single-case study. Am J Occup Ther 2001; 55:
9096.
12. Cook S, Chambers E and Coleman JH. Occupational ther-
apy for people with psychotic conditions in community
settings: a pilot randomized controlled trial. Clin Rehabil
2009; 23: 4052.
13. Schindler VP. A client-centred, occupation-based occu-
pational therapy programme for adults with psychiatric
diagnoses. Occup Ther Int 2010; 17: 105112.
14. Law M, Baptiste S, Carswell A, et al. Canadian occu-
pational performance measure. 4th ed. Ottawa: CAOT
Publications ACE, 2005.
15. Kay SR, Fiszbein A and Opler LA. The positive and nega-
tive syndrome scale (PANSS) for schizophrenia. Schizophr
Bull 1987; 13: 261276.
16. Law M, Baptiste S and Mills J. Client-centred practice:
what does it mean and does it make a difference? Can J
Occup Ther 1995; 62: 250257.
17. Canadian Association of Occupational Therapists. Enabling
occupation: an occupational therapy perspective. Ottawa:
CAOT Publications ACE, 1997.
18. Sumsion T and Law M. A review of evidence on the
conceptual elements informing client-centred practice.
Can J Occup Ther 2006; 73: 153162.
19. Ikebuchi E, Satoh S and Anzai N. What impedes discharge
support for persons with schizophrenia in psychiatric hospi-
tals? Seishin Shinkeigaku Zasshi 2008; 110: 10071022 (in
Japanese).
20. Kirkpatrick B, Fenton WS, Carpenter WT Jr, et al. The
NIMH-MATRICS consensus statement on negative symp-
toms. Schizophr Bull 2006; 32: 214219.
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.