The OT Generalist Shifting into Gear for the IADL of Driving and Community Mobility

Carol Blackburn, OTR/L, CDRSCarol Blackburn, OTR/L, CDRS

Susan Pierce, OTR/L, SCDCM, CDRSSusan Pierce, OTR/L, SCDCM, CDRSAdaptive Mobility Services, Inc.Adaptive Mobility Services, Inc.

Presented at FLOTA ConferencePresented at FLOTA Conference

Orlando, FLOrlando, FL

February 8, 2009February 8, 2009

The Objectives:The Objectives:

At the end of the presentation, the participant will:At the end of the presentation, the participant will: understand the value of OT in addressing driving & understand the value of OT in addressing driving &

community mobility as an instrumental activity of community mobility as an instrumental activity of daily livingdaily living

recognize the OT process for addressing driving & recognize the OT process for addressing driving & community mobility.community mobility.

understand the role of the OT Generalist and the OT understand the role of the OT Generalist and the OT Specialist in Driving &Community Mobility Specialist in Driving &Community Mobility (SCDCM) regarding the occupation of driving(SCDCM) regarding the occupation of driving

experience the emotions of our clients as they gain experience the emotions of our clients as they gain their freedom and independence with drivingtheir freedom and independence with driving

The OT Practice Framework – Driving & Community Mobility

Sections adapted from the AOTA. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609-639.

NOTE: will be referenced in text as OTPF, 2002 with page number.

Is Community Mobility within the Domain of Occupational Therapy?

““Occupation is everything people do to Occupation is everything people do to occupy themselves, including looking after occupy themselves, including looking after themselves…enjoying life…and themselves…enjoying life…and contributing to the social and economic contributing to the social and economic fabric of their communities.” fabric of their communities.”

OTPF (2002), pg 609OTPF (2002), pg 609––639. 639.

Engagement in Occupations

Occupational therapy supports “…engagement in Occupational therapy supports “…engagement in occupations and in activities that allow desired or occupations and in activities that allow desired or needed participation in home, school, workplace, needed participation in home, school, workplace, and community life situations.” and community life situations.” (OTPF, pg 611)(OTPF, pg 611)

OT addresses engagement in occupation from a OT addresses engagement in occupation from a dual and holistic perspective:dual and holistic perspective: Subjective (emotional and psychological)Subjective (emotional and psychological) Objective (physically observable)Objective (physically observable)

With this perspective, OT addresses “all With this perspective, OT addresses “all aspects of performance (physical, cognitive, aspects of performance (physical, cognitive, psychosocial, and contextual) when psychosocial, and contextual) when providing interventions designed to support providing interventions designed to support engagement in occupations and daily life engagement in occupations and daily life activities.” activities.”

(AOTA(AOTA Framework, pg 611)Framework, pg 611)

The difference between activities & occupations:

““Activity describes a general class of human Activity describes a general class of human actions that is goal directedactions that is goal directed. A person may . A person may participate in activities to achieve a goal, participate in activities to achieve a goal, but but these activities do not assume a place of these activities do not assume a place of central importancecentral importance or meaning for the or meaning for the person.”person.”

(OTPF, 2002, pg 610)(OTPF, 2002, pg 610)

Occupations are…

“…“…activities having unique meaning and purpose in a activities having unique meaning and purpose in a person’s life…person’s life…central to a person’s identity and central to a person’s identity and competence, and they influence how one spends time and competence, and they influence how one spends time and makes decisionsmakes decisions.” .”

(OTPF, 2002, pg 610)(OTPF, 2002, pg 610)

When individuals engage in occupations, they are When individuals engage in occupations, they are committed to performance as a result of self-choice, committed to performance as a result of self-choice, motivation, and meaning. motivation, and meaning.

(AOTA Framework, pg 611)(AOTA Framework, pg 611)

Areas of occupation in OTPF:

Activities of daily livingActivities of daily living Instrumental activities of daily livingInstrumental activities of daily living EducationEducation WorkWork Play/leisurePlay/leisure Social participationSocial participation

Instrumental Activities of Daily Living:

“…“…are oriented toward are oriented toward interacting with the interacting with the environmentenvironment and that and that are often are often complexcomplex – – generally generally optional in optional in naturenature.” .”

(OT Practice Framework, pg 620)(OT Practice Framework, pg 620)

care of otherscare of others care of petscare of pets child rearingchild rearing financial managementfinancial management community mobilitycommunity mobility health management & health management &

maintenancemaintenance home establishment & home establishment &

managementmanagement meal preparation & meal preparation &

cleaningcleaning safety procedures & safety procedures &

emergency responsesemergency responses shoppingshopping

Relating the OTPF to Driving & Community Mobility:

Performance Performance Performance Performance

SkillsSkills PatternsPatterns

motor motor habits habits

process process routines routines

communication/interaction communication/interaction roles roles

ContextContext Activity Demands Activity Demands Client FactorsClient Factors

adapted from OTPF, 2002, pg 611adapted from OTPF, 2002, pg 611

OTPF defines 2 Types of Mobility that are inter-related:

Functional MobilityFunctional Mobility as an BADL as an BADL

Community MobilityCommunity Mobility as an IADL as an IADL

Functional mobility includes “mobilizing in the community”

:“…“…mmoving from one position or place to oving from one position or place to

anotheranother (during performance of everyday (during performance of everyday activities), such as in-bed mobility, activities), such as in-bed mobility, wheelchair mobility, transfers…wheelchair mobility, transfers…

performing functional ambulation and performing functional ambulation and transporting objects.” transporting objects.”

(OTPF, 2002, pg 620)(OTPF, 2002, pg 620)

Community Mobility

“…moving self in the community and using public or private transportation, such as driving, or accessing buses, taxi cabs, or other public transportation systems.”

(OTPF, 2002, pg 620)

Community mobility is a vital activity of life that allows a person to engage outside the home.

Vital: “essential to Vital: “essential to life, of greatest life, of greatest importance, & importance, & indispensable.” indispensable.” (Webster’s dictionary)(Webster’s dictionary)

If community mobility & driving is an IADL………then OTs then OTs

have an have an obligation to obligation to treat it as any treat it as any other ADL.other ADL.

……we must we must include it as include it as routinely as routinely as the ADLs of the ADLs of bathing and bathing and dressing.dressing.

THE FACTS: Driving Driving is one of most complex IADLis one of most complex IADL

DrivingDriving should be one of the last ADL addressed should be one of the last ADL addressed

DrivingDriving is an ADL skill that can kill so assessing is an ADL skill that can kill so assessing readiness within a medical model is important.readiness within a medical model is important.

We have the skill set to address community mobility & driving.

medical background.medical background. understands primary/secondary diagnoses and understands primary/secondary diagnoses and

implications.implications. understands aging process with or without a disability or understands aging process with or without a disability or

chronic condition.chronic condition. understands the concept of the “whole person and the understands the concept of the “whole person and the

whole picture.” whole picture.” qualified to assess the motor, sensory and processing skills qualified to assess the motor, sensory and processing skills

related to community mobility.related to community mobility. Can break down a task into its integral areas of function.Can break down a task into its integral areas of function.

The demographics of aging are changing dramatically.

Today: 35 million Americans are > age 65Today: 35 million Americans are > age 65 By 2030: 70 million Americans will be > age 65By 2030: 70 million Americans will be > age 65 age 85 & > is growing faster than any other age groupage 85 & > is growing faster than any other age group There will be more licensed drivers who will drive later in There will be more licensed drivers who will drive later in

life, more frequently and for greater distances.life, more frequently and for greater distances. Driving & community mobility will always be the key to Driving & community mobility will always be the key to

independence in our societyindependence in our society

Our holistic view allows us to understand the BIG picture of community mobility.

Client centered approachClient centered approach Consideration of:Consideration of:

Performance skillsPerformance skills Performance patternsPerformance patterns Context or contextsContext or contexts Activity demandsActivity demands Client factorsClient factors

An OT Team is usually necessary to address driving on the IADL continuum.

The OT GeneralistThe OT Generalist

The OT Specialist in Driving The OT Specialist in Driving & Community Mobility& Community Mobility

During the ADL evaluation, the OT Generalist should: Develop an occupational profile regarding Develop an occupational profile regarding

the importance of community mobility & the importance of community mobility & driving driving Identify the client’s needs, problems & Identify the client’s needs, problems &

concerns about driving concerns about driving Identify roles & prioritiesIdentify roles & priorities

Evaluate occupational performance in Evaluate occupational performance in regards to driving/CM skillsregards to driving/CM skills

Consider client factorsConsider client factors Include treatment in the intervention plan to Include treatment in the intervention plan to

improve or enhance sub-skills needed for improve or enhance sub-skills needed for driving or CMdriving or CM

Ask if person is or was a licensed driver or Ask if person is or was a licensed driver or has interest in being evaluated for driving has interest in being evaluated for driving potentialpotential

Discuss process for addressing driving Discuss process for addressing driving issuesissues

Inform re: resources & referral to a Inform re: resources & referral to a specialist if necessaryspecialist if necessary

Communicate with other disciplinesCommunicate with other disciplines Determine readiness or appropriateness for Determine readiness or appropriateness for

referral to OT Specialist in Driving and referral to OT Specialist in Driving and Community MobilityCommunity Mobility

Serve as “gate keeper” until ready for Serve as “gate keeper” until ready for formal evaluation or for a recommendationformal evaluation or for a recommendation

If struggling with a decision about driving for a client, consider the conflicting values and exercise reasonable judgment.

The client’s independence vs potential The client’s independence vs potential danger to self and othersdanger to self and others

The public’s safety vs the client’s right to The public’s safety vs the client’s right to confidentiality and independence.confidentiality and independence.

In Considering Driver Readiness:

Use your common sense about what you Use your common sense about what you know about the occupation of driving.know about the occupation of driving.

Use critical thinking skills and what you Use critical thinking skills and what you know about your client.know about your client.

The OT process can assist for a good The OT process can assist for a good outcome.outcome.

Counsel, inform & educate family/client Counsel, inform & educate family/client not not to drive until it has been approved or until to drive until it has been approved or until appointment with OT Driving Specialistappointment with OT Driving Specialist

It is It is NOTNOT the OT Generalist’s role to pass the OT Generalist’s role to pass or fail for driving or fail for driving unless unless there are specific there are specific deficits that contraindicate safe drivingdeficits that contraindicate safe driving

Consider vision &/or visual skills:

State’s standardsState’s standardsVA – 20/50VA – 20/50FOV – continual 140 degreesFOV – continual 140 degrees

visual neglect ?visual neglect ? homonymous hemianopsia ?homonymous hemianopsia ? needs cataract surgeryneeds cataract surgery suspect for glaucoma, diabetic retinopathy, suspect for glaucoma, diabetic retinopathy,

macular degeneration or other problemmacular degeneration or other problem

You can report an unsafe driver in Florida!

www.myflorida.comwww.myflorida.com Click into driver licenseClick into driver license Go to link for reporting an unsafe driverGo to link for reporting an unsafe driver Complete form and send to MAB with Complete form and send to MAB with

driver licensingdriver licensing

If driving retirement is the answer….

Counsel and be a listening earCounsel and be a listening ear Look at transportation alternatives in Look at transportation alternatives in

client’s communityclient’s community Evaluate their ability to use transportation Evaluate their ability to use transportation

optionsoptions Document all actions & recommendations Document all actions & recommendations

in regards to driving and community in regards to driving and community mobilitymobility

The OT Generalist’s responsibility is:

to understand your role in addressing driving to understand your role in addressing driving as an IADL as you do all other ADL.as an IADL as you do all other ADL.

to know how & when to refer to the OT to know how & when to refer to the OT specialist in driving in your area for a specialist in driving in your area for a comprehensive driver evaluation.comprehensive driver evaluation.

to understand your limitations to understand your limitations but to actbut to act when you should as the OTwhen you should as the OT

notnot to recommend adaptive equipment or to recommend adaptive equipment or where they go to get the equipmentwhere they go to get the equipment

Note of Caution:

If you are providing If you are providing the clinical the clinical evaluation and evaluation and referring to an referring to an outside source for outside source for the in-car the in-car evaluation: evaluation:

YOU are acting YOU are acting in the role of the in the role of the Specialist in Specialist in Driving & Driving & Community Community MobilityMobility

Brief summary of the role of the OT specialist in driving & community mobility:

To assist the OT generalist in determining if To assist the OT generalist in determining if person meets state requirementsperson meets state requirements

When necessary, perform in-depth When necessary, perform in-depth evaluation of performance skills & client evaluation of performance skills & client factor and determine their effect on driving factor and determine their effect on driving abilitiesabilities

The OT Driving Evaluation ProcessThe OT Driving Evaluation Process

Step 1: Occupational ProfileStep 1: Occupational Profile

Step 2: Analysis of Occupational PerformanceStep 2: Analysis of Occupational Performance

Step 3: Vehicle AssessmentStep 3: Vehicle Assessment

Step 4: Equipment AssessmentStep 4: Equipment Assessment

Step 5: In-Traffic AssessmentStep 5: In-Traffic Assessment

Step 6: InterventionStep 6: Intervention

Step 7: PrescriptionStep 7: Prescription

Step 8: Final Vehicle FittingStep 8: Final Vehicle Fitting

Provide on-road assessment with consideration of Provide on-road assessment with consideration of contextual factors, performance patterns and contextual factors, performance patterns and habitshabits

Provide in-car training or specialized driver Provide in-car training or specialized driver education education

Determine if adaptive equipment is required and Determine if adaptive equipment is required and follow-up for vehicle adaptationsfollow-up for vehicle adaptations

Determine if person is at-risk, can continue to Determine if person is at-risk, can continue to drive safely or has potential to learn to drivedrive safely or has potential to learn to drive

Resources for finding an OT Specialist in Driving & Community Mobility

www.www.aotaaota.org.org Older driver linkOlder driver link

www.www.adedaded.net.net

DonDonThe The power power of of

occupational occupational therapytherapy

59 YO male with C7 SCI 59 YO male with C7 SCI had not driven since injury had not driven since injury

onset in 2004onset in 2004 married to RN , 3 dogsmarried to RN , 3 dogs power wheelchairpower wheelchair hospital administrator, on hospital administrator, on

community boardscommunity boards dependent upon wife for dependent upon wife for

transportation as public bus transportation as public bus was inadequate to meet his was inadequate to meet his needs/scheduleneeds/schedule

MargaretMargaretThe The

functionality functionality of of occupational occupational therapytherapy

41YO who had 10 TIAs in 1 year41YO who had 10 TIAs in 1 year Had CVA while putting in Had CVA while putting in

sprinkler system in yard alonesprinkler system in yard alone Traveling Insurance agentTraveling Insurance agent Uses folding manual w/cUses folding manual w/c Missed being out and about, Missed being out and about,

loved her Wal-Martloved her Wal-Mart

ChristineChristineThe The

adaptability adaptability of of occupational occupational therapytherapy

15YO with dwarfism 3’8”, 59 lbs., 15YO with dwarfism 3’8”, 59 lbs., scoliosis, hearing aidsscoliosis, hearing aids

multiple orthopedic surgeriesmultiple orthopedic surgeries never drivennever driven uses walker to carry school booksuses walker to carry school books uses w/c in communityuses w/c in community active with school & friendsactive with school & friends supportive mothersupportive mother now in collegenow in college

RitaRitaThe The holistic holistic

approach of approach of occupational occupational therapytherapy

33YO, 59 lbs., 3’9”33YO, 59 lbs., 3’9” born in Indonesia, transported born in Indonesia, transported

only in taxi or bus, never could only in taxi or bus, never could see out, never drivensee out, never driven

married to a person who is married to a person who is blindblind

co-operates a courthouse co-operates a courthouse cafeteria and a vending cocafeteria and a vending co

job requires frequent job requires frequent movement in the community movement in the community for inventory and re-stockingfor inventory and re-stocking

CarolineCaroline

The The ultimate ultimate independenceindependence of of occupational occupational therapytherapy

18YO with OI, able to walk 18YO with OI, able to walk but has had numerous fx but has had numerous fx

uses rigid frame manual w/cuses rigid frame manual w/c parents divorced, living with parents divorced, living with

overbearing fatheroverbearing father graduated with honors from graduated with honors from

high school and accepted and high school and accepted and U of F for FallU of F for Fall

aspires to be architectaspires to be architect

CeliaCeliaThe The

excitementexcitement of of occupational occupational therapytherapy

36YO single mother36YO single mother SMA muscular dystrophySMA muscular dystrophy caregiver for mother & auntcaregiver for mother & aunt power w/cpower w/c hospital administrator hospital administrator transportation by bus/traintransportation by bus/train never drivennever driven

ChuckChuckThe The realityreality

of of occupational occupational therapytherapy

46YO with incomplete SCI C4-546YO with incomplete SCI C4-5 Walked with cane then scooter Walked with cane then scooter

and now power w/cand now power w/c Traveling/consulting pastorTraveling/consulting pastor Lives with wife who has limited Lives with wife who has limited

her income in order to her income in order to transport himtransport him

Drove well for 30 yrs before Drove well for 30 yrs before began having driving difficultiesbegan having driving difficulties

Fundraisers bought his van, VR Fundraisers bought his van, VR modified the vanmodified the van

ElyseElyse

The The perseverance perseverance of of occupational occupational therapytherapy

adopted from Vietnam by parents adopted from Vietnam by parents who work with persons who are who work with persons who are deafdeaf

totally dependent, unable to walk or totally dependent, unable to walk or talk when came to U.S., learned talk when came to U.S., learned sign language before she talked, sign language before she talked, now ADL independentnow ADL independent

loves school, aspires to have college loves school, aspires to have college degree & teach special educationdegree & teach special education

aspires to live on her ownaspires to live on her own Was first turned down for driving Was first turned down for driving

on 18on 18thth b’day but felt she was not b’day but felt she was not giving a fair chancegiving a fair chance

NancyNancyThe The normal normal

of of occupational occupational therapytherapy

69YO, divorced, retired69YO, divorced, retired bilateral LE amputationsbilateral LE amputations power w/cpower w/c moved into retirement centermoved into retirement center enjoys outdoors, church choir, enjoys outdoors, church choir,

bridge, family & friendsbridge, family & friends learned to take bus but yearned learned to take bus but yearned

for more freedom for more freedom working on second master’s working on second master’s

degreedegree

DannyDannyThe The

teamwork teamwork of of occupational occupational therapytherapy

34YO with cerebral palsy, 34YO with cerebral palsy, power w/cpower w/c

never driven, was always told never driven, was always told he couldn’the couldn’t

lived with supportive parents lived with supportive parents who transported him to/from who transported him to/from work as computer draftsman in work as computer draftsman in county appraiser’s officecounty appraiser’s office

recently marriedrecently married is now on 2is now on 2ndnd adapted van adapted van

JustinJustinThe The simplicity simplicity

of of occupational occupational therapytherapy

Spinal Meningitis when 13 Spinal Meningitis when 13 months oldmonths old

15YO with bil AE & LE 15YO with bil AE & LE amputationsamputations

ADL indep except w/ ADL indep except w/ prosthesesprostheses

active in sports, skateboard active in sports, skateboard championchampion

excellent problem solver & excellent problem solver & quick learnerquick learner

ElizabethElizabethThe The freedomfreedom

of of occupational occupational therapytherapy

26YO with Werdnig Hoffman’s 26YO with Werdnig Hoffman’s MD, had never drivenMD, had never driven

Manager of Shakespearean Manager of Shakespearean Festival, grant-writerFestival, grant-writer

single, family up north, many single, family up north, many friends, loves the arts and friends, loves the arts and teachingteaching

loves her scooterloves her scooter has to live the distance to work has to live the distance to work

that her scooter charge will take that her scooter charge will take herher

SaraSaraThe The WOWWOW of of

occupational occupational therapytherapy

48YO, polio at age 348YO, polio at age 3 Married to a retired Married to a retired

engineerengineer Has companion dogHas companion dog Loves to socializeLoves to socialize Active in communityActive in community Recently moved to “The Recently moved to “The

Villages”Villages”

To learn more about the OT Generalist Role:

Driving and Community Mobility for Older Driving and Community Mobility for Older Adults: Occupational Therapy RolesAdults: Occupational Therapy Roles , , AOTA Online CEU Course, 2005, AOTA Online CEU Course, 2005, www.aota-learning.org. ($112.50 members)www.aota-learning.org. ($112.50 members)

Free Information:

Physician’s Guide to Assessing and Counseling Older DriversPhysician’s Guide to Assessing and Counseling Older Drivers http://www.ama-assn.org/go/olderdrivershttp://www.ama-assn.org/go/olderdrivers

How to Help an Older Driver: A Guide for Planning Safe How to Help an Older Driver: A Guide for Planning Safe TransportationTransportation www.seniordrivers.orgwww.seniordrivers.org

Driving Safely While Aging GracefullyDriving Safely While Aging Gracefully www.nhtsa.dot.govwww.nhtsa.dot.gov

Drivers 55 Plus: Check Your Own PerformanceDrivers 55 Plus: Check Your Own Performance www.aaafoundation.orgwww.aaafoundation.org

When you are concerned: A guide for Families concerned When you are concerned: A guide for Families concerned about the safety of an older driverabout the safety of an older driver NysofaNysofa@@ofaofa.state..state.nyny.us.us

Websites www.www.aarpaarp.org.org www.www.niapublicationsniapublications.org.org www.www.usaaedfoundationusaaedfoundation.org.org www.www.ctaactaa.org.org www.seniordrivers.orgwww.seniordrivers.org www.www.niania..nihnih..govgov/news/news www.aaafoundation.orgwww.aaafoundation.org www.www.trbtrb.org.org (Transportation Research (Transportation Research

Board)Board) www.www.uabuab..eduedu//safemobilitysafemobility www.www.seniordriversseniordrivers.org.org www.thehartford.comwww.thehartford.com www.www.iihsiihs.org.org (Insurance Institute for (Insurance Institute for

Highway Safety)Highway Safety)

www.www.beverlyfoundationbeverlyfoundation.org.org Template of Template of

transportation options transportation options www.www.asagingasaging.org.org

Promoting safety and Promoting safety and independence through independence through older driver wellnessolder driver wellness

www.granddriver.info/www.granddriver.info/ Driver refresher coursesDriver refresher courses Finding a driver rehab specialistFinding a driver rehab specialist Alternative transportation Alternative transportation

optionsoptions Family resourcesFamily resources Older driver factsOlder driver facts

References: American Occupational Therapy Association (2002). Occupational therapy American Occupational Therapy Association (2002). Occupational therapy

practice framework: domain and process. American Journal of Occupational practice framework: domain and process. American Journal of Occupational Therapy, 56, 609-639.Therapy, 56, 609-639.

American Occupational Therapy Association (2005). Driving and Community American Occupational Therapy Association (2005). Driving and Community Mobility Statement. American Journal of Occupational Therapy, 59, 666-670.Mobility Statement. American Journal of Occupational Therapy, 59, 666-670.

American Occupational Therapy Association (2005). Screening Driving and American Occupational Therapy Association (2005). Screening Driving and Community Mobility Status. OT Practice, March 21, 2005.Community Mobility Status. OT Practice, March 21, 2005.

Pierce, S.L. Driving as an Instrumental Activity of Daily LivingPierce, S.L. Driving as an Instrumental Activity of Daily Living .. Glen Gillen Glen Gillen & Ann Burkhardt (Eds.), 2004, & Ann Burkhardt (Eds.), 2004, Stroke Rehabilitation: A Function-Based Stroke Rehabilitation: A Function-Based ApproachApproach, , MosbyMosby

Pierce, S.L. Restoring Competence in Mobility. C. A. Trombly & M. V. Pierce, S.L. Restoring Competence in Mobility. C. A. Trombly & M. V. Radomski (Eds.), 2007, Radomski (Eds.), 2007, Occupational Therapy for Physical DysfunctionOccupational Therapy for Physical Dysfunction. . Philadelphia: Lippincott Williams & WilkinsPhiladelphia: Lippincott Williams & Wilkins

Hunt, LA, Weston, K: Assessment of Driving Capacity. Handbook of Hunt, LA, Weston, K: Assessment of Driving Capacity. Handbook of Geriatric Assessment, New York: John Wiley and Sons, Inc, Lichtenberg, PA, Geriatric Assessment, New York: John Wiley and Sons, Inc, Lichtenberg, PA, 1999. 1999.

Driver Rehabilitation Across Age and Disability: A Occupational Therapy Driver Rehabilitation Across Age and Disability: A Occupational Therapy GuideGuide by Sue Redepenning by Sue Redepenning, OTR/L, CDRS. AOTA,, OTR/L, CDRS. AOTA, 2006. 2006.

Driver Rehabilitation and Community Mobility: Principles and Practice Driver Rehabilitation and Community Mobility: Principles and Practice by by Pellerito & multiple contributors. Published by Elsevier Mosby, 2006Pellerito & multiple contributors. Published by Elsevier Mosby, 2006