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A M Davis,
A V Perruccio,
S Ibrahim,
S Hogg-Johnson,
R Wong,
D L Streiner, D E Beaton,
P Côté,
M A Gignac,
J Flannery,
E Schemitsch,
N N Mahomed,
E M Badley
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ABSTRACT: Primary total hip (THR) and knee (TKR) replacement outcomes typically include pain and function with a single time of follow-up post-surgery. This research evaluated the trajectory of recovery and inter-relationships within and across time of physical impairments (PI) (e.g., symptoms), activity limitations (AL), and social participation restrictions (PR) in the year following THR and TKR for osteoarthritis.
Participants (hip: n=437; knee: 494) completed measures pre-surgery and at 2 weeks, 1, 3, 6 and 12 months post-surgery. These included PI (Hip Disability and Osteoarthritis Outcome Score (HOOS)/Knee Injury and Osteoarthritis Outcome Score (KOOS) symptoms and Chronic Pain Grade); AL (HOOS/KOOS activities of daily living and sports/leisure activities); and, PR (Late Life Disability and the Calderdale community mobility). Repeated measures analysis of variance (RANOVA) was used to evaluate the trajectory of recovery of outcomes and the inter-relationships of PI, AL and PR were evaluated using path analysis. All analyses were adjusted for age, sex, obesity, THR/TKR, low back pain and mood.
THR: age 31-86 years with 55% female; TKR: age 35-88 years with 65% female. Significant improvements in outcomes were observed over time. However, improvements were lagged over time with earlier improvements in PI and AL and later improvements in PR. Within and across time, PI was associated with AL and AL was associated with PR. The magnitude of these inter-relationships varied over time.
Given the lagged inter-relationship of PI, AL and PR, the provision and timing of interventions targeting all constructs are critical to maximizing outcome. Current care pathways focusing on short-term follow-up with limited attention to social and community participation should be re-evaluated.
Osteoarthritis and Cartilage 08/2011; 19(12):1413-21. · 3.90 Impact Factor
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ABSTRACT: The underlying causes of incident fractures--bone fragility and the tendency to fall--remain under-diagnosed and under-treated. This care gap in secondary prevention must be addressed to minimise both the debilitating consequences of subsequent fractures for patients and the associated economic burden to healthcare systems. Clinical systems aimed at ensuring appropriate management of patients following fracture have been developed around the world. A systematic review of the literature showed that 65% of systems reported include a dedicated coordinator who acts as the link between the orthopaedic team, the osteoporosis and falls services, the patient and the primary care physician. Coordinator-based systems facilitate bone mineral density testing, osteoporosis education and care in patients following a fragility fracture and have been shown to be cost-saving. Other success factors included a fracture registry and a database to monitor the care provided to the fracture patient. Implementation of such a system requires an audit of existing arrangements, creation of a network of healthcare professionals with clearly defined roles and the identification of a 'medical champion' to lead the project. A business case is needed to acquire the necessary funding. Incremental, achievable targets should be identified. Clinical pathways should be supported by evidence-based recommendations from national or regional guidelines. Endorsement of the proposed model within national healthcare policies and advocacy programmes can achieve alignment of the objectives of policy makers, professionals and patients. Successful transformation of care relies upon consensus amongst all participants in the multi-disciplinary team that cares for fragility fracture patients.
Osteoporosis International 07/2011; 22(7):2051-65. · 4.58 Impact Factor
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ABSTRACT: Healthcare utilization data may be used to examine the quality of osteoporosis management by identifying dual-energy X-ray absorptiometry (DXA) testing (sensitivity = 98%, specificity = 93%) and osteoporosis pharmacotherapy (κ = 0.81) with minimal measurement error.
In osteoporosis, key quality indicators among older women include risk assessment by DXA and/or pharmacotherapy within 6 months following fracture.
The purpose of this study was to examine healthcare utilization data for use as quality indicators of osteoporosis management. We linked data from 858 community-dwelling women aged over 65 years who completed a standardized telephone interview about osteoporosis management to their healthcare utilization (medical and pharmacy claims) data. Agreement between self-report of osteoporosis pharmacotherapy and pharmacy claims was examined using kappa statistics. We examined the sensitivity and specificity of medical claims to identify DXA testing as well as the sensitivity and specificity of medical and pharmacy claims to identify those with DXA-documented osteoporosis (T-score ≤ -2.5).
Participants were aged 75 (SD = 6) years on average; 96% were Caucasian. Agreement between self-report and claims-based osteoporosis pharmacotherapy was very good (κ = 0.81; 95% CI = 0.76, 0.86). The sensitivity of medical claims to identify DXA testing was 98% (95% CI = 95.9, 99.1), with estimated specificity of 93% (95% CI = 89.8, 95.4). We abstracted DXA results from test reports of 359 women, of whom 114 (32%) were identified with osteoporosis. Medical (osteoporosis diagnosis) and pharmacy (osteoporosis pharmacotherapy) claims within a year after DXA testing had a sensitivity of 80% (95% CI = 71.3, 86.8) and specificity of 72% (95% CI = 66.2, 77.8) to identify DXA-documented osteoporosis.
Healthcare utilization data may be used to examine the quality of osteoporosis management by identifying DXA testing and osteoporosis pharmacotherapy (care processes) with minimal measurement error. However, medical and pharmacy claims alone do not provide a good means for identifying women with underlying osteoporosis.
Osteoporosis International 05/2011; 22(5):1335-42. · 4.58 Impact Factor
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ABSTRACT: The purpose of this literature review is to determine whether and to what extent current post-fracture osteoporosis interventions utilize theories of health behaviour change and whether those that are theory-based are more successful in producing desired behaviour changes. Studies were identified by applying additional criteria to the final selection stage of a systematic review of non-surgical osteoporosis interventions in the orthopaedic environment. We identified 42 primary studies targeted at patients and improving post-fracture osteoporosis care. As well as describing the studies (in terms of design, population, interventions, outcomes), we focused on theoretical framework and elements of behaviour change models. The 42 studies included in this review utilized a variety of post-fracture interventions; however, none of them reported using an underlying theoretical base. Only three studies drew on what we felt to be elements of a theoretical framework. The lack of theoretically based studies points to a currently under-utilized area of behaviour change research that could be applied to post-fracture interventions in order to make them more effective. Despite an abundance of literature supporting theories of behaviour change, post-fracture osteoporosis interventions do not report utilizing these theories. Theories of behaviour change could be applied to post-fracture osteoporosis interventions to explain why patients initiate osteoporosis management. Future research should explore the application of theories of health behaviour change to post-fracture interventions.
Osteoporosis International 01/2011; 22(8):2213-24. · 4.58 Impact Factor
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ABSTRACT: Post-fracture osteoporosis care is becoming recognized as essential by the orthopaedic community, but programs and systems are needed to ensure that this care is routinely provided. Chart documentation related to OP, which is valuable for continuity of care, increased significantly following establishment of an osteoporosis program with a dedicated coordinator.
Post-fracture osteoporosis (OP) care has been repeatedly reported to be inadequate. Through a coordinator-based program, we addressed OP care for more than 95% of fragility fracture patients (1), but we do not know if documentation by orthopaedic surgeons improved. The literature suggests that chart documentation, though underestimating true care, is an indicator of the salient aspects of a condition. Thus chart documentation could be used to reflect an emerging recognition of OP as an important issue to be addressed in the orthopaedic management of the fragility fracture. The purpose of this study was to evaluate if there was an increased documentation of OP by orthopaedic surgeons before and after introduction of a coordinator-based program where the coordinator was known to address OP in 95% of cases.
Chart audits were conducted to quantify OP documentation for patients treated after program initiation compared with age-, sex-, and fracture type-matched controls who presented prior to program implementation. Documentation rates were compared using chi(2) tests. Multivariable logistic regression analyses were performed to identify patient characteristics associated with OP-related documentation.
After program implementation, chart documentation of OP diagnosis (unadjusted OR 2.2, 95% CI 1.1-4.4), of referral for OP follow-up (unadjusted OR 3.1, 95% CI 1.5-6.1), and of initiation of OP management (unadjusted OR 8.2, 95% CI 4.0-16.5) by orthopaedic surgeons was more likely. Being in the post-implementation group was stronger than any patient factors in predicting OP charting.
Physicians working in a clinic with a coordinator-based OP program were more likely to document OP-related care in patients' medical charts. We believe this in turn reflected increased attention to OP by physicians in the orthopaedic management of fragility fractures.
Osteoporosis International 09/2007; 18(8):1127-36. · 4.58 Impact Factor
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ABSTRACT: In older women, knowledge about risk factors for osteoporosis was good, with over 75% responding correctly to questions about lifestyle factors, family history, height loss, and menopausal status. However, significant knowledge deficits were identified regarding osteoporosis "consequences" and "prevention and treatment."
We examined osteoporosis knowledge by testing the psychometric properties of the 10-item knowledge component of the "Osteoporosis and You" questionnaire. Several knowledge domains were hypothesized.
Community-dwelling women aged 65-90 years residing within two regions of Ontario, Canada were studied (N = 869). Data were collected by standardized telephone interviews in 2003 and 2004. Items to which 75% or more responded correctly were identified as having a low index of difficulty; the remaining items identified areas of knowledge deficit. Confirmatory factor analysis was used to test scale structure.
Six of the ten items had a low index of difficulty. These items largely examined osteoporosis risk factors. The remaining four items identified significant knowledge deficits in the areas of osteoporosis consequences, prevention, and treatment. Confirmatory factor analysis identified four distinct osteoporosis knowledge domains. However, the internal consistency was low for all but one domain, which examined "prevention and treatment."
Although older women appear to be aware of osteoporosis risk factors, knowledge deficits regarding the consequences of osteoporosis and that treatment exists to prevent bone loss were identified. Better understanding of the multi-dimensional aspects of osteoporosis knowledge may help to inform the development of effective educational interventions.
Osteoporosis International 08/2007; 18(7):981-9. · 4.58 Impact Factor
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ABSTRACT: Fragility fractures are a strong indicator of underlying osteoporosis (OP). With the risk of future fracture being increased 1.5- to 9.5-fold following a fragility fracture, the diagnosis and treatment of OP in men and women with fragility fractures provides the opportunity to prevent future fragility fractures. This review describes the current status of practice in investigation and diagnosis of OP in men and women with fragility fractures, the rates and types of postfracture treatment in patients with fragility fractures and OP, interventions undertaken in this population, and the barriers to OP identification and treatment. A literature search performed in Medline, Healthstar, CINAHL, EMBASE, PreMedline, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews identified 37 studies on OP diagnosis, treatment, and interventions. The studies varied in design methodology, study facilities, types of fractures, and pharmacological treatments. Some studies revealed that no patients with fragility fractures received investigation or treatment for underlying OP. Investigation of OP by bone mineral density was low: 14 of 16 studies reported investigation of less than 32% of patients. Investigation by bone mineral density resulted in high rates of OP diagnosis (35-100%), but only moderate use of calcium and vitamin D (8-62%, median 18%) and bisphosphates (0.5-38%) in patients investigated postfracture. Studies on barriers to OP identification and treatment focused on various groups of health practitioners. Barriers included the cost of therapies, time and cost of resources for diagnosis, concerns about medications, and the lack of clarity regarding the responsibility to undertake this care.
Osteoporosis International 11/2004; 15(10):767-78. · 4.58 Impact Factor
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ABSTRACT: This study is based on secondary analysis of Western Ontario McMaster Osteoarthritis Index (WOMAC) data from a community sample over 55 years and total hip or knee arthroplasty samples presurgery and 1-year postoperative.
The WOMAC data were evaluated by Rasch analysis. Data were considered to fit the Rasch mathematical model for the pain and physical dimensions of the WOMAC if unidimensionality was confirmed by principle component analysis of the subscale and the residuals from the Rasch analysis, infit and outfit statistics were in the range of 0.80 to 1.20; if there was no differential item functioning based on gender or hip vs. knee subjects; and, if there was stability of the item logits across the three data samples.
A three-item pain dimension (excluding night pain and pain on standing) and a 14-item physical dimension (excluding heavy domestic duties, getting in and out of the bath and getting on and off the toilet) fit the Rasch model based on these criteria.
In evaluating existing health status questionnaires using Rasch methodology, it is important to evaluate relevant patient samples and longitudinal data when the measure is intended to evaluate change in status. By these criteria, a modified WOMAC questionnaire fits the Rasch model and has interval-level scaling properties.
Journal of Clinical Epidemiology 12/2003; 56(11):1076-83. · 4.27 Impact Factor
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ABSTRACT: Responsiveness is quickly becoming a critical criterion for the selection of outcomes measures in studies of treatment effectiveness, economic appraisals, and other program evaluations. Statistical characteristics, specifically "large effect sizes," are often felt to indicate the relative worth of one instrument over another. However, debates about their meaning led the present authors to propose a taxonomy for responsiveness based on the context of the study concerned. The three axes underlying the classification system relate to: who is this being analyzed for (individuals or groups); which scores are being contrasted (over time/at one point in time); and the type of change being quantified (for example, observed change or important change). It is concluded that responsiveness should be considered a highly contextualized attribute of an instrument, rather than a static property and should be described only in that way. A questionnaire could thus be described as being "responsive to" a given category in the new taxonomy.
Journal of Clinical Epidemiology 01/2002; 54(12):1204-17. · 4.27 Impact Factor
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ABSTRACT: Research into the meaning of illness has often focused on an individual's transition into a state of being ill, for example the adoption of a sick role. The question "Are you better?" addresses the transition out of this state and is fundamental to the patient-clinician relationship, guiding decisions about treatment. However, the question assumes that all patients have the same meaning for "being better." The purpose of this study was to explore the meaning of the concept of recovery (getting better) in a group of people with upper limb musculoskeletal disorders.
Qualitative (grounded theory) methods were used. Individual interviews were conducted with 24 workers with work-related musculoskeletal disorders of the upper limb. The audiotaped interviews were transcribed and coded for content. Categories were linked, comparisons made, and a theory built about how people respond to the question "Are you better?"
The perception of "being better" is highly contextualized in the experience of the individual. Being better is not only reflected in changes in the state of the disorder (resolution) but could be an adjustment of life to work around the disorder (readjustment) or an adaptation to living with the disorder (redefinition). The experience of the disorder can be influenced by factors such as the perceived legitimacy of the disorder, the comparators used to define health and illness, and coping styles, which in turn can influence being better.
Two patients could mean very different things when saying that they are better. Some may not actually have a change in disease state as measured by symptoms, impairments, or function.
Arthritis & Rheumatism 07/2001; 45(3):270-9. · 7.87 Impact Factor
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ABSTRACT: In this study, we assessed the validity of a subjective histological-histochemical scoring system as compared to an automated histomorphometry program for analyzing cartilage repair tissue. In the first part of the study, we assessed the ability of the human eye to estimate the percent cartilage in a histological section. Twenty-nine rabbit periosteal explants that had been cultured in agarose transforming growth factor-beta (TGF-beta) were selected so that the percentage of cartilage in the specimens was distributed equally from 0% to 100%. Color photomicrographs were evaluated by 5 expert observers who gave a visual estimate of the percent cartilage. There was a strong correlation between the estimated and actual percent cartilage (R(2) = 0.92, p < 0.0001) and among the observers (I.C.C. = 0.89). On average, the estimated percent cartilage was within ten percent of the actual percent measured. In the second part, we compared the data derived using a simple cartilage score with those obtained by automated image analysis. The histological slides from 159 explants cultured under various experimental conditions (14 treatment groups) in two different experiments were analyzed. The cartilage content was estimated visually and a score from 0 to 3 was assigned. A previously validated, computerized image analysis system was used to measure the actual percent cartilage. Statistical analyses revealed a good linear regression (R(2) = 0.84, p = 0.0001), and even better polynomial correlation between the actual measurement and the score (R(2) = 0.88, p = 0.0001). These data demonstrate the validity of a simple histological-histochemical subjective scoring system. A computerized automated program such as the one employed in this study is preferable due to its many advantages. However, a subjective scoring system may be appropriate to use when the funding and expertise required for a computerized image analysis program are not available.
Tissue Engineering 07/2001; 7(3):313-20. · 4.02 Impact Factor
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ABSTRACT: Data on the use of various therapeutic interventions among working populations at risk for musculoskeletal disorders are rare, despite the need for such information in assessing adherence to best practices. Using the results of a cross-sectional survey of newspaper workers who reported neck and upper limb pain or discomfort (n = 309), we describe the prevalence of a wide range of clinical and workplace interventions. Information/education, exercises, and physical treatments were the most common interventions, and work changes were less prevalent. Those with more frequent, longer-duration, and/or more severe symptoms more commonly reported visits to physiotherapists and health practitioners at work and use of physical treatments, medications, and devices. The multiplicity of interventions used pose evaluation challenges for occupational health practitioners and researchers.
Journal of Occupational and Environmental Medicine 04/2001; 43(3):265-75. · 2.06 Impact Factor
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ABSTRACT: A proposed standard "core set" of outcome measures for low back pain includes 5 domains: back-specific function, generic health status, pain, work disability, and patient satisfaction. This paper focuses on the 2 recommended back-specific measures of function: the Roland-Morris Disability Questionnaire (RDQ) and the Oswestry Disability Index (ODI). We specifically address their ability to measure change. A systematic review of the literature identified a total of 78 and 71 (RDQ and ODI, respectively) articles as potentially relevant. Detailed tables are provided for each citation, with the type of back pain population studied, the type of change measured, the estimate of change, and the interval over which the change was studied. These tables should be used as a reference for sample size calculation. The responsiveness of the RDQ found in the literature ranges from 2 to 8 points on its 0 to 24 scale depending on what change is being measured. As a rough guide, Roland recommends that a change in 2-3 points on the RDQ should be considered the minimum clinically important change. Choosing any value larger than 5 in designing a clinical trial would risk underpowering the trial, since fewer patients are needed if a trial is designed on the basis of a large change score.
The Journal of Rheumatology 03/2001; 28(2):431-8. · 3.69 Impact Factor
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ABSTRACT: The purpose of this paper is to describe a classification system for studies of responsiveness that was designed to help organize these studies, and identify those with the potential to provide information on minimal clinically important difference (MCID). We developed a 3 dimensional cube into which studies of responsiveness can be categorized based on their evaluation of 3 attributes: 1. individual or group setting; 2. which scores are contrasted; and 3. the type of change or difference being assessed. We present and discuss examples of studies that fit into categories in the classification cube. This classification system helps to focus attention on whether the literature is able to provide information on the specific type of change a person is interested in. It reinforces that the ability of an instrument to detect a certain category of discrimination within the cube does not mean it will necessarily be responsive to another category. The cube has been shown here as a means to separate out studies that address important change. These studies can then be examined as the source of information on MCID.
The Journal of Rheumatology 03/2001; 28(2):400-5. · 3.69 Impact Factor
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Spine 01/2001; 25(24):3186-91. · 2.08 Impact Factor
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D E Beaton
Spine 01/2001; 25(24):3192-9. · 2.08 Impact Factor
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ABSTRACT: To evaluate the limb-specific outcome and general health status of patients with osteonecrosis of the femoral head treated with vascularized fibular grafting.
A retrospective review.
A single tertiary care centre.
Fifty-five consecutive patients with osteonecrosis of the femoral head who underwent fibular grafting (8 bilaterally).
Vascularized fibular grafting.
Limb-specific scores (Harris Hip Score, St. Michael's Hospital Hip Score), general health status (Nottingham Health Profile, SF-36 health status survey) and radiographic outcome measures (Steinberg stage).
Patients were young (mean age 34 years, range from 18 to 52 years) and 80% had advanced osteonecrosis (Steinberg stages IV and V). Fifty-nine hips were followed up for an average of 50 months (range from 24 to 117 months) after vascularized fibular grafting. Sixteen hips (27%) were converted to total hip arthroplasty (THA). To date, 73% of hips treated with vascularized fibular grafting have required no further surgery. Preoperative and postoperative Harris Hip Scores were 57.3 and 83.6 respectively (p < 0.001). As measured by patient-oriented health status questionnaires (SF-36, Nottingham Health Profile) and compared with population controls, patients had normal mental health scores and only slight decreases in physical component scores.
Free vascularized fibular grafting for osteonecrosis of the femoral head provides satisfactory pain relief, functional improvement and general health status and halts the progression of symptomatic disease.
Canadian journal of surgery. Journal canadien de chirurgie 08/1999; 42(4):274-83. · 1.05 Impact Factor
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ABSTRACT: We have developed and tested a color-based method for automated computerized histomorphometric analysis of cartilage. Histological sections stained with safranin O from 29 rabbit periosteal agarose-cultured explants were selected with various amounts of cartilage (0-100%). Color photomicrographs of these sections were visually assessed by five expert observers who estimated the percent area occupied by cartilage and outlined (in pen) the areas they considered to be cartilage. Manual histomorphometry was performed by cutting out and weighing the outlined areas. The average area for each of the five observers ranged from 31% to 43% (intraclass correlation coefficient = 0.70). The average of these values was used as a "gold standard" against which to compare the computer measurements. When point counting histomorphometry was performed on the 29 sections, the data agreed with the measurements made by the other five cartilage experts (r2 = 0.96; p < 0.0001). The analysis of cartilage is based on safranin O stain, using a custom-designed Vidas 2.1 Image Analysis Program (Zeiss). The computer-based results correlated very closely with those obtained by manual (p = 0.0001; r2 = 0.92) and point counting (r2 = 0.92; p < 0.0001) histomorphometry. The mean percentage of the sections occupied by cartilage measured in the automated mode was only 6% higher than that using the gold standard. Histological complexity had only a minor effect on the computerized values. The automated computerized image analysis system has the advantages of objectivity, accuracy, repeatability, and ease of use.
Tissue Engineering 02/1999; 5(1):13-23. · 4.02 Impact Factor
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ABSTRACT: Current elbow-scoring systems are based on the observer-derived assessment of a variety of clinical and functional criteria, which are scored separately and then aggregated. The aggregate score then is assigned a categorical ranking that ranges from excellent to poor. The developers of different elbow-scoring systems have chosen different outcome criteria, assigned different weights to each criterion, and accorded different ranges of values to each categorical ranking. Five different elbow-scoring systems (the Mayo elbow-performance index and the systems of Broberg and Morrey, Ewald et al., The Hospital for Special Surgery, and Pritchard) were used to evaluate the same group of patients. The validity of the scoring systems was determined with use of visual-analog scales for the assessment of pain and function, patient and physician-derived ratings of the severity of impairment of the elbow, and two functional questionnaires completed by the patient (the Disabilities of the Arm, Shoulder and Hand questionnaire and the Modified American Shoulder and Elbow Surgeons patient self-evaluation form). The study sample consisted of sixty-nine patients who had sought treatment at one of two tertiary referral clinics because of problems related to the elbow. Pearson product-moment correlation coefficients were used to compare the raw aggregate scores, and kappa statistics were used to determine the level of agreement among the categorical rankings (excellent, good, fair, and poor). Examination of the five scoring systems revealed a remarkable lack of concordance with regard to the aspects of elbow function that were assessed. Good correlation was observed when the systems were compared on the basis of raw scores (Pearson product-moment correlation coefficients, 0.79 to 0.90), but only slight-to-moderate correlation was noted when the systems were compared on the basis of categorical rankings (quadratic weighted kappa coefficients, 0.18 to 0.49). Validity testing showed the system of Ewald et al. and the Mayo elbow-performance index to be the most discriminating, the system of Pritchard to be the least discriminating, and the system of The Hospital for Special Surgery and the system of Broberg and Morrey to be intermediate. The scores determined with the elbow-scoring systems demonstrated only moderate correlation with the score for function on the visual analog scale (Pearson product-moment correlation coefficients, 0.44 to 0.66), whereas those derived from the functional questionnaires completed by the patient demonstrated moderate-to-good correlation with the score for function (Pearson product-moment correlation coefficients, 0.72 and 0.80).
The Journal of Bone and Joint Surgery 03/1998; 80(2):154-62. · 3.27 Impact Factor
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M F Polanyi,
D C Cole, D E Beaton,
J Chung,
R Wells,
M Abdolell,
L Beech-Hawley,
S E Ferrier,
M V Mondloch,
S A Shields,
J M Smith,
H S Shannon
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ABSTRACT: At a metropolitan newspaper office in Canada with extensive video display terminal (VDT) use, researchers carried out a survey (n = 1,007, 84% response) to establish baseline prevalence of work-related musculoskeletal disorders (WMSDs) and to identify demographic, postural, task, and psychosocial factors associated with WMSD symptoms. One-fifth of the respondents reported moderate or worse upper limb pain recurring at least monthly or lasting more than a week over the previous year. Logistic regression showed that employees who faced frequent deadlines and high psychological demands (fast work pace and conflicting demands), had low skill discretion and social support, spent more time keyboarding, or who had their screen in a non-optimal position were more likely to report moderate to severe symptoms. Women reported significantly higher levels of symptoms than men.
American Journal of Industrial Medicine 01/1998; 32(6):620-8. · 1.63 Impact Factor
