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HOW TO OBTAIN CONTACT HOURS BY READING THIS ARTICLE

Instructions2.1 contact hours will be awarded for this activity. A contact hour is 60 min-utes of instruction. This is a Learner-Paced Program. Vindico Medical Educa-tion does not require submission of quiz answers. A contact hour certificate will be awarded 4 to 6 weeks upon receipt of your completed Registration Form, including the Evaluation portion. To obtain contact hours:

1. Read the article “TITLE” by AUTHORS on pages xx-xx, carefully noting the tables and other illustrative materials that are provided to enhance your knowledge and understanding of the content.

2. Read each question and record your answers. After completing all ques-tions, compare your answers to those provided at the end of the quiz.

3. Type or print your full name, address, and date of birth in the spaces provided on the registration form.

4. Indicate the total time spent on the activity (reading article and complet-ing quiz). Forms and quizzes cannot be processed if this section is incom-plete. All participants are required by the accreditation agency to attest to the time spent completing the activity.

5. Forward the completed form with your check or money order for $20 made payable to JGN-CNE. All payments must be made in U.S. dollars and checks must be drawn on U.S. banks. CNE Registration Forms must be received no later than Month Day, 20XX.

This activity is co-provided by Vindico Medical Education and the Journal of GerontoloGical nursinG. Vindico Medical Education is an approved provider of continuing nursing education by New Jersey State Nurses Association, an accredited approver, by the American Nurses Credentialing Center’s Commis-sion on Accreditation, P#188-6/09-12.

Activity Objectives1. Objective 1

2. Objective 2

3. Objective 3

4. Objective 4

5. Objective 5

Author Disclosure StatementStatement

Commercial Support StatementAll authors and planners have agreed that this activity will be free of commercial bias. There is no commercial support for this activity. There is no non-commercial support for this activity.

HOW TO OBTAIN CONTACT HOURS BY READING THIS ARTICLE

Instructions2.1 contact hours will be awarded for this activity. A contact hour is 60 min-utes of instruction. This is a Learner-Paced Program. Vindico Medical Educa-tion does not require submission of quiz answers. A contact hour certificate will be awarded 4 to 6 weeks upon receipt of your completed Registration Form, including the Evaluation portion. To obtain contact hours:

1. Read the article “Chair Yoga: Benefits for Community-Dwelling Older Adults With Osteoarthritis” by Juyoung Park, PhD; and Ruth McCaffrey, DNP, ARNP, FNP-BC, GNP-BC on pages 12-22, carefully noting the tables and other illustrative materials that are provided to enhance your knowl-edge and understanding of the content.

2. Read each question and record your answers. After completing all ques-tions, compare your answers to those provided at the end of the quiz.

3. Type or print your full name, address, and date of birth in the spaces provided on the registration form.

4. Indicate the total time spent on the activity (reading article and complet-ing quiz). Forms and quizzes cannot be processed if this section is incom-plete. All participants are required by the accreditation agency to attest to the time spent completing the activity.

5. Forward the completed form with your check or money order for $20 made payable to JGN-CNE. All payments must be made in U.S. dollars and checks must be drawn on U.S. banks. CNE Registration Forms must be received no later than May 31, 2014.

This activity is co-provided by Vindico Medical Education and the Journal of GerontoloGical nursinG. Vindico Medical Education is an approved provider of continuing nursing education by New Jersey State Nurses Association, an accredited approver, by the American Nurses Credentialing Center’s Commis-sion on Accreditation, P#188-6/09-12.

Activity Objectives1. Identify the prevalence of functional limitation associated with osteoar-

thritis (OA) in older adults.

2. Discuss the components and use of yoga for treatment of OA in older adults.

3. Describe the methodology used in the study of chair yoga conducted by the authors.

4. Discuss the themes identified by the focus group following implementa-tion of the chair yoga sessions.

5. Describe the limitations of the study.

Author Disclosure StatementDr. Park and Dr. McCaffrey disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. This pilot study was supported by the Florida Atlantic University mentoring grant (seed grant).

Commercial Support StatementAll authors and planners have agreed that this activity will be free of commercial bias. There is no commercial support for this activity. There is no non-commercial support for this activity.

Osteoarthritis (OA), as a degenerative joint dis-ease, is the most common

type of arthritis and a major cause of pain and disability (Burkes, 2005; Centers for Disease Control and Prevention [CDC], 2002; Felson & Zhang, 1998). OA affects 27 million people in the United States, and the incidence continues to increase, par-

ticularly with age (Arthritis Foun-dation, 2012; CDC, 2011; Vitiello, Rybarczyk, Von Korff, & Stepan-ski, 2009). Thus, OA is a significant problem for the aging population (Peyron & Altman, 1992). Nearly 50% of adults 65 and older have symptoms associated with OA, and approximately 11% are functionally limited due to the disease (Lawrence et al., 1998). Symptoms associated with OA often include morning stiffness, joint pain, limited range of motion, and depression (Kolasinski et al., 2005; World Health Organi-zation, 2003).

Older adults with unrelieved knee pain from OA were more likely to need assistance with bath-ing, dressing, and transferring than those without knee pain, adding to the cost of care for this group (Nishiwaki, Michikawa, Yamada, Eto, & Takebayashi, 2011). Knee and hip joint replacements account-ed for 35% of total arthritis-related procedures during hospitalizations (Mannoni et al., 2003). OA pain often increases depression and de-creases life satisfaction (Jakobsson & Hallberg, 2002).

The purpose of managing OA is to relieve pain and improve func-

tion and quality of life (American Academy of Orthopaedic Surgeons, 2003). Although pharmacological treatments are considered to be a typical approach to managing OA, older adults are at high risk for ad-verse events or side effects associat-ed with medications (Kolasinski et al., 2005), which highlights the need to identify alternatives to a solely pharmaceutical approach to treat-ment of OA in older adults (Berman et al., 2004).

Nonpharmacological approaches have been shown to reduce pain, improve function, and mitigate emotional problems due to pain in chronic pain patients (Dominick et al., 2004). Research has shown that many older adults with OA are interested in nonpharmacological pain therapies (Konvicka, Meyer, McDavid, & Roberson, 2008). Re-searchers have identified the need for evidence-based interventions to address the broad range of biophys-ical and psychosocial difficulties ex-perienced by older adults with OA (Rizzo, 2009). Yoga is one of the several nonpharmacological pain therapies that address physical and psychosocial components and have demonstrated effectiveness in treat-ment of OA (Hurley & Scott, 1998; Kolasinski, 1999).

BACkgrOunDYoga is a popular alternative form

of mind-body therapy (Chukum-nerd, Hatthakit, & Chuaprapaisilp, 2011) that involves a combination of physical postures (asanas), breath-ing (pranayama), deep relaxation (savasana), and meditation (Nayak & Shankar, 2004).

The possible therapeutic benefits of yoga have been studied for a va-riety of medical conditions; yoga

ABStrACt

The aim of this pilot study was to examine whether chair yoga was effective in reduc-

ing pain level and improving physical function and emotional well-being in a sample

of community-dwelling older adults with osteoarthritis. One-way repeated mea-

sures analysis of variance was performed to examine the effectiveness of chair yoga

at baseline, midpoint (4 weeks), and end of the intervention (8 weeks). Although

chair yoga was effective in improving physical function and reducing stiffness in old-

er adults with osteoarthritis, it was not effective in reducing pain level or improving

depressive symptoms. Future research planned by this team will use rigorous study

methods, including larger samples, randomized controlled trials, and follow up for

monitoring home practice after the interventions.

Juyoung Park, PhD; and Ruth McCaffrey, DNP, ARNP, FNP-BC, GNP-BC

12 13Journal of GerontoloGical nursinG • Vol. 38, no. 5, 2012Copyright © SLACK Incorporated

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has been associated with improved health outcomes in research trials, in particular for people with hyperten-

sion (Patel & North, 1975), epilepsy (Lundgren, Dahl, Yardi, & Melin, 2008), multiple sclerosis (Oken et

al., 2004), carpal tunnel syndrome (Garfinkel et al., 1998), cancer (Car-son et al., 2007), back pain (Sherman, Cherkin, Erro, Miglioretti, & Deyo, 2005), and depression (Shapiro et al., 2007). Yoga is also effective in treat-ing various forms of arthritis (Garfin-kel & Schumacher, 2000), including OA (Garfinkel, Schumacher, Hu-sain, Levy, & Reshetar, 1994; Kolas-inski et al., 2005; Krishnamurthy & Telles, 2007) and rheumatoid arthritis (Badsha, Chhabra, Leibman, Mofti, & Kong, 2009; Bosch, Traustadót-tir, Howard, & Matt, 2009; Dash & Telles, 2001). In particular, studies of yoga treatment for OA (Garfinkel et al., 1994; Kolasinski et al., 2005) and carpal tunnel syndrome (Garfinkel et al., 1998) have shown significant alleviation of musculoskeletal pain during activity. In addition to pain reduction, yoga has been associ-ated with significant improvement in range of motion and function, decreased tenderness (Garfinkel et al., 1994), and alleviated depression (Krishnamurthy & Telles, 2007).

A few studies have been conduct-ed to determine the effect of yoga in people with OA (Bukowski, Con-way, Glentz, Kurland, & Galantino, 2006; Garfinkel et al., 1994; Kola-sinski et al., 2005; Taibi & Vitiello, 2011), but only one (Garfinkel et al., 1994) used a randomized controlled trial. These studies have contributed to the body of evidence demonstrat-ing positive health benefits of yoga (Ross & Thomas, 2010). A knee OA study (Kolasinski et al., 2005) re-ported that an 8-week yoga program was beneficial in reducing pain and disability and improving physical functioning, and a hand OA study (Haugen, Slatkowsky-Christensen, Lessem, & Kvien, 2009) noted im-provement in finger tenderness and finger range of motion, whereas a study of general arthritis (Sharma, 2005) reported no improvements as measured by responses to their symptom self-report instrument.

The studies reported in the litera-ture include relatively small samples

SIDeBAr

ChAIr YOgA PrOgrAm OutlIne

I. Breath of Life—The Revivers (10 minutes; one breathing technique per class)

A. Diaphragmatic breathing

B. Alternate nostril breathing

C. Ujjayi breath

II. The Body Proper—The Antidotes (20 minutes)

A. Rotation Extension

1. Cervical Vertebra Release 11. Half Inversion

2. Finger Flecks 12. Cat

3. Hand Wake-Up 13. Fan Palm

4. Mountain 14. Sciatica Stretch

5. Eagle 15. Half Moon

6. Sun Breath 16. Dancer

7. Stick 17. Half and Full Gate

8. Calf Shaper 18. Triangle

9. Shin Toner 19. Warrior I

10. Head to Knee 20. Warrior II

B. Contraction

1. Cobra

III. Warrior in the Body—The Rechargers (5 minutes)

As students progress, the poses below are done standing (holding chair if necessary). Students may also continue seated.

A. Balance

1. Stork

2. Tree

B. Strengthening

1. Mountain

2. Warrior I and II

C. Flexibility

1. Half Moon

2. Triangle

3. Cobra

4. Locust

5. Table

IV. Mind-Body Connection—The Transformers (10 minutes)

A. Tense and relax

B. Total body relaxation

C. Visualization—A transformed you!

and scope, different doses of yoga, poor statistical power, lack of ran-domization, unclear selection crite-ria, and/or short duration (Haaz & Bartlett, 2011). They have also dif-fered regarding frequency and dura-tion of yoga practice, as well as yoga styles and content of yoga sessions (Haaz & Bartlett, 2011).

A growing body of research sug-gests that yoga intervention is ac-cepted by older adults and may reduce OA pain (Kolasinski et al., 2005). However, limited studies have reviewed yoga for the treat-ment of chronic pain in older adults (Morone & Greco, 2007), and these demonstrated methodological limi-tations, as well as lack of random-ization, unclear inclusion/exclusion criteria, and short duration (Haaz & Bartlett, 2011). Kolasinski et al. (2005) identified that yoga may pro-vide a feasible treatment for previ-ously yoga naïve, obese patients older than 50; they reported that an 8-week yoga intervention reduced pain levels, improved physical func-tion, and prevented disability caused by knee OA. The study concluded that yoga can be a feasible treatment for people 50 and older who had not participated in yoga previously and can provide pain reduction and dis-ability caused by OA. Some older adults are unable to participate in regular yoga classes because they are required to stand while doing certain yoga poses. They may feel insecure due to decreased balance ability and increased fear of falling (Rejeski, Brawley, Ettinger, Mor-gan, & Thompson, 1997).

Chair yoga is a gentle form of yoga that is practiced sitting in a chair or standing and using a chair for support. Chair yoga is appropri-ate for older adults with OA who are unable to participate in regular standing yoga or other exercise. It is particularly safe to practice, easy to learn, and not likely to lead to falls. It is often used by older adults who need the security of sitting in a chair; it requires less physical

strength than a strenuous exercise, and it can be modified to allow frail older adults to practice individually or in groups.

Although many older adults have been practicing chair yoga and the efficacy of chair yoga has been iden-tified, no study has used chair yoga exclusively for measuring reduction of pain and disability and improve-ment in function in older adults with OA. The chair yoga program intervention in this study, designed

for older adults with OA, was de-veloped by Kristine Lee, a yoga in-structor with more than 20 years of experience. Participants came to the yoga studio located in the Universi-ty College of Nursing and received the 45-minute sessions. The Sidebar provides an overview of each of the four sections of the yoga interven-tion. Because this intervention was only for older adults with OA, care-ful attention was paid to the stress on joints and connective tissue, as

tABle 1

DemOgrAPhIC ChArACterIStICS Of the PArtICIPAntS (N = 7)

Characteristic n (%)

Sex

Women 6 (86)

Men 1 (14)

Race

Caucasian 7 (100)

Marital status

Divorced 3 (43)

Married 2 (29)

Widowed 2 (29)

Current living situationa

Alone 4 (57)

With spouse 2 (29)

With significant others 1 (14)

Health insuranceb

Medicare 7 (100)

Private 6 (86)

Health care choicesc

Private physician’s office 7 (100)

Outpatient clinic 3 (43)

Physical therapy 2 (29)

Alternative medicine 1 (14)

Emergency department 1 (14)

Other clinic 1 (14)

Physical health

Excellent 1 (14)

Very good 2 (29)

Good 3 (43)

Fair 1 (14)

14 15Copyright © SLACK Incorporated Journal of GerontoloGical nursinG • Vol. 38, no. 5, 2012

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well as consideration of range of motion of joints.

SPeCIfIC AImS AnD reSeArCh QueStIOnS

This pilot project was an attempt to provide preliminary evidence for designing a larger study to determine the effect of chair yoga on manage-ment of OA pain, stiffness, physical function, and emotional health. The specific aim was to determine the effect of 8 weeks of twice-weekly chair yoga sessions on pain, stiffness, physical function, and depression in older adults with OA. Two research questions were formulated:

1. Will older adults with OA who participate in an 8-week chair yoga session demonstrate improvement in pain intensity, stiffness, physical

function, and emotional well-being as measured by scores on the West-ern Ontario and McMaster Universi-ties Osteoarthritis Index (WOMAC; Bellamy, Buchanan, Goldsmith, Campbell, & Stitt, 1988) and the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977) at baseline, midpoint, and end of intervention?

2. What benefits are reported by older adults diagnosed with OA af-ter participating in an 8-week chair yoga intervention?

methODProcedure

The study was approved by the University’s Institutional Review Board. Study participants (N = 10) were recruited. Participants in the

chair yoga group attended 45-minute chair yoga sessions biweekly for 8 weeks, for a total of 16 sessions. The group was led by a certified yoga instructor who was knowledgeable and experienced in chair yoga ses-sions. Chair yoga was performed while sitting in a chair equipped with arms for easy access to sitting and standing. Participants in this group sat during the entire 45-minute yoga session.

The WOMAC was completed by participants before the intervention, at midpoint (Session 8), and at the end of the intervention (Session 16). On completion of the yoga sessions, participants were invited to partici-pate in a focus group to report the perceived effects of chair yoga. Par-ticipants received a $10 gift card after the focus group session.

ParticipantsTen participants were recruited

by placing flyers and announce-ments at the University Continu-ing Education Center and at an independent living facility in south Florida. Each participant met the following inclusion criteria: (a) age 65 and older; (b) living in the com-munity and noninstitutionalized at the time of the study; (c) diag-nosed by a health care professional as having OA in one or more joints (knees, hips, lower back, neck, fin-gers, thumb, and/or big toe); (d) having chronic pain at least 15 days of the month at a level of 4 on pain scale of 1 (no pain) to 10 (excruciat-ing pain); (e) not currently partici-pating in yoga or other nonphar-macological pain therapies; and (f) able to speak, read, and understand English. Exclusion criteria were: (a) severe cognitive impairment or (b) inability to come to the research site weekly.

This study was supported by a university mentoring grant that subsidized the cost of the yoga ses-sions. Participants were offered the opportunity to continue chair yoga sessions led by the same instructor

tABle 1

DemOgrAPhIC ChArACterIStICS Of the PArtICIPAntS (N = 7)

Characteristic n (%)

Type of diseased

Back problems 4 (57)

Broken bones 3 (43)

Cancer 3 (43)

Osteoporosis 2 (29)

Dental problems 1 (14)

Fibromyalgia 1 (14)

Headache 1 (14)

Heart disease 1 (14)

Stroke 1 (14)

Home health care

No 6 (86)

Yes 1 (14)

mean (SD), range

Age 77 (3.6 years), 71 to 81

Note. Percentages may not total 100 due to rounding. a Number and percentage total more than 7 (100%) because several participants have lived with more than one person. b Number and percentage total more than 7 (100%) because several participants have had more than one type of health insurance. c Number and percentage total more than 7 (100%) because several participants have had more than one health care choice. d Number and percentage total more than 7 (100%) because several participants have had more than one disease.

after the study was conducted. The participants voted to postpone con-tinuation of chair yoga until they re-turned to Florida from their homes in other states. Therefore, the chair yoga program was scheduled to re-sume August 22, 2011, at a partici-pant cost of $6 per session.

Data CollectionData consisted of participants’

scores on the WOMAC Index and the CES-D at baseline, mid-intervention, and end of interven-tion, and participant responses in the focus group session.

WOMAC. The WOMAC (Bel-lamy et al., 1988) consists of 24 items in three subscales: pain (5 items), stiffness (2 items), and physical func-tion (17 items). Response choices are offered on a Likert-type scale of 0 to 4. Scores for items in each of the three subscales are summed, with possible ranges as follows: pain = 0 to 20, stiffness = 0 to 8, and physi-cal function = 0 to 68. Higher scores indicate worse pain, stiffness, and functional limitations (Bellamy et al., 1988). Internal consistency (Cron-bach’s alpha coefficient = 0.86) and test-retest reliability (Kendall’s tau c statistic = 0.68) have been reported as moderate to excellent for pain.

CES-D. Depressive symptoms were measured with the CES-D (Radloff, 1977). The CES-D is used to assess the degree of depressive symptoms over the past week but does not identify the diagnostic cat-egory of depressive disorder. The CES-D consists of 20 items using a 4-point, Likert-type scale of 0 (rare-ly) to 3 (all of the time; 5 to 7 days). Scores can range from 0 to 60, with a higher score indicating a higher lev-el of depressive symptoms. A score greater than 16 (cut-off score) indi-cates significant symptomatology in need of further assessment. High Cronbach’s alpha coefficients of 0.85 for adults without a psychiatric diagnosis and 0.90 for adults with a psychiatric diagnosis have been re-ported (Radloff, 1977). The CES-D

has also been tested with communi-ty samples of older adults (Krause, 1986), as well as with populations with arthritis (Blalock, DeVellis, Brown, & Wallston, 1989).

Focus Group. Two researchers, as group leaders, developed a set of open-ended questions and a series of probing questions to elicit the participants’ experience in attending the chair yoga sessions. The open-ended questions were:

l What did you experience by participating in the 8-week chair yoga intervention?

l Was the chair yoga program helpful in managing OA?

The focus group session was audiorecorded and professionally transcribed. The transcription was analyzed by the two authors to identify emerging themes.

Data AnalysisDescriptive data analysis was

performed to identify sample char-acteristics. To address the first re-search question, one-way repeated measures of analysis of variance (ANOVA) were performed to compare baseline, midpoint, and final data with the within-subjects (time) factor to compare scores on the pain, stiffness, physical func-tion, and depressive symptoms subscales. Greenhouse-Geisser ad-justed degrees of freedom were used to evaluate interaction effects when appropriate. Significant ANOVA interactions were examined us-ing the Tukey procedure (Stevens, 2002) as a post-hoc test to deter-mine which of the contrasts among three time points were significant: (a) baseline versus 4 weeks, (b) 4

tABle 2

rePeAteD meASureS AnAlYSIS Of VArIAnCe fOr the WOmAC AnD CeS-D At BASelIne, mIDPOInt, AnD fInAl (N = 7)

measure and time Point mean (SD) n F p Value

Physical function 17.1 0.03

Baseline 30.3 (8.9) 4

Midpoint 20.5 (3.0) 4

Final 14.8 (5.6) 4

Stiffness 6.5 0.05

Baseline 4.2 (1.5) 6

Midpoint 2.5 (1.8) 6

Final 1.8 (1.2) 6

Pain 6.3 0.07

Baseline 8.6 (4.2) 5

Midpoint 4.4 (1.9) 5

Final 2.8 (1.6) 5

Depressive symptoms 100 0.06

Baseline 13 (1.4) 2

Midpoint 5 (1.4) 2

Final 3 (0) 2

Note. WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index (Bellamy, Buchanan, Goldsmith, Campbell, & Stitt, 1988), in which higher scores indicate worse pain, stiffness, and functional limitations; CES-D = Center for Epidemiologic Studies Depression Scale (Radloff, 1977), in which higher scores indicate a higher level of depressive symptoms.

(COntInueD)

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weeks versus 8 weeks, and (c) base-line versus 8 weeks.

To address the second research question, data from the focus group discussions were analyzed using the-matic analysis. The researchers were present at the focus group session, listened to the recordings, and read and reread the transcript. Analysis of the collected data proceeded using a theme-based content analysis of the narrative data composed of descrip-tions of experiences of the yoga inter-vention reported by the participants in the focus group session. The two researchers who conducted the focus group made field notes concerning attitudes, word emphasis, and body language of participants. Each of the four researchers in the study read and reread the transcripts of the focus group discussion, then met to discuss individual findings and reach consen-sus regarding the meaning of the focus group content and to extract themes.

reSultSSample Characteristics

The age range of participants in this study was 71 to 81 (mean age = 77, SD = 3.6 years). Of the 10 indi-viduals who agreed to participate, 7 (70%) completed the chair yoga ses-sions. Various reasons were given by those who withdrew (e.g., “I had an extremely painful reaction to the first session in my shoulder and neck” [re-ported by a participant with cervical spine stenosis, whose physician rec-ommended she not continue in the presence of pain], “I cannot make time for these sessions as I have a lot of other appointments and obliga-tions,” and “I have other things to do”).

Characteristics of the 7 partici-pants who completed all sessions are presented in Table 1. Six reported having had chronic pain associated with OA for more than 1 year. Three participants reported having experi-enced lower back pain, and 2 reported having experienced knee pain. In re-sponse to the question, “How much does your chronic pain affect your

life?” (0 = no effect at all to 9 = se-verely affects my life), 2 participants gave a response of 5 or higher. Three participants reported taking over-the-counter medications, such as acet-aminophen (n = 2) or aspirin (n = 1).

One-Way Repeated Measures ANOVA

Data from the 7 program com-pleters were analyzed using a one-way repeated measures ANOVA. To address the first research ques-tion, frequencies, means, standard deviations, F, and significance

levels for pain, stiffness, physical function, and depressive symp-toms by time (baseline, midpoint [4 weeks], and final [8 weeks]) are presented in Table 2. Higher scores on the WOMAC indicate worse pain, stiffness, and functional limitations (Bellamy et al., 1988). ANOVA showed a statistically sig-nificant difference of 15.5 points in mean scores for physical function,

F(1, 3) = 17.1, p = 0.03, indicating that physical function improved from baseline to midpoint to final. ANOVA showed a statistically sig-nificant difference of 2.4 points in mean scores for stiffness, F(1, 5) = 6.5, p = 0.05, decreasing from base-line to midpoint to final, indicat-ing that stiffness was reduced af-ter chair yoga sessions. Regarding pain, ANOVA also showed that, although the mean score for pain level declined by 5.8 points from baseline to midpoint to final, the overall differences in mean scores for pain were not statistically sig-nificant, F(1, 4) = 6.3, p = 0.07. In addition, ANOVA showed that, although the mean score for de-pressive symptoms declined from baseline to midpoint to final, the overall differences in mean scores for depressive symptoms were not statistically significant, F(1, 1) = 100, p = 0.06.

Tukey post-hoc comparisons were conducted for stiffness and physical function to determine which of the comparisons were significant (base-line versus midpoint [4 weeks], mid-point versus final [8 weeks], baseline versus final). For stiffness, the mean score at baseline (3.4, SD = 2.02) was not significantly different from the mean score at midpoint (2.8, SD = 1.54), p = 0.08. The mean score at midpoint was not significantly dif-ferent from the mean score at final (2.3, SD = 1.5), p = 0.091. The mean score at baseline was also not signifi-cantly different from the mean score at final, p = 0.064.

For physical function, the mean score at baseline (22, SD = 12.9) was not significantly different from the mean score at midpoint (18, SD = 6.51), p = 0.091. The mean score at midpoint was significantly differ-ent from the mean score at final (13, SD = 8.18), p = 0.05, which indicat-ed that physical function improved from midpoint to final. The mean score was also significantly differ-ent (9 points) at baseline and final, p = 0.046.

Focus Group Data AnalysisAnalysis of the data from the fo-

cus group discussion yielded three overall themes regarding their ex-perience in the chair yoga interven-tion and their perceptions of the major benefits of chair yoga: Pain Reduction and Improved Mobility, Feeling of Security, and Improve-ment in Sense of Well-Being.

Pain Reduction and Improved Mobility. The first theme was that the 8-week chair yoga sessions re-duced pain associated with OA and improved mobility. The following quotes from the focus group ses-sion highlight this theme:

l “I felt better in terms of my ability to do more things at home.”

l “It makes my body feel bet-ter and I have less pain.”

l “I feel it’s easier to bend over to stretch to reach for something.”

l “I feel a difference in my body the way I am able to stretch.”

l “I feel the results of the ex-ercise moving through my whole body. It kind of touches every place where I feel pain and makes me feel better.”

l “It stretches my muscles and I feel good.”

l “This yoga experience has been one of generally feeling a little more limber and having less pain in my joints.”

l “Yoga helps to stretch areas that are otherwise constricted or too tight. The stretching increases my blood flow.”

l “I was terribly frightful of any movement, fearful of any movement and learning that I could do it and not, nothing hap-pened or what I was hearing in the joints was not breaking or splin-tering or lots of other things that can happen to me. It made it easy to do more.”

Feeling of Security. The second theme expressed by the chair yoga focus group was a feeling of secu-rity in having the chair while prac-

ticing yoga. The following quotes from the focus group session dem-onstrate this theme:

l “I think that in regular yoga you are getting up from the floor and down and so forth and I think that is more difficult when you have any back or any other issues to just get yourself up from a posi-tion.”

l “This type of yoga with the chair is better for anyone who is afraid to attempt regular yoga.”

l “That is a big thing as you get older and as you have more problems with getting off the floor by yourself.”

l “In regular yoga, getting up and down from the floor or stand-ing for a long time is difficult for me, but when you have the chair, it is better.”

l “I don’t think I could do the yoga unless I had something be-side me to help me. The chair yoga offers security for me.”

l “I think the chair yoga offers security but I also think it’s the way to exercise if you are not able to get up and down from lying down on the floor.”

l “The chair yoga is a good stretching and bending exercise. When you do standing yoga, you sometimes get wobbly and you

don’t have the security of the chair to hold on to.”

Improvement in Sense of Well-Being. The third theme expressed by the chair yoga focus group was an improved sense of well-being af-ter the yoga intervention. The fol-lowing quotes illustrate this theme:

l “I learned how to relax, which I didn’t really know before. I learned how it makes your body feel better.”

l “The yoga helps you with sleeping and limberness and re-laxation and well-being; those are very important aspects of life.”

l “There is no question that these sessions have improved my sense of well-being, my psycho-logical, my sociological, all of them.”

l “Nothing in my situation has changed but my attitude toward my life has changed for the better. I am more calm.”

l “At home I do some of the breathing exercise. It helps me to feel calmer and more relaxed.”

l “Coming to the class is very important to me because it helps me to be ‘all right,’ to feel like things in my life are not so bad.”

l “I feel good about the fact that I am doing this for myself. The breathing exercises have made

keYPOIntSPark, J., & McCaffrey, R. (2012). Chair Yoga: Benefits for Community-Dwelling Older Adults With Osteoarthritis. Journal of Gerontological Nursing, 38(5), 12-22.

1 Yoga is one of the nonpharmacological pain therapies that address physical and psychosocial components and has demonstrated ef-fectiveness in treatment of osteoarthritis (OA).

2 Although chair yoga was effective in improving physical func-tion and reducing stiffness in older adults with OA, its effect on reducing pain level or improving depressive symptoms was not statistically significant.

3 The focus group discussion yielded three overall themes regard-ing participants’ experience in the chair yoga intervention and their perceptions of its major benefits: Pain Reduction and Im-proved Mobility, Feeling of Security, and Improvement in Sense of Well-Being.Chair yoga is

appropriate for older adults with OA who are unable to participate in regular standing yoga or other exercise. It is particularly safe to practice, easy to learn, and not likely to lead to falls.

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a great difference for me. As I become more conscious of the breathing, it helps me to relax and even sleep better at night.”

DISCuSSIOnThis pilot study examined the ef-

fect of chair yoga on reducing pain and stiffness and improving physical function and depressive symptoms in older adults with OA. Compared with their health status prior to taking the chair yoga sessions, the partici-pants had statistically significant im-provement in physical function and stiffness, as measured by the WOM-AC Physical Function and Stiffness subscales, which were congruent with results reported in other studies (Chen et al., 2008, 2010; Garfinkel et al., 1994; Kolasinski et al., 2005). In the studies by Chen et al. (2008, 2010), results showed that physical fitness in older adults in the Silver Yoga group had improved significantly by the end of the intervention.

Consistent with previous studies (Taibi & Vitiello, 2011), this trial dem-onstrated that the chair yoga sessions did not produce significant improve-ment in pain level or depressive symp-toms. However, these findings were not congruent with those from other studies (Garfinkel et al., 1994; Wil-liams et al., 2005). Williams et al. noted that significant reductions in pain and disability scores were found for people who completed the yoga classes rela-tive to the educational control group. In the study, 60 adults with chronic low back pain were randomized to weekly yoga classes (90 minutes per week) for 16 weeks or an educational group. Because the 7 participants in the current study attended yoga sessions only twice per week for 45 minutes per session, it is plausible that the lack of significant pain reduction could be due to a suboptimal dose of the yoga intervention (Haaz & Bartlett, 2011) and the small sample.

The researchers provided partici-pants with a DVD to practice chair yoga at home since it has been deter-mined that home practice for long-

term effectiveness of chair yoga after the intervention is convenient and affordable, without the need for ex-pensive equipment or access to spe-cific facilities (Haaz & Bartlett, 2011). However, only 1 of the 7 participants had a DVD player, and she was not willing to practice on her own. Such issues could be a barrier to home prac-tice of chair yoga by older adults with OA. A chair yoga manual developed by Kristine Lee (who has taught yoga since 1997), which includes a picture for each yoga position, will be used in

a large-scale study. For those who are not willing to practice chair yoga on their own, it is recommended to prac-tice with other people who have OA instead of home practice.

The chair yoga program for this pilot study was designed to provide preliminary data for developing an in-novative and evidence-based program for older adults who are unable to at-tempt more strenuous exercise due to pain, balance, physical function, or simply fear of falling. This study de-termined the feasibility and safety of

practicing chair yoga by older adults with OA. Four participants stated that when they had pain, they sat and did some postures remembered from the program, which they anticipated would reduce pain levels. One partic-ipant reported shoulder and neck pain as an adverse effect of participating in chair yoga sessions and left the study during the second session. The results suggest that a supervised 8-week ses-sion of chair yoga can be beneficial in improving physical function and re-ducing stiffness in symptomatic OA patients.

The participants in the focus group described chair yoga as a self-healing modality. The focus group partici-pants also reported improvement in breathing, blood circulation, stress, and sleep after 16 sessions of chair yoga. While the WOMAC results did not indicate a statistically significant reduction in pain levels, the benefits of chair yoga that were most fre-quently reported in the focus group discussion were reduced pain associ-ated with OA and improved mobil-ity, a feeling of security in having a chair, and an improved sense of well-being. The findings from the focus group session provide promising pre-liminary support for the physical and psychological benefits of chair yoga in older adults with OA.

The findings from this pilot study suggest that chair yoga practice may improve physical function and, when tailored to older adults with OA, may offer a cost-effective method to pre-vent or reduce age-related changes.

lImItAtIOnSThe small sample is recognized as

a study limitation, in that the results lacked power to adequately evaluate the magnitude of the effect of chair yoga on OA. The small sample was likely the cause of the failure to demonstrate significant differences in pain level and depressive symp-toms. The lack of a formal manual for chair yoga; differences in chair yoga instructions and yoga instruc-tor; variation in styles, doses, and

format (Haaz & Bartlett, 2011); and lack of consistency in the design of the intervention may limit general-izability of the findings.

COnCluSIOn AnD ImPlICAtIOnS

Compared with other studies of yoga for OA, the current study had a relatively high dropout rate (30%). However, this percentage is misleading due to the small sample. One participant withdrew from the study after the first session (“I had an extremely painful reaction to the first session in my shoulder and neck”), which may lead the re-searchers to review and revise yoga poses to consider the needs of older adults with severe back pain. With the exception of this participant, the dropout rate was not related to adverse events from participating in the chair yoga; the major reason for dropping out was inability to attend sessions due to time constraints.

Future studies should use rigor-ous study methodologies, includ-ing larger samples, and randomized controlled trials. Specific plans for the next step in this research in-clude (a) sample size increased to 90 participants to increase power and measure differences within- and between-subject groups, (b) randomized selection of sites from local agencies, and (c) sufficient fol-low up (e.g., 3 months, 6 months) of monitored home practice, which can be effective for long-term ef-fectiveness in managing OA. Future studies should be conducted with a variety of populations, based on medical conditions and participant characteristics. For example, few studies have addressed patterns of ethnic disparity in the efficacy of yoga, and research is needed to un-derstand perceptions and knowl-edge about practice of chair yoga by older adults across ethnicities.

Older adults with OA can ben-efit from participation in chair yoga by incorporating yoga practice into a comprehensive pain management

plan. The overall recommendation of this pilot study is that more re-search about chair yoga be conduct-ed for older adults with OA.

Gerontological nurses could use a holistic approach for pain manage-ment that includes therapies con-sidered complementary-alternative medicine (CAM) with the tradition-al medical treatments. Chair yoga may be a valuable CAM therapy for nurses to introduce to patients with OA who are unable to attend stand-ing yoga or other exercise programs due to pain, weakness, or fear of falling. More important, geronto-logical nurses should have sufficient follow up to determine whether a patient with OA can obtain benefits from a chair yoga program.

referenCeSAmerican Academy of Orthopaedic Surgeons.

(2003). AAOS clinical practice guidelines on osteoarthritis of the knee. Rosemont, IL: Author.

Arthritis Foundation. (2012). What is arthritis? Retrieved from http://www.arthritistoday.org/conditions/osteoarthritis/all-about-oa/what-is-oa.php

Badsha, H., Chhabra, V., Leibman, C., Mofti, A., & Kong, K.O. (2009). The benefits of yoga for rheumatoid arthritis: Results of a preliminary, structured 8-week program. Rheumatology International, 29, 1417-1421.

Bellamy, N., Buchanan, W.W., Goldsmith, C.H., Campbell, J., & Stitt, L.W. (1988). Validation study of WOMAC: A health status instrument for measuring clinically important patient relevant outcomes to an-tirheumatic drug therapy in patients with osteoarthritis of the hip or knee. Journal of Rheumatology, 15, 1833-1840.

Berman, B.M., Lao, L., Langenberg, P., Lee, W.L., Gilpin, A.M.K., & Hochberg, M.C. (2004). Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: A randomized, controlled trial. An-nals of Internal Medicine, 141, 901-910.

Blalock, S.J., DeVellis, R.F., Brown, G.K., & Wallston, K.A. (1989). Validity of the Cen-ter for Epidemiologic Studies Depression Scale in arthritis populations. Arthritis & Rheumatism, 32, 991-997. doi:10.1002/anr.1780320808

Bosch, P.R., Traustadóttir, T., Howard, P., & Matt, K.S. (2009). Functional and physi-ological effects of yoga in women with rheu-matoid arthritis: A pilot study. Alternative Therapies in Health and Medicine, 15, 24-31.

Bukowski, E.L., Conway, A., Glentz, L.A., Kurland, K., & Galantino, M.L. (2006). The

effect of Iyengar yoga and strengthening exercises for people living with osteoarthri-tis of the knee: A case series. International Quarterly of Community Health Education, 26, 297-305.

Burkes, K. (2005). Osteoarthritis in older adults: Current treatments. Journal of Gerontologi-cal Nursing, 31(5), 11-19.

Carson, J.W., Carson, K.M., Porter, L.S., Keefe, F.J., Shaw, H., & Miller, J.M. (2007). Yoga for women with metastatic breast cancer: Results from a pilot study. Journal of Pain and Symptom Management, 33, 331-341. doi:10.1016/j.jpainsymman.2006.08.009

Centers for Disease Control and Prevention. (2002). Prevalence of self-reported arthritis or chronic joint symptoms among adults—United States, 2001. Morbidity and Mortal-ity Weekly Report, 51. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5142a2.htm

Centers for Disease Control and Prevention. (2011). Osteoarthritis. Retrieved from http://www.cdc.gov/arthritis/basics/osteoarthritis.htm

Chen, K.-M., Chen, M.-H., Hong, S.-M., Chao, H.-C., Lin, H.-S., & Li, C.-H. (2008). Physi-cal fitness of older adults in senior activity centers after 24-week silver yoga exercises. Journal of Clinical Nursing, 17, 2634-2646. doi:10.1111/j.1365-2702.2008.02338.x

Chen, K.-M., Fan, J.-T., Wang, H.-H., Wu, S.-J., Li, C.-H., & Lin, H.-S. (2010). Silver yoga exercises improved physical fitness of transi-tional frail elders. Nursing Research, 59, 364-370. doi:10.1097/NNR.0b013e3181ef37d5

Chukumnerd, P., Hatthakit, U., & Chuaprapa-isilp, A. (2011). The experience of persons with allergic respiratory symptoms: Practic-ing yoga as a self-healing modality. Holistic Nursing Practice, 25, 63-70. doi:10.1097/HNP.0b013e31820dbbae

Dash, M., & Telles, S. (2001). Improvement in hand grip strength in normal volunteers and rheumatoid arthritis patients following yoga training. Indian Journal of Physiology and Pharmacology, 45, 335-360.

Dominick, K.L., Bosworth, H.B., Dudley, T.K., Waters, S.J., Campbell, L.C., & Keefe, F.J. (2004). Patterns of opioid analgesic prescrip-tion among patients with osteoarthritis. Journal of Pain and Palliative Care Pharma-cotherapy, 18(1), 31-46.

Felson, D.T., & Zhang, Y. (1998). An update on the epidemiology of knee and hip osteoarthritis with a view to prevention. Arthritis & Rheu-matism, 41, 1343-1355. doi:10.1002/1529-0 1 3 1 ( 1 9 9 8 0 8 ) 4 1 : 8 < 1 3 4 3 : : A I D -ART3>3.0.CO;2-9

Garfinkel, M., & Schumacher, H.R., Jr. (2000). Yoga. Rheumatic Disease Clinics of North America, 26(1), 125-132. doi:10.1016/S0889-857X(05)70126-5

Garfinkel, M.S., Schumacher, H.R., Jr., Husain, A., Levy, M., & Reshetar, R. (1994). Evalua-tion of a yoga based regimen for treatment

The results suggest that a supervised 8-week session of chair yoga can be beneficial in improving physical function and reducing stiffness in symptomatic OA patients.

20 21Copyright © SLACK Incorporated Journal of GerontoloGical nursinG • Vol. 38, no. 5, 2012

Earn 2.1 Contact Hours

cnearticle

of osteoarthritis of the hands. Journal of Rheumatology, 21, 2341-2343.

Garfinkel, M.S., Singhal, A., Katz, W.A., Al-lan, D.A., Reshetar, R., & Schumacher, H.R., Jr. (1998). Yoga-based intervention for carpal tunnel syndrome: A random-ized trial. Journal of the American Medical Association, 280, 1601-1603. doi:10.1001/jama.280.18.1601

Haaz, S., & Bartlett, S.J. (2011). Yoga for ar-thritis: A scoping review. Rheumatic Dis-ease Clinics of North America, 37, 33-46. doi:10.1016/j.rdc.2010.11.001

Haugen, I.K., Slatkowsky-Christensen, B., Lessem, J., & Kvien, T.K. (2009). The responsiveness of joint counts, patient-reported measures and proposed compos-ite scores in hand osteoarthritis: Analyses from a placebo-controlled trial. Annals of the Rheumatic Disease, 69, 1436-1440. doi:10.1136/ard.2008.100156

Hurley, M.V., & Scott, D.L. (1998). Improve-ments in quadriceps sensorimotor func-tion and disability of patients with knee osteoarthritis following a clinically prac-ticable exercise regime. Rheumatology, 37, 1181-1187. doi:10.1093/rheumatol-ogy/37.11.1181

Jakobsson, U., & Hallberg, I.R. (2002). Pain and quality of life among older people with rheumatoid arthritis and/or osteoar-thritis: A literature of review. Journal of Clinical Nursing, 11, 430-443.

Kolasinski, S.L. (1999). The use of alternative therapies by patients with rheumatic dis-ease. Journal of Clinical Rheumatology, 5, 1-2.

Kolasinski, S.L., Garfinkel, M., Tsai, A.G., Matz, W., Van Dyke, A., & Schumacher, H.R. (2005). Iyengar yoga for treating symptoms of osteoarthritis of the knee: A pilot study. Journal of Alternative and Complementary Medicine, 11, 689-693.

Konvicka, J.J., Meyer, T.A., McDavid, A.J., & Roberson, C.R. (2008). Complementary/ alternative medicine use among chronic pain clinic patients. Journal of Perianes-thesia Nursing, 23(1), 17-23.

Krause, N. (1986). Social support, stress, and well-being among older adults. Journal of Gerontology, 41, 512-519. doi:10.1093/geronj/41.4.512

Krishnamurthy, M.N., & Telles, S. (2007). Assessing depression following two an-cient Indian interventions: Effects of yoga and ayurveda on older adults in a resi-dential home. Journal of Gerontological Nursing, 33(2), 17-33.

Lawrence, R.C., Helmick, C.G., Arnett, F.C., Deyo, R.A., Felson, D.T., Giannini, E.H.,...Wolfe, F. (1998). Estimates of the prevalence of arthritis and selected mus-culoskeletal disorders in the United States. Arthritis & Rheumatism, 41, 778-799.

Lundgren, T., Dahl, J., Yardi, N., & Melin, L. (2008). Acceptance and commitment ther-

apy and yoga for drug-refractory epilep-sy: A randomized controlled trial. Epilep-sy & Behavior, 13, 102-108. doi:10.1016/j.yebeh.2008.02.009

Mannoni, A., Briganti, M.P., Di Bari, M., Ferrucci, L., Costanza, S., Serni, U.,...Marchionni, N. (2003). Epidemiological profile of symptomatic osteoarthritis in older adults: A population based study in Dicomano, Italy. Annals of the Rheumatic Diseases, 62, 576-578.

Morone, N.E., & Greco, C.M. (2007). Mind-body interventions for chronic pain in older adults: A structured review. Pain Medicine, 8, 359-375. doi:10.1111/j.1526-4637.2007.00312.x

Nayak, N.N., & Shankar, K.S. (2004). Yoga: A therapeutic approach. Physical Medi-cine and Rehabilitation Clinics of North America, 15, 783-798. doi:10.1016/j.pmr.2004.04.004

Nishiwaki, Y., Michikawa, T., Yamada, M., Eto, N., & Takebayashi, T. (2011). Knee pain and future self-reliance in older adults: Evidence from a community-based 3-year cohort study in Japan. American Journal of Epidemiology, 21, 184-190.

Oken, B.S., Kishiyama, S., Zajdel, D., Bour-dette, D., Carlsen, J., Haas, M.,...Mass, M. (2004). Randomized controlled trial of yoga and exercise in multiple sclerosis. Neurology, 62, 2058-2064. doi:10.1212/01.WNL.0000129534.88602.5C

Patel, C., & North, W.R.S. (1975). Ran-domised controlled trial of yoga and bio-feedback in management of hypertension. Lancet, 306, 93-95. doi:10.1016/S0140-6736(75)90002-1

Peyron, J., & Altman, R. (1992). The epidemi-ology of osteoarthritis. In R.W. Moskow-itz, D.S. Howell, V.M. Goldberg , & H.J. Mankin (Eds.), Osteoarthritis diagnosis and medical/surgical management (2nd ed., pp. 15-37). Philadelphia: Saunders.

Radloff, L.S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psy-chological Measurement, 1, 385-401. doi:10.1177/014662167700100306

Rejeski, W.J., Brawley, L.R., Ettinger, W., Morgan, T., & Thompson, C. (1997). Compliance to exercise therapy in older participants with knee osteoarthritis: Im-plications for treating disability. Medicine & Science in Sports & Exercise, 29, 977-985.

Rizzo, V. (2009). Section 2.5 Osteoarthri-tis—A chronic incapacitating disease. In Chronic illness and aging. Retrieved from the National Center for Geronto-logical Social Work Education website: http://www.cswe.org/CentersInitiatives/G e r o E d C e n t e r / P r o g r a m s / M A C /Reviews/Health/22419/22584.aspx

Ross, A., & Thomas, S. (2010). The health benefits of yoga and exercise: A review of

comparison studies. Journal of Alterna-tive and Complementary Medicine, 16(1), 3-12.

Shapiro, D., Cook, I.A., Davydov, D.M., Ot-taviani, C., Leuchter, A.F., & Abrams, M. (2007). Yoga as a complementary treat-ment of depression: Effects of traits and moods on treatment outcome. Evidence-Based Complementary and Alternative Medicine, 4, 493-502.

Sharma, M. (2005). Effects of a yoga interven-tion as a supportive therapy in arthritis. Yoga Studies, 4, 12-16.

Sherman, K.J., Cherkin, D.C., Erro, J., Mi-glioretti, D.L., & Deyo, R.A. (2005). Comparing yoga, exercise, and a self-care book for chronic low back pain: A ran-domized, controlled trial. Annals of Inter-nal Medicine, 143, 849-857.

Stevens, J.P. (2002). Applied multivariate sta-tistics for the social sciences (4th ed.). Mah-wah, NJ: Erlbaum.

Taibi, D.M., & Vitiello, M.V. (2011). A pilot study of gentle yoga for sleep disturbance in women with osteoarthritis. Sleep Medi-cine, 12, 512-517.

Vitiello, M.V., Rybarczyk, B., Von Korff, M., & Stepanski, E.J. (2009). Cognitive behav-ioral therapy for insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and osteoarthritis. Jour-nal of Clinical Sleep Medicine, 5, 355-362.

Williams, K.A., Petronis, J., Smith, D., Go-odrich, D., Wu, J., Ravi, N.,...Steinberg, L. (2005). Effect of Iyengar yoga therapy for chronic low back pain. Pain, 115, 107-117.

World Health Organization. (2003). The bur-den of musculoskeletal conditions at the start of the new millennium: Report of a WHO scientific group. Retrieved from http://whqlibdoc.who.int/trs/WHO_TRS_919.pdf

ABOUT THE AUTHORSDr. Park is Assistant Professor,

School of Social Work, and Dr. Mc-Caffrey is Professor, College of Nurs-ing, Florida Atlantic University, Boca Raton, Florida.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. This pilot study was supported by the Florida Atlantic University mentoring grant (seed grant).

Address correspondence to Juyoung Park, PhD, Assistant Professor, School of Social Work, Florida Atlantic Uni-versity, 777 Glades Road, Boca Raton, FL 33431; e-mail: jpark14@fau.edu.

Received: April 30, 2011Accepted: December 16, 2011Posted: April 25, 2012doi:10.3928/00989134-20120410-01

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