Left Right Judgement Task and Sensory, Motor, and Cognitive Assessment in Participants with Wrist/Hand Pain

René Pelletier, Daniel Bourbonnais, Johanne Higgins, Maxime Mireault, Michel Alain Danino, Patrick G Harris, René Pelletier, Daniel Bourbonnais, Johanne Higgins, Maxime Mireault, Michel Alain Danino, Patrick G Harris

Abstract

The Left Right Judgement Task (LRJT) involves determining if an image of the body part is of the left or right side. The LRJT has been utilized as part of rehabilitation treatment programs for persons with pain associated with musculoskeletal injuries and conditions. Although studies often attribute changes and improvement in LRJT performance to an altered body schema, imaging studies suggest that the LRJT implicates other cortical regions. We hypothesized that cognitive factors would be related to LRJT performance of hands and feet and that sensory, motor, and pain related factors would be related to LRJT in the affected hand of participants with wrist/hand pain. In an observational cross-sectional study, sixty-one participants with wrist/hand pain participated in a study assessing motor imagery ability, cognitive (Stroop test), sensory (Two-Point Orientation Discrimination, pressure pain thresholds), motor (grip strength, Purdue Pegboard Test), and pain related measures (West Haven Yale Multidimensional Pain Inventory) as well as disability (Disability of the Arm, Shoulder and Hand). Multiple linear regression found Stroop test time and motor imagery ability to be related to LRJT performance. Tactile acuity, motor performance, participation in general activities, and the taking of pain medications were predictors of LRJT accuracy in the affected hand. Participants who took pain medications performed poorly in both LRJT accuracy (p=0.001) and reaction time of the affected hand (p=0.009). These participants had poorer cognitive (p=0.013) and motor function (p=0.002), and higher pain severity scores (p=0.010). The results suggest that the LRJT is a complex mental task that involves cognitive, sensory, motor, and behavioural processes. Differences between persons with and without pain and improvement in LRJT performance may be attributed to any of these factors and should be considered in rehabilitation research and practice utilizing this task.

Figures

Figure 1
Figure 1
Left Right Judgement Task (LRJT) performance in participants with musculoskeletal disorders of the wrist/hand. Mean±95% Confidence Intervals.
Figure 2
Figure 2
Left Right Judgement performance accuracy and reaction time in participants who were taking pain medication (PainMeds) and not taking pain medication (NoPainMeds) on the day of the evaluation. x-±95% Confidence Intervals. ∗ False Discovery Rate Statistical significance below α=0.05.

References

    1. Moseley G. L. The Graded Motor Imagery Handbook. Noigroup publications; 2012.
    1. Moseley G. L. Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial. Pain. 2004;108(1-2):192–198. doi: 10.1016/j.pain.2004.01.006.
    1. Moseley G. L. Graded motor imagery for pathologic pain: A randomized controlled trial. Neurology. 2006;67(12):2129–2134. doi: 10.1212/01.wnl.0000249112.56935.32.
    1. Bowering K. J., O'Connell N. E., Tabor A., et al. The effects of graded motor imagery and its components on chronic pain: a systematic review and meta-analysis. The Journal of Pain. 2013;14(1):3–13. doi: 10.1016/j.jpain.2012.09.007.
    1. Dilek B., Ayhan C., Yagci G., Yakut Y. Effectiveness of the graded motor imagery to improve hand function in patients with distal radius fracture: A randomized controlled trial. Journal of Hand Therapy. 2018;31(1):2.e1–9.e1. doi: 10.1016/j.jht.2017.09.004.
    1. Pedler A., Motlagh H., Sterling M. Laterality judgments are not impaired in patients with chronic whiplash associated disorders. Manual Therapy. 2013;18(1):72–76. doi: 10.1016/j.math.2012.07.006.
    1. Elsig S., Luomajoki H., Sattelmayer M., Taeymans J., Tal-Akabi A., Hilfiker R. Sensorimotor tests, such as movement control and laterality judgment accuracy, in persons with recurrent neck pain and controls. A case-control study. Manual Therapy. 2014;19(6):555–561. doi: 10.1016/j.math.2014.05.014.
    1. Linder M., Michaelson P., Röijezon U. Laterality judgments in people with low back pain - A cross-sectional observational and test-retest reliability study. Manual Therapy. 2016;21:128–133. doi: 10.1016/j.math.2015.07.001.
    1. Coslett H. B., Medina J., Kliot D., Burkey A. R. Mental motor imagery indexes pain: The hand laterality task. European Journal of Pain. 2010;14(10):1007–1013. doi: 10.1016/j.ejpain.2010.04.001.
    1. Pelletier R., Higgins J., Bourbonnais D. Laterality recognition of images, motor performance, and aspects related to pain in participants with and without wrist/hand disorders: An observational cross-sectional study. Musculoskeletal Science and Practice. 2018;35:18–24. doi: 10.1016/j.msksp.2018.01.010.
    1. Stanton T. R., Lin C.-W. C., Smeets R. J. E. M., Taylor D., Law R., Lorimer Moseley G. Spatially defined disruption of motor imagery performance in people with osteoarthritis. Rheumatology. 2012;51(8):1455–1464. doi: 10.1093/rheumatology/kes048.
    1. Schmid A. B., Coppieters M. W. Left/right judgment of body parts is selectively impaired in patients with unilateral carpal tunnel syndrome. The Clinical Journal of Pain. 2012;28(7):615–622. doi: 10.1097/AJP.0b013e31823e16b9.
    1. Lewis J. S., Kersten P., McCabe C. S., McPherson K. M., Blake D. R. Body perception disturbance: A contribution to pain in complex regional pain syndrome (CRPS) Pain. 2007;133(1-3):111–119. doi: 10.1016/j.pain.2007.03.013.
    1. Lotze M., Moseley G. L. Role of distorted body image in pain. Current Rheumatology Reports. 2007;9(6):488–496. doi: 10.1007/s11926-007-0079-x.
    1. Reinersmann A., Haarmeyer G. S., Blankenburg M., et al. Left is where the L is right. Significantly delayed reaction time in limb laterality recognition in both CRPS and phantom limb pain patients. Neuroscience Letters. 2010;486(3):240–245. doi: 10.1016/j.neulet.2010.09.062.
    1. Bray H., Moseley G. L. Disrupted working body schema of the trunk in people with back pain. British Journal of Sports Medicine. 2011;45(3):168–173. doi: 10.1136/bjsm.2009.061978.
    1. Reinersmann A., Landwehrt J., Krumova E. K., Ocklenburg S., Güntürkün O., Maier C. Impaired spatial body representation in complex regional pain syndrome type 1 (CRPS I) Pain. 2012;153(11):2174–2181. doi: 10.1016/j.pain.2012.05.025.
    1. Moseley G. L. Why do people with complex regional pain syndrome take longer to recognize their affected hand? Neurology. 2004;62(12):2182–2186. doi: 10.1212/01.WNL.0000130156.05828.43.
    1. Moseley G. L., Sim D. F., Henry M. L., Souvlis T. Experimental hand pain delays recognition of the contralateral hand - Evidence that acute and chronic pain have opposite effects on information processing? Cognitive Brain Research. 2005;25(1):188–194. doi: 10.1016/j.cogbrainres.2005.05.008.
    1. Schwoebel J., Friedman R., Duda N., Coslett H. B. Pain and the body schema: evidence for peripheral effects on mental representations of movement. Brain. 2001;124((Pt 10)):2098–2104. doi: 10.1093/brain/124.10.2098.
    1. Schwoebel J., Coslett H. B., Bradt J., Friedman R., Dileo C. Pain and the body schema: Effects of pain severity on mental representations of movement. Neurology. 2002;59(5):775–777. doi: 10.1212/WNL.59.5.775.
    1. Shenton J. T., Schwoebel J., Coslett H. B. Mental motor imagery and the body schema: Evidence for proprioceptive dominance. Neuroscience Letters. 2004;370(1):19–24. doi: 10.1016/j.neulet.2004.07.053.
    1. Ionta S., Fourkas A. D., Fiorio M., Aglioti S. M. The influence of hands posture on mental rotation of hands and feet. Experimental Brain Research. 2007;183(1):1–7. doi: 10.1007/s00221-007-1020-2.
    1. Kosslyn S. M., DiGirolamo G. J., Thompson W. L., Alpert N. M. Mental rotation of objects versus hands: neural mechanisms revealed by positron emission tomography. Psychophysiology. 1998;35(2):151–161. doi: 10.1017/s0048577298001516.
    1. Parsons L. M. Integrating cognitive psychology, neurology and neuroimaging. Acta Psychologica. 2001;107(1-3):155–181. doi: 10.1016/S0001-6918(01)00023-3.
    1. Hurley M. V., Scott D. L., Rees J., Newham D. J. Sensorimotor changes and functional performance in patients with knee osteoarthritis. Annals of the Rheumatic Diseases. 1997;56(11):641–648. doi: 10.1136/ard.56.11.641.
    1. Lysholm M., Ledin T., Ödkvist L. M., Good L. Postural control - a comparison between patients with chronic anterior cruciate ligament insufficiency and healthy individuals. Scandinavian Journal of Medicine & Science in Sports. 1998;8(6):432–438. doi: 10.1111/j.1600-0838.1998.tb00464.x.
    1. Brumagne S., Lysens R., Spaepen A. Lumbosacral position sense during pelvic tilting in men and women without low back pain: Test development and reliability assessment. Journal of Orthopaedic & Sports Physical Therapy. 1999;29(6):345–351. doi: 10.2519/jospt.1999.29.6.345.
    1. Fischer-Rasmussen T., Jensen P. E. Proprioceptive sensitivity and performance in anterior cruciate ligament-deficient knee joints. Scandinavian Journal of Medicine & Science in Sports. 2000;10(2):85–89. doi: 10.1034/j.1600-0838.2000.010002085.x.
    1. O'Sullivan P. B., Burnett A., Floyd A. N., et al. Lumbar repositioning deficit in a specific low back pain population. The Spine Journal. 2003;28(10):1074–1079. doi: 10.1097/00007632-200305150-00022. doi: 10.1097/01.BRS.0000061990.56113.6F.
    1. Flor H., Braun C., Elbert T., Birbaumer N. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neuroscience Letters. 1997;224(1):5–8. doi: 10.1016/S0304-3940(97)13441-3.
    1. Giesecke T., Gracely R. H., Grant M. A. B., et al. Evidence of augmented central pain processing in idiopathic chronic low back pain. Arthritis & Rheumatism. 2004;50(2):613–623. doi: 10.1002/art.20063.
    1. Lloyd D., Findlay G., Roberts N., Nurmikko T. Differences in low back pain behavior are reflected in the cerebral response to tactile stimulation of the lower back. The Spine Journal. 2008;33(12):1372–1377. doi: 10.1097/BRS.0b013e3181734a8a.
    1. Ochi M., Iwasa J., Uchio Y., Adachi N., Sumen Y. The regeneration of sensory neurones in the reconstruction of the anterior cruciate ligament. The Journal of Bone & Joint Surgery. 1999;81(5):902–906. doi: 10.1302/0301-620X.81B5.9202.
    1. Ochi M., Iwasa J., Uchio Y., Adachi N., Kawasaki K. Induction of somatosensory evoked potentials by mechanical stimulation in reconstructed anterior cruciate ligaments. The Journal of Bone & Joint Surgery. 2002;84(5):761–766. doi: 10.1302/0301-620X.84B5.0840761.
    1. Strutton P. H., Catley M., McGregor A. H., Davey N. J. Corticospinal excitability in patients with unilateral sciatica. Neuroscience Letters. 2003;353(1):33–36. doi: 10.1016/j.neulet.2003.09.005.
    1. On A. Y., Uludağ B., Taşkiran E., Ertekin C. Differential Corticomotor Control of a Muscle Adjacent to a Painful Joint. Neurorehabilitation and Neural Repair. 2004;18(3):127–133. doi: 10.1177/0888439004269030.
    1. Strutton P. H., Theodorou S., Catley M., McGregor A. H., Davey N. J. Corticospinal excitability in patients with chronic low back pain. Journal of Spinal Disorders & Techniques. 2005;18(5):420–424. doi: 10.1097/01.bsd.0000169063.84628.fe.
    1. Héroux M. E., Tremblay F. Corticomotor excitability associated with unilateral knee dysfunction secondary to anterior cruciate ligament injury. Knee Surgery, Sports Traumatology, Arthroscopy. 2006;14(9):823–833. doi: 10.1007/s00167-006-0063-4.
    1. Tsao H., Galea M. P., Hodges P. W. Reorganization of the motor cortex is associated with postural control deficits in recurrent low back pain. Brain. 2008;131(8):2161–2171. doi: 10.1093/brain/awn154.
    1. Kapreli E., Athanasopoulos S., Gliatis J., et al. Anterior cruciate ligament deficiency causes brain plasticity: a functional MRI study. The American Journal of Sports Medicine. 2009;37(12):2419–2426. doi: 10.1177/0363546509343201.
    1. Berth A., Pap G., Neuman W., Awiszus F. Central neuromuscular dysfunction of the deltoid muscle in patients with chronic rotator cuff tears. Journal of Orthopaedics and Traumatology. 2009;10(3):135–141. doi: 10.1007/s10195-009-0061-7.
    1. Berth A., Pap G., Neumann W., Awiszus F. Altered neuromuscular control of a hand muscle in chronic rotator cuff tears. Archives of Orthopaedic and Trauma Surgery. 2010;130(5):705–710. doi: 10.1007/s00402-009-1012-8.
    1. Schwenkreis P., Scherens A., Rönnau A.-K., Höffken O., Tegenthoff M., Maier C. Cortical disinhibition occurs in chronic neuropathic, but not in chronic nociceptive pain. BMC Neuroscience. 2010;11:p. 73. doi: 10.1186/1471-2202-11-73.
    1. Tsao H., Druitt T. R., Schollum T. M., Hodges P. W. Motor training of the lumbar paraspinal muscles induces immediate changes in motor coordination in patients with recurrent low back pain. The Journal of Pain. 2010;11(11):1120–1128. doi: 10.1016/j.jpain.2010.02.004.
    1. Tsao H., Galea M. P., Hodges P. W. Driving plasticity in the motor cortex in recurrent low back pain. European Journal of Pain. 2010;14(8):832–839. doi: 10.1016/j.ejpain.2010.01.001.
    1. Schabrun S. M., et al. Novel adaptations in motor cortical maps: the relationship to persistent elbow pain. Medicine and Science in Sports and Exercise. 2014;47(4):381–390.
    1. Elgueta-Cancino E. L., Schabrun S. M., Hodges P. W. Smudging of the motor cortex is related to the severity of low back pain. The Spine Journal. 2015
    1. Bradnam L., Shanahan E. M., Hendy K., et al. Afferent inhibition and cortical silent periods in shoulder primary motor cortex and effect of a suprascapular nerve block in people experiencing chronic shoulder pain. Clinical Neurophysiology. 2015;127(1):769–778. doi: 10.1016/j.clinph.2015.03.012.
    1. Ngomo S., Mercier C., Bouyer L. J., Savoie A., Roy J.-S. Alterations in central motor representation increase over time in individuals with rotator cuff tendinopathy. Clinical Neurophysiology. 2015;126(2):365–371. doi: 10.1016/j.clinph.2014.05.035.
    1. Shanahan C. J., et al. Organisation of the motor cortex differs between people with and without knee osteoarthritis. Arthritis Research & Therapy. 2015;17(1):1–11.
    1. Malfliet A., Coppieters I., Van Wilgen P., et al. Brain changes associated with cognitive and emotional factors in chronic pain: A systematic review. European Journal of Pain. 2017;21(5):769–786.
    1. Botnmark I., Tumilty S., Mani R. Tactile acuity, body schema integrity and physical performance of the shoulder: A cross-sectional study. Manual Therapy. 2016;23:9–16. doi: 10.1016/j.math.2016.02.001.
    1. Stanton T. R., Lin C.-W. C., Bray H., et al. Tactile acuity is disrupted in osteoarthritis but is unrelated to disruptions in motor imagery performance. Rheumatology. 2013;52(8):1509–1519. doi: 10.1093/rheumatology/ket139.
    1. Oldfield R. C. The assessment and analysis of handedness: the Edinburgh inventory. Neuropsychologia. 1971;9(1):97–113. doi: 10.1016/0028-3932(71)90067-4.
    1. Wallwork S. B., Butler D. S., Fulton I., Stewart H., Darmawan I., Moseley G. L. Left/right neck rotation judgments are affected by age, gender, handedness and image rotation. Manual Therapy. 2013;18(3):225–230. doi: 10.1016/j.math.2012.10.006.
    1. Breckenridge J. D., et al. The development of a shoulder specific left/right judgement task: validity & reliability. Musculoskeletal Science and Practice. 2017;28:39–45. doi: 10.1016/j.msksp.2017.01.009.
    1. Kerns R., Turk D. C., Rudy T. E. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI) Pain. 1985;23(4):345–356. doi: 10.1016/0304-3959(85)90004-1.
    1. Riley J. L., III, Zawacki T. M., Robinson M. E., Geisser M. E. Empirical test of the factor structure of the West Haven-Yale multidimensional pain inventory. The Clinical Journal of Pain. 1999;15(1):24–30. doi: 10.1097/00002508-199903000-00005.
    1. Nussbaum E. L., Downes L. Reliability of clinical pressure-pain algometric measurement obtained on consecutive days. Physical Therapy. 1998;78(2):160–169. doi: 10.1093/ptj/78.2.160.
    1. Chiarotto A., Fernandez-de-las-Peñas C., Castaldo M., Negrini S., Villafañe J. H. Widespread pressure pain hypersensitivity in elderly subjects with unilateral thumb carpometacarpal osteoarthritis. Hand. 2013;8(4):422–429. doi: 10.1007/s11552-013-9537-2.
    1. Dellon A. L., Mackinnon S. E., Crosby P. M. Reliability of two-point discrimination measurements. Journal of Hand Surgery. 1987;12(5 Pt 1):693–696. doi: 10.1016/S0363-5023(87)80049-7.
    1. Catley M. J., Tabor A., Wand B. M., Moseley G. L. Assessing tactile acuity in rheumatology and musculoskeletal medicine-How reliable are two-point discrimination tests at the neck, hand, back and foot? Rheumatology. 2013;52(8):1454–1461. doi: 10.1093/rheumatology/ket140.
    1. Tong J., Mao O., Goldreich D. Two-point orientation discrimination versus the traditional two-point test for tactile spatial acuity assessment. Frontiers in Human Neuroscience. 2013;7
    1. Tsay A., Allen T. J., Proske U., Giummarra M. J. Sensing the body in chronic pain: A review of psychophysical studies implicating altered body representation. Neuroscience & Biobehavioral Reviews. 2015;52:221–232. doi: 10.1016/j.neubiorev.2015.03.004.
    1. Kalisch T., Kattenstroth J., Kowalewski R., Tegenthoff M., Dinse H. Age-related changes in the joint position sense of the human hand. Clinical Interventions in Aging. 2012;7:499–507. doi: 10.2147/CIA.S37573.
    1. Mathiowetz V., Weber K., Volland G., Kashman N. Reliability and validity of grip and pinch strength evaluations. Journal of Hand Surgery-American Volume. 1984;9a(2):222–226. doi: 10.1016/S0363-5023(84)80146-X.
    1. Tiffin J., Asher E. J. The Purdue Pegboard: norms and studies of reliability and validity. Journal of Applied Psychology. 1948;32(3):234–247. doi: 10.1037/h0061266.
    1. Buddenberg L. A., Davis C. Test-retest reliability of the purdue pegboard test. The American Journal of Occupational Therapy. 2000;54(5):555–558. doi: 10.5014/ajot.54.5.555.
    1. Hudak P. L., Amadio P. C., Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The upper extremity collaborative group. American Journal of Industrial Medicine. 1996;29(6):602–608. doi: 10.1002/(SICI)1097-0274(199606)29:6<602::AID-AJIM4>;2-L.
    1. Gummesson C., Atroshi I., Ekdahl C. The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: Longitudinal construct validity and measuring self-rated health change after surgery. BMC Musculoskeletal Disorders. 2003;4:p. 11. doi: 10.1186/1471-2474-4-1.
    1. Roelofs J., Peters M. L., Zeegers M. P. A., Vlaeyen J. W. S. The modified Stroop paradigm as a measure of selective attention towards pain-related stimuli among chronic pain patients: A meta-analysis. European Journal of Pain. 2002;6(4):273–281. doi: 10.1053/eujp.2002.0337.
    1. Dick B. D., Rashiq S. Disruption of attention and working memory traces in individuals with chronic pain. Anesthesia & Analgesia. 2007;104(5):1223–1229. doi: 10.1213/01.ane.0000263280.49786.f5.
    1. Stroop J. R. Studies of interference in serial verbal reactions. Journal of Experimental Psychology. 1935;18(6):643–662. doi: 10.1037/h0054651.
    1. Bajaj J. S., Heuman D. M., Sterling R. K., et al. Validation of encephalapp, smartphone-based stroop test, for the diagnosis of covert hepatic encephalopathy. Clinical Gastroenterology and Hepatology. 2015;13(10):1828 e1–1835 e1. doi: 10.1016/j.cgh.2014.05.011.
    1. Gregg M., Hall C., Butler A. The MIQ-RS: a suitable option for examining movement imagery ability. Evidence-Based Complementary and Alternative Medicine. 2010;7(2):249–257. doi: 10.1093/ecam/nem170.
    1. Benjamini Y., Hochberg Y. Controlling the false discovery rate: a practical and powerful approach to multiple testing. Journal of the Royal Statistical Society B: Methodological. 1995;57(1):289–300.
    1. Verhoeven K. J. F., Simonsen K. L., McIntyre L. M. Implementing false discovery rate control: Increasing your power. Oikos. 2005;108(3):643–647. doi: 10.1111/j.0030-1299.2005.13727.x.
    1. Bowering K. J., Butler D. S., Fulton I. J., Moseley G. L. Motor imagery in people with a history of back pain, current back pain, both, or neither. The Clinical Journal of Pain. 2014;30(12):1070–1075. doi: 10.1097/AJP.0000000000000066.
    1. Ganis G., Keenan J. P., Kosslyn S. M., Pascual-Leone A. Transcranial magnetic stimulation of primary motor cortex affects mental rotation. Cerebral Cortex. 2000;10(2):175–180. doi: 10.1093/cercor/10.2.175.
    1. Parsons L. M. Temporal and Kinematic Properties of Motor Behavior Reflected in Mentally Simulated Action. Journal of Experimental Psychology: Human Perception and Performance. 1994;20(4):709–730. doi: 10.1037//0096-1523.20.4.709.
    1. Isaac A. R., Marks D. F. Individual differences in mental imagery experience: Developmental changes and specialization. British Journal of Psychology. 1994;85(4):479–500. doi: 10.1111/j.2044-8295.1994.tb02536.x.
    1. Scarpina F., Tagini S. The stroop color and word test. Frontiers in Psychology. 2017;8:p. 557.
    1. Higgins D. M., Martin A. M., Baker D. G., Vasterling J. J., Risbrough V. The relationship between chronic pain and neurocognitive function. Clinical Journal of Pain. 2018;34(3):262–275.
    1. Pleger B., Ragert P., Schwenkreis P., et al. Patterns of cortical reorganization parallel impaired tactile discrimination and pain intensity in complex regional pain syndrome. NeuroImage. 2006;32(2):503–510. doi: 10.1016/j.neuroimage.2006.03.045.
    1. Agnew J., Kawas C. H. Purdue Pegboard Age and Sex Norms for People 40 Years Old and Older. Developmental Neuropsychology. 1988;4(1):29–35. doi: 10.1080/87565648809540388.
    1. Randles D., Kam J. W. Y., Heine S. J., Inzlicht M., Handy T. C. Acetaminophen attenuates error evaluation in cortex. Social Cognitive and Affective Neuroscience. 2016;11(6):899–906. doi: 10.1093/scan/nsw023.
    1. Moseley G. L., Flor H. Targeting cortical representations in the treatment of chronic pain: a review. Neurorehabilitation and Neural Repair. 2012;26(6):646–652. doi: 10.1177/1545968311433209.
    1. Denison E., Åsenlöf P., Lindberg P. Self-efficacy, fear avoidance, and pain intensity as predictors of disability in subacute and chronic musculoskeletal pain patients in primary health care. Pain. 2004;111(3):245–252. doi: 10.1016/j.pain.2004.07.001.
    1. Buckelew S. P., et al. Self‐efficacy, pain, and physical activity among fibromyalgia subjects. Arthritis & Rheumatology. 1995;8(1):43–50. doi: 10.1002/art.1790080110.
    1. Kjeken I., Dagfinrud H., Slatkowsky-Christensen B., et al. Activity limitations and participation restrictions in women with hand osteoarthritis: patients' descriptions and associations between dimensions of functioning. Annals of the Rheumatic Diseases. 2005;64(11):1633–1638. doi: 10.1136/ard.2004.034900.

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