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Keywords:

  • Hand functioning;
  • Hand osteoarthritis;
  • Outcome measure

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Objective

To determine which self-report instruments best explain hand functioning measured by a generic comprehensive hand function test.

Methods

Six questionnaires currently used in hand osteoarthritis (OA), namely, the Arthritis Impact Measurement Scales 2 Short Form (AIMS2-SF), the Australian/Canadian Osteoarthritis Hand Index (AUSCAN), the Cochin scale, the Functional Index of Hand OA (FIHOA), the Health Assessment Questionnaire (HAQ), and the Score for Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (SACRAH), were administered once in 100 patients with hand OA together with the Jebsen-Taylor Hand Function Test (JTHFT). In addition, 3 other hand function tests with short administration time were used: the Moberg Picking-Up Test (MPUT), the Button Test (BT), and grip strength. The Short Form 36 was used to describe health status. The relationship between the instruments and the JTHFT was determined by correlation analyses.

Results

AIMS2-SF total scores had the highest raw correlation coefficient to the JTHFT, followed by AIMS2-SF upper body limitation subscale, SACRAH stiffness subscale, and SACRAH total score. If controlled for age, the HAQ had the highest correlation coefficient. Of the 3 short hand function tests, the MPUT showed the highest raw correlation coefficient to the JTHFT; if controlled for age, the BT had the highest correlation coefficient.

Conclusion

To comprehensively assess hand functioning in patients with hand OA, we recommend using both a self-report instrument used more generally in various arthritides and a self-report instrument specifically developed for hand OA. If a short test is preferred, we recommend using the MPUT or BT.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Osteoarthritis (OA) is the most common joint disease and most frequently involves joints of the hands (1). OA in general is characterized by a progressive loss of articular cartilage, deformity, swelling, stiffness, deceased range of joint motion, and periods of pain in and around the affected joints (2, 3). Consequently, hand OA leads to a reduction of grip strength (4), increased difficulties when performing tasks of everyday life (5), loss of productive work time (6), and a decreased ability to perform manual activities (7). Hand OA has an enormous socioeconomic impact because it affects 60–70% of the population over age 65 years (8–10) and in particular women already over age 47 years (11). Because today almost 80% of the population can expect to live through most of their seventh decade of life, the socioeconomic impact of OA is likely to increase even further in the future (8).

Pain and loss of hand functioning negatively influence patients' quality of life. Drug treatment recommended for hand OA includes analgesics, nonsteroidal antiinflammatory drugs, and glucosamine sulfate (12). In addition, to improve their functional performance, persons with hand OA are commonly referred to occupational and physical therapists (13).

To measure the clinical effects of treatment, measurement of functioning is recommended in the literature by expert consensus (Outcome Measures in Rheumatology Clinical Trials [OMERACT]/Osteoarthritis Research Society International [OARSI]) for hip, knee, and hand OA (14), specifically for hand OA (3), although there is no consensus on how functioning should be measured. Function can be measured by directly observing performance or by using a self-report instrument. Performance always requires measurement by a test (15). If function measured by a self-report instrument and performance measured by a test are considered separate entities, it may be interesting to compare self-report instruments with a comprehensive hand function test.

Some clinicians argue that they prefer hand function tests to questionnaires because filling in a questionnaire might depend on the educational level and the motivation of the patient (16, 17). In other rheumatic diseases, hand function tests with relatively short administration time, such as the Moberg Picking-Up Test (MPUT), Button Test (BT), or a grip strength (GS) measurement, were found to be feasible in busy clinical settings (16, 18). These short hand function tests differ from a comprehensive test in that they measure performance in only some aspects of hand function, whereas comprehensive tests would include more components of hand function in the total score. However, the disadvantage of comprehensive hand function tests is that they require trained observers and a specific setting in time and place (19, 20). Thus, self-report instruments may be considered more feasible in busy clinical settings than any (even short) function test because they do not require the presence of professional trained staff and allocation of space when administered. Therefore, it might be important to know which self-report instruments best explain hand functioning measured by a comprehensive test when administered in the same patients.

The self-report instruments that are recommended in the literature for assessing functioning in patients with hand OA (15, 21) have considerable differences in their item content (22). To date, there are no data derived from empirical studies comparing the available self-report instruments to determine which should be used to assess hand functioning in patients with hand OA.

The goal of this study was to determine which instruments described in the literature for the assessment of hand functioning in patients with hand OA best reflect hand functioning measured by a generic comprehensive hand function test. The specific goals were 1) to compare the results of all self-report instruments recommended in the literature for the assessment of hand functioning with a generic comprehensive hand function test, 2) to compare hand function tests with short administration time with the generic comprehensive hand function test in patients with hand OA, and 3) to recommend instruments for comprehensively measuring hand functioning in patients with hand OA that are feasible in clinical settings and relevant for routine practice and research purposes.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Patients.

A total of 100 patients from our rheumatology outpatient clinic who met the American College of Rheumatology criteria for hand OA (5) were included in the study. To avoid excluding patients with hand OA in an early stage, patients were also eligible to participate in this study if they had bony swelling of at least one interphalangeal joint of the second to fifth finger and/or pain or bony swelling of at least one carpometacarpal joint 1. Patients with evidence of rheumatoid arthritis or any rheumatic disease other than OA were excluded. Furthermore, persons with elevated C-reactive protein level (>0.5 mg/dl) as a sign of active inflammation at the test visit and/or with soft tissue swelling of any of the finger joints on either hand were excluded.

Participants were informed in detail about the study procedures. All patients were required to give oral and written informed consent. The institutional ethical committee approved the study.

Instruments.

We used the Jebsen-Taylor Hand Function Test (JTHFT) (20) as a comprehensive generic hand function test. This test was selected because it includes various components of hand function (20), can be used for various health conditions, and has been used previously in rheumatic diseases (23, 24). We used a generic hand function test rather than an arthritis-specific test, such as Backman and Mackie's arthritis hand function test (19), for this exercise because we wanted to stay as broad as possible and not exclude tasks a priori that may not be considered impaired through arthritis. Furthermore, the JTHFT was found to be etiologically neutral (25), which means that it does not bridge to the health condition, but rather uses a comprehensive understanding of hand function that does not only relate to the disease perspective. The JTHFT takes ∼40 minutes to perform. It consists of 7 subtests that are all timed with a stopwatch and summarized to obtain the total score: writing; turning cards (simulated page turning); picking up small objects; simulated feeding with beans and a spoon; stacking checkers upon each other; placing large, light objects on a board; and placing large, heavy objects on a board. The JTHFT is a unilateral test (each hand measured separately). Total scores were calculated by summing up the scores of the 7 subtests from both hands (20).

Self-report instruments used to measure functioning in patients with hand OA were identified in a structured literature search. The search and selection methodology has been described elsewhere (22). The following questionnaires were included in this analysis: the Health Assessment Questionnaire (HAQ) (26, 27), the Australian/Canadian Osteoarthritis Hand Index (AUSCAN) (28, 29), the Cochin scale (30, 31), the Functional Index of Hand OA (FIHOA) (32, 33), the Score for Assessment and Quantification of Chronic Rheumatoid Affections of the Hands questionnaire (SACRAH) (34, 35), and the Arthritis Impact Measurement Scales 2 Short Form questionnaire (AIMS2-SF) (36, 37). The AIMS2-SF questionnaire includes 26 items and is the short form of the 78-item AIMS2 questionnaire. The short form was selected for reasons of brevity and feasibility in a busy routine setting as mentioned above. In a theoretical content analysis, the AUSCAN, Cochin scale, FIHOA, and SACRAH were found to cover hand-specific items regarding the problems of patients with hand OA, whereas the HAQ and AIMS2-SF, which are used more generally in various arthritides, were found to cover broader aspects of functioning (22).

In addition to the self-report instruments, we used the following 3 short hand function tests: the MPUT (18, 38), the BT (16), and GS measured by a vigorimeter (39). These tests were selected because they 1) have been used in persons with various rheumatic diseases, 2) have been found to be feasible in busy clinical settings, 3) can be administered in a short time (a maximum of 5 minutes), and 4) do not require formal staff training (16, 18, 40, 41). Each test was administered according to the protocol described in the literature (16, 18, 38, 39). The time to complete the MPUT and BT was measured with a stop watch and recorded in seconds, whereas GS was measured using a vigorimeter.

The Short Form 36 Health Survey (SF-36) (42) was used to evaluate the health status of each patient. All instruments were administered once and the patients were tested at their routine visit in the rheumatology outpatient clinic.

Relationship between the instruments.

Demographic data of the patients regarding age, sex, and disease duration were obtained. Total scores of each instrument as well as the scores for all subscales including the SF-36 (42) were calculated according to the instructions in the literature (26–37). The total score of the JTHFT was calculated by adding the time of the 7 subtests (20). For calculating the total scores of the MPUT, the BT, and GS, the measurements of the dominant and nondominant hand were added and divided by 2 (16, 18, 38, 39).

We tested all scores for Gaussian distribution (normality test). Depending on the distribution of the data, we calculated Pearson's or Spearman's correlation coefficients of all total scores and the scores of each subscale of all self-report instruments, including the subscales of the SF-36 (42). We then determined possible influences of age, sex, and disease duration on the results of the JTHFT. To correct for potential influences on hand function, we calculated partial correlation coefficients. Statistical analyses were performed using SPSS software, version 12.0.1 (SPSS, Munich, Germany) on a personal computer.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Demographic data of the patients.

The mean ± SD age of the patients was 60.7 ± 8.7 years and their mean ± SD disease duration was 8.1 ± 8.5 years. Eighty-seven women (87%) and 13 men (13%) participated.

Correlations between instruments.

Mean scores, standard deviations, and quartiles of the JTHFT, the instruments, and the subscales of the SF-36 are presented in Table 1. The correlation coefficients between the total scores, including all subscales of the self-report instruments, and the JTHFT are shown in Table 2. Because of the non-normal distribution of the data, Spearman's correlations were calculated. The highest correlation coefficient was found between the JTHFT and the AIMS2-SF total scores, followed by the AIMS2-SF upper body limitation subscale, the SACRAH stiffness subscale, and the SACRAH total score, whereas the AIMS2-SF social interaction subscale had the lowest correlation coefficient.

Table 1. Characteristics of the JTHFT, MPUT, BT, GS, and the 6 self-report instruments*
 Mean ± SDMedianIQRRange
  • *

    Total scores are reported for all instruments except the M-SACRAH and the subscales of the SF-36. In all instruments higher scores indicate worse outcome, except for the SF-36 and GS in which higher scores indicate better health status or better performance. JTHFT = Jebsen-Taylor Hand Function Test; MPUT = Moberg Picking-Up Test; BT = Button Test; GS = grip strength; IQR = interquartile range; AIMS2-SF = Arthritis Impact Measurement Scales 2 Short Form; AUSCAN = Australian/Canadian Osteoarthritis Hand Index; FIHOA = Functional Index of Hand Osteoarthritis; HAQ = Health Assessment Questionnaire; SACRAH = Score for Assessment and Quantification of Chronic Rheumatoid Affections of the Hands; M-SACRAH = modified SACRAH; SF-36 = Short Form 36 Health Survey; bar = a unit for the measurement of pressure.

  • We tested both dominant and nondominant hands of the patients because the standardized protocol of the JTHFT recommends testing both hands (20) and the scores of the MPUT, BT, and GS should be best comparable with the JTHFT.

JTHFT (in seconds)116.7 ± 34.1112.094.9–131.968.5–314.4
AIMS2-SF20.4 ± 9.317.714.7–25.04.3–42.0
AUSCAN13.4 ± 6.512.28.3–18.90.5–28.5
Cochin scale17.7 ± 16.512.05.0–29.00–73.0
FIHOA9.0 ± 6.48.04.0–13.00–26.0
HAQ0.7 ± 0.50.60.3–1.10–2.8
SACRAH32.6 ± 23.027.211.9–48.62.2–93.3
M-SACRAH24.5 ± 21.819.07.28–36.10–97.4
SF-36 general health perception51.7 ± 20.052.040.0–67.05.0–92.0
SF-36 physical functioning66.7 ± 22.770.047.5–85.00–100.0
SF-36 bodily pain42.3 ± 21.641.030.8–50.30–100.0
SF-36 physical role limitation46.1 ± 40.450.00–100.00–100.0
SF-36 vitality52.7 ± 19.852.540.0–65.05.0–100.0
SF-36 social functioning79.4 ± 22.487.562.5–100.00.0–100.0
SF-36 mental health65.6 ± 20.064.052.0–83.012.0–100.0
SF-36 emotional role limitation67.0 ± 41.8100.033.3–100.00–100.0
MPUT (in seconds)17.8 ± 21.612.711.0–17.46.3–165.5
BT (in seconds)29.9 ± 7.329.125.0–34.116.6–56.0
GS (in bar)0.30 ± 0.270.280.12–0.380–1.51
Table 2. Correlation coefficients between the Jebsen-Taylor Hand Function Test (JTHFT) and the total scores and subscales of the self-report instruments*
 Correlation JTHFTPRank
  • *

    Negative correlation coefficients indicate an inverse relationship between the variables: higher scores on the JTHFT mean that a patient needed more time to complete the task, whereas higher scores on the SF-36 mean a better health status. See Table 1 for definitions.

  • The sequence of the instruments and subscales regarding the strength of their correlation to the JTHFT.

AIMS2-SF total score0.672< 0.00011
AIMS2-SF upper body limitation0.448< 0.00012
AIMS2-SF symptom score0.406< 0.00017
AIMS2-SF role (work) score0.3250.03815
AIMS2-SF lower body limitation0.2940.00518
AIMS2-SF affect scale0.2810.00621
AIMS2-SF social interaction scale0.1320.20827
AUSCAN total score0.375< 0.000112
AUSCAN function score0.386< 0.000110
AUSCAN pain score0.3160.00216
AUSCAN stiffness score0.2820.00619
Cochin scale0.369< 0.000114
FIHOA0.387< 0.00019
HAQ0.424< 0.00015
SACRAH total score0.436< 0.00014
SACRAH stiffness scale0.437< 0.00013
SACRAH function scale0.418< 0.00016
SACRAH pain score0.371< 0.000113
M-SACRAH0.388< 0.00018
SF-36 physical functioning scale−0.377< 0.000111
SF-36 vitality scale−0.2980.00417
SF-36 mental health scale−0.2600.01322
SF-36 general health perception scale−0.2830.00620
SF-36 bodily pain scale−0.1940.06224
SF-36 physical role limitation−0.1770.09025
SF-36 emotional role limitation scale−0.1970.05923
SF-36 social functioning scale−0.1360.18526

Because the JTHFT correlated significantly with age (correlation coefficient 0.276, P = 0.007), we corrected for age in a secondary analysis (Table 3). No significant correlation was found between the JTHFT and sex (correlation coefficient 0.147, P = 0.160) and disease duration (correlation coefficient 0.040, P = 0.710). Therefore, this secondary analysis was not corrected for sex and disease duration. If controlled for age, the HAQ had the highest correlation coefficient, followed by the Cochin scale, the modified SACRAH, and the AIMS2-SF total score, whereas the SF-36 social functioning subscale showed the lowest correlation coefficient (Table 3).

Table 3. Partial correlation coefficients between the Jebsen-Taylor Hand Function Test (JTHFT) and the total scores and subscales of the self-report instruments*
 Partial correlation JTHFT, controlled for ageRank
  • *

    We calculated partial correlations by controlling for age because the JTHFT showed a statistically significant correlation to age in our sample. See Table 1 for definitions.

  • The sequence of the instruments and subscales regarding the strength of their correlation to the JTHFT.

AIMS2-SF total score0.6894
AIMS2-SF upper body limitation0.6567
AIMS2-SF symptom score0.58615
AIMS2-SF role (work) score0.30025
AIMS2-SF lower body limitation0.20426
AIMS2-SF affect scale0.44520
AIMS2-SF social interaction scale0.33924
AUSCAN total score0.59513
AUSCAN function score0.62011
AUSCAN pain score0.55616
AUSCAN stiffness score0.44021
Cochin scale0.7392
FIHOA0.6628
HAQ0.7631
SACRAH total score0.57912
SACRAH stiffness scale0.57514
SACRAH function scale0.6776
SACRAH pain score0.6419
M-SACRAH0.6993
SF-36 physical functioning scale−0.6855
SF-36 vitality scale−0.36623
SF-36 mental health scale−0.61010
SF-36 general health perception scale−0.51117
SF-36 bodily pain scale−0.51018
SF-36 physical role limitation−0.37022
SF-36 emotional role limitation scale−0.42819
SF-36 social functioning scale−0.19227

The correlation coefficients between the JTHFT and the 3 hand function tests with short administration time are shown in Table 4. The MPUT had the highest correlation coefficient, whereas GS had the lowest correlation coefficient. If controlled for age, the BT showed the highest correlation coefficient, whereas GS still had the lowest correlation coefficient.

Table 4. Correlation coefficients between the Jebsen-Taylor Hand Function Test (JTHFT) and the hand function tests with short administration time*
 Correlation JTHFTPRank
  • *

    Higher scores on the JTHFT mean that a patient used more time to complete the task, whereas higher scores on grip strength measurement mean a better hand function.

  • The value of the correlation coefficient to the JTHFT.

Raw score   
 Moberg Picking-Up Test0.690< 0.00011
 Button Test0.523< 0.00012
 Grip strength−0.395< 0.00013
Controlled for age   
 Moberg Picking-Up Test0.3190.0032
 Button Test0.528< 0.00011
 Grip strength−0.1370.0283

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

In this study, we compared the results of 6 self-report instruments recommended in the literature for measurement of hand functioning in patients with hand OA with results of a generic comprehensive hand function test. In addition, we compared 3 hand function tests with short administration time, which measure some aspects of hand function, with the same generic comprehensive hand function test. Use of the JTHFT in a busy clinical setting is impractical because it takes ∼40 minutes to perform and requires professional and trained staff, as well as at least a separate desk, when administered.

Both the self-report instruments specifically developed for hand OA and the questionnaires used more generally in various arthritides such as the HAQ or AIMS2-SF showed similar correlation coefficients with the JTHFT. This finding may be attributed to the fact that the latter instruments also include items specific for hand functioning, such as “Could you easily button a shirt or blouse?” (in the AIMS2-SF) and “open a new milk carton” (in the HAQ). However, this finding could also reflect that more general items on functioning, including participation in daily life activities, may be important in order to explain hand functioning as measured by the JTHFT. Examples of more general items that are related to hand function but that also assess participation in daily life activities are “driving a car” (in the AIMS2-SF) and “shopping” (in the HAQ).

When completing self-report instruments, patients may have in mind more general aspects of functioning in daily life that are not solely related to hand-specific activities. In a qualitative analysis, personal/intrinsic factors, issues of personal future, and perceptions of normality were among the themes that were important to patients with rheumatoid arthritis (43). In a qualitative focus group study, we identified being in control of the disease, the unpredictable course of a rheumatic disease, and attitudes towards individuals with health problems to be important to patients with psoriatic arthritis (44). These issues might also reflect that in patients with hand OA, a broader concept of hand functioning including aspects of participation, satisfaction with the ability to perform particular activities, and attitudes toward one's abilities may influence the score on a questionnaire. It may therefore be important to include more general items on functioning in the assessment of health status in persons with rheumatic diseases. Thus, we suggest including both a self-report instrument specifically developed for hand OA and an instrument that covers more general items. Future research could focus on developing a composite score from the existing instruments that weighs specific and more general items.

The results of the analysis underscore our findings from an earlier theoretical analysis in which we compared the content of the self-report instruments by linking them to the International Classification of Functioning, Disability and Health (ICF) (22). In this earlier theoretical analysis, we recommended that researchers and clinicians should include both one instrument covering disease-specific aspects and another instrument covering broader aspects of functioning including some aspects of participation. The present empirical analysis supports this recommendation.

If all self-report instruments and tests were taken together, the MPUT had the highest total correlation to the JTHFT. This may be explained because tests measure the ability of a patient to perform a standardized task, whereas self-report instruments measure functioning from the perspective of the patient. This is emphasized in the ICF (45), which was developed by the World Health Organization to define a unifying frame of reference for the definition and assessment of functioning. From the perspective of the ICF, hand function tests may be considered to measure the capacity of a person to perform a certain task, whereas a self-report instrument may measure functioning from the perspective of a person's daily life. The person who is answering the question might think about his or her ability to perform the particular task in daily life as influenced by environmental and personal factors and not about a standardized task, which is commonly used in a test. This may also underscore the difference between function and performance (capacity in the ICF), which has been indicated in the literature (15).

In general, patient-reported outcome may be regarded to be superior to measuring capacity in a test. However, some clinicians argue that they prefer hand function tests to questionnaires because filling in a questionnaire might depend on the educational level of the patient (16, 17), whereas motivation of the patient may influence both self-report instruments and performance tests. However, even the 3 short hand function tests showed different correlations to the JTHFT. This result may be due to the fact that the MPUT and BT as well as the JTHFT require in-hand manipulation, whereas GS does not. A comprehensive test includes the ability of a person to perform a few tasks and may therefore be preferable for research purposes to a short test that includes only one task. From the perspective of feasibility in clinical settings, the MPUT or BT might be preferable in patients with hand OA because these tests had higher correlation coefficients than GS in our analysis.

A limitation of our study may be that the questionnaires were administered in the same order and patients may have become tired filling in the scales at the end. However, most patients had a break when filling in the questionnaires during their waiting time because they were seen by the rheumatologist in between questionnaires and filled in the rest afterwards. In approximately half of the patients, the hand function tests were administered before completion of the questionnaires and the visit to the rheumatologist, whereas in the other half of the patients, the hand function tests were administered afterwards.

Potential limitations of using the JTHFT as a gold standard are that the JTHFT, as a timed test, measures speed, which is only one aspect of hand function; simulated tasks are used (the subtest “simulated feeding” does not require a person to place actual food in the mouth); and the writing subtest was conducted with both dominant and nondominant hands, making it a nontypical task. A limitation of measuring grip strength with the vigorimeter is that it is not as reliable as other more standardized instruments, such as the Grippit (46). However, only the vigorimeter test was available for this study.

Even though sex has been described in the literature as an important factor in hand function in rheumatic diseases (46), a relationship between sex and the JTHFT could not be found in our study. In the secondary analysis, we therefore controlled for age, but not for sex. A reason why no relationship between sex and the JTHFT was found in our study could be due to the fact that only 13% of the participants were men. The AIMS2-SF social interaction subscale and the SF-36 social functioning subscale showed the lowest correlations to the JTHFT. Therefore, social functioning was obviously less often impaired in our sample. These findings obviously correspond with high scores in the other SF-36 subscales, in particular for physical functioning and physical role limitations, indicating a rather high general health status of the participants in the study. Another indicator for a rather high health and function status of the participants in our study may be that 9 instruments demonstrated floor effects (the minimum score was 0; see Table 1). Further research should focus on exploring the perspective of patients with hand OA concerning which particular problems in health status and with daily activities are relevant and important to these individuals. This may also demonstrate the need for the development of new instruments.

To comprehensively assess hand functioning in patients with hand OA, we recommend using both a self-report instrument that is used more generally in various arthritides and one self-report instrument specifically developed for hand OA. We recommend using 2 self-report instruments even though both had high correlations to the JTHFT because in our earlier theoretical analysis in which we compared the content of the self-report instruments by linking them to the ICF (22), we identified considerable differences in item content between instruments used more generally in various arthritides and such instruments specifically developed for hand OA. If a short test that is feasible in a clinical setting is preferred, we recommend using the MPUT or BT.

AUTHOR CONTRIBUTIONS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Dr. Stamm had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study design. Stamm, Kloppenburg, Machold, Smolen.

Acquisition of data. Stamm, Mathis.

Analysis and interpretation of data. Stamm, Machold.

Manuscript preparation. Stamm, Mathis, Aletaha, Kloppenburg, Machold, Smolen.

Statistical analysis. Stamm, Aletaha.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES
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