Login Register Cart 0
Generic placeholder image

Current Rheumatology Reviews

Editor-in-Chief

ISSN (Print): 1573-3971
ISSN (Online): 1875-6360

Back
Journal Home About Journal Editorial Board Journal Insight Current Issue Volumes/Issues
Subscribe
Research Article

Assessment of Rheumatoid Hand Function as a Characteristic Feature of Rheumatoid Arthritis in Patients Treated with Methotrexate or Methotrexate with Biological Agents with or without Deformation of Hands

Author(s): Tomasz Chruściak and Małgorzata Wisłowska*

Volume 18, Issue 3, 2022

Published on: 30 March, 2022

Page: [212 - 223] Pages: 12

DOI: 10.2174/1573397118666220215092045

Price: $65

Abstract

Background: The hand is an excellent work tool that provides the functional ability to mechanical work. The hand is affected in rheumatoid arthritis (RA) patients, it is a significant problem in the functional sphere as a result of deformities, the grasping function limitation and muscle strength.

Objectives: The aim of the study was the assessment of grip strength, endurance and manipulation abilities of rheumatoid hands with or without deformities treated with methotrexate (MTX) or MTX plus biologics (MTX+BIO).

Methods: The study involved 80 RA women, (40 received MTX+BIO, 40 MTX), treated at the Rheumatology Department of the Central Clinical Hospital of Interior Affairs in Warsaw. VASpain, DAS28, SDAI, HAQ, HAQ hands, estimation of hand grip strength, endurance, and manipulation ability were analyzed.

Results: In group MTX+BIO, values of DAS28 (3.7±1.3 vs. 4.3±1.2, p=0.019), HAQ (0.72 ± 0.57 vs. 1.08± 0.87, p=0.011) and HAQ-hand (0.85±0.65 vs. 1.19±0.68, p=0.024) were statistically lower than in MTX group. Hand deformations were recorded in 35 (43.7%) cases, 16 (40%) in MTX group, 19 (47.5%) in MTX+BIO. Comparison of grip strength, endurance, and manipulation ability showed better results in MTX+BIO group with deformities (significance level from 0.013 to 0.046) than in MTX group. Relative differences in hand function in MTX + BIO group ranged from 10.8% (maximal power grip strength) to 127.6% (minimal hand endurance), after disease duration adjustment - from 28.2% (maximal power grip strength) to 148.4% (minimal hand endurance).

Conclusion: Measuring grip strength, hand endurance, manipulation abilities are useful in RA patients with hand deformities.

Keywords: Rheumatoid arthritis, hand grip strength, hand deformity, endurance, swan neck deformity, boutonniere deformity, methotrexate, biological agent.

« Previous Next »
Graphical Abstract

[1]
Vliet Vlieland TP, van der Wijk TP, Jolie IMM, Zwinderman AH, Hazes JMW. Determinants of hand function in patients with rheumatoid arthritis. J Rheumatol 1996; 23(5): 835-40.
[PMID: 8724294]
[2]
Johnsson PM, Eberhardt K. Hand deformities are important signs of disease severity in patients with early rheumatoid arthritis. Rheumatology (Oxford) 2009; 48(11): 1398-401.
[http://dx.doi.org/10.1093/rheumatology/kep253] [PMID: 19720679]
[3]
Lindqvist E, Saxne T, Geborek P, Eberhardt K. Ten year outcome in a cohort of patients with early rheumatoid arthritis: Health status, disease process, and damage. Ann Rheum Dis 2002; 61(12): 1055-9.
[http://dx.doi.org/10.1136/ard.61.12.1055] [PMID: 12429534]
[4]
Medenci E, Gursoy S. Hand deformity in rheumatoid arthritis and its impact on the quality of life. Pain Clin 2003; 15(3): 255-60.
[http://dx.doi.org/10.1163/156856903767650772]
[5]
Eberhardt K, Johnson PM, Rydgren L. The occurrence and significance of hand deformities in early rheumatoid arthritis. Br J Rheumatol 1991; 30(3): 211-3.
[http://dx.doi.org/10.1093/rheumatology/30.3.211] [PMID: 2049583]
[6]
Ekdahl C, Eberhardt K, Andersson SI, Svensson B. Assessing disability in patients with rheumatoid arthritis. Use of a Swedish version of the Stanford Health Assessment Questionnaire. Scand J Rheumatol 1988; 17(4): 263-71.
[http://dx.doi.org/10.3109/03009748809098795] [PMID: 3187457]
[7]
Rath S. Hand kinematics: Application in clinical practice. Indian J Plast Surg 2011; 44(2): 178-85.
[http://dx.doi.org/10.4103/0970-0358.85338] [PMID: 22022027]
[8]
Fowler NK, Nicol AC. Functional and biomechanical assessment of the normal and rheumatoid hand. Clin Biomech (Bristol, Avon) 2001; 16(8): 660-6.
[http://dx.doi.org/10.1016/S0268-0033(01)00057-2] [PMID: 11535347]
[9]
Bajuri MN, Kadir MRA, Raman MM, Kamarul T. Mechanical and functional assessment of the wrist affected by rheumatoid arthritis: A finite element analysis. Med Eng Phys 2012; 34(9): 1294-302.
[http://dx.doi.org/10.1016/j.medengphy.2011.12.020] [PMID: 22277308]
[10]
Bielefeld T, Neumann DA. The unstable metacarpophalangeal joint in rheumatoid arthritis: Anatomy, pathomechanics, and physical reha-bilitation considerations. J Orthop Sports Phys Ther 2005; 35(8): 502-20.
[http://dx.doi.org/10.2519/jospt.2005.35.8.502] [PMID: 16187511]
[11]
Chinchalkar SJ, Lanting BA, Ross D. Swan neck deformity after distal interphalangeal joint flexion contractures: A biomechanical analysis. J Hand Ther 2010; 23(4): 420-5.
[http://dx.doi.org/10.1016/j.jht.2009.11.005] [PMID: 20189756]
[12]
van der Giesen FJ, Nelissen RG, van Lankveld WJ, et al. Swan neck deformities in rheumatoid arthritis: A qualitative study on the patients’ perspectives on hand function problems and finger splints. Musculoskelet Care 2010; 8(4): 179-88.
[http://dx.doi.org/10.1002/msc.180] [PMID: 21108491]
[13]
Smith GC, Amirfeyz R. The flexible swan neck deformity in rheumatoid arthritis. J Hand Surg Am 2013; 38(7): 1405-7.
[http://dx.doi.org/10.1016/j.jhsa.2013.01.002] [PMID: 23455410]
[14]
McKeon KE, Lee DH. Posttraumatic boutonnière and swan neck deformities. J Am Acad Orthop Surg 2015; 23(10): 623-32.
[http://dx.doi.org/10.5435/JAAOS-D-14-00272] [PMID: 26320165]
[15]
Rehart B, Braun C, Hilker A, Effenberger H. Swan neck and boutonniere deformities on rheumatoid long finger. Orthopade 2005; 34(10): 34-5.
[16]
Terrono AL. The rheumatoid thumb. J Hand Surg Am 2001; 1(2): 81-92.
[http://dx.doi.org/10.1053/jssh.2001.23906] [PMID: 2269799]
[17]
Ladd AL, Weiss AP, Crisco JJ, et al. The thumb carpometacarpal joint: Anatomy, hormones, and biomechanics. Instr Course Lect 2013; 62: 165-79.
[PMID: 23395023]
[18]
Bodur H, Yilmaz O, Keskin D. Hand disability and related variables in patients with rheumatoid arthritis. Rheumatol Int 2006; 26(6): 541-4.
[http://dx.doi.org/10.1007/s00296-005-0023-1] [PMID: 16079993]
[19]
Morel J, Combe B. How to predict prognosis in early rheumatoid arthritis. Best Pract Res Clin Rheumatol 2005; 19(1): 137-46.
[http://dx.doi.org/10.1016/j.berh.2004.08.008] [PMID: 15588975]
[20]
Wisłowska M, Chruściak T. A comparison between methotrexate and methotrexate with biological agents treatment in hand deformities in patients with rheumatoid arthritis. EC Orthopedics 2016; 4(2): 454-66.
[21]
Porter BJ, Brittain A. Rheumatoid arthritis - splinting and hand exercise for free common hand deformities in rheumatoid arthritis: A clinical perspective. Curr Opin Rheumatol 2012; 24: 215-21.
[http://dx.doi.org/10.1097/BOR.0b013e3283503361] [PMID: 22269659]
[22]
Remicade™ rapidly reduces signs and symptoms of rheumatoid arthritis. ATTRACT Study Results Positive on All Endpoints. In: New York: PR Newswire Association LLC 1998; pp. 1-3.
[23]
Klarenbeek NB, Güler-Yüksel M, van der Kooij SM, et al. The impact of four dynamic, goal-steered treatment strategies on the 5-year outcomes of rheumatoid arthritis patients in the BeSt study. Ann Rheum Dis 2011; 70(6): 1039-46.
[http://dx.doi.org/10.1136/ard.2010.141234] [PMID: 21415052]
[24]
Emery P, Breedveld FC, Hall S, et al. Comparison of methotrexate monotherapy with a combination of methotrexate and etanercept in active, early, moderate to severe rheumatoid arthritis (COMET): A randomised, double-blind, parallel treatment trial. Lancet 2008; 372(9636): 375-82.
[http://dx.doi.org/10.1016/S0140-6736(08)61000-4] [PMID: 18635256]
[25]
van der Heijde D, Klareskog L, Singh A, et al. Patient reported outcomes in a trial of combination therapy with etanercept and methotrexate for rheumatoid arthritis: The TEMPO trial. Ann Rheum Dis 2006; 65(3): 328-34.
[http://dx.doi.org/10.1136/ard.2005.035709] [PMID: 16079172]
[26]
Weinblatt ME, Keystone EC, Furst DE, Kavanaugh AF, Chartash EK, Segurado OG. Long term efficacy and safety of adalimumab plus methotrexate in patients with rheumatoid arthritis: ARMADA 4 year extended study. Ann Rheum Dis 2006; 65(6): 753-9.
[http://dx.doi.org/10.1136/ard.2005.044404] [PMID: 16308341]
[27]
Hoff M, Kvien TK, Kälvesten J, Elden A, Haugeberg G. Adalimumab therapy reduces hand bone loss in early rheumatoid arthritis: Explorative analyses from the PREMIER study. Ann Rheum Dis 2009; 68(7): 1171-6.
[http://dx.doi.org/10.1136/ard.2008.091264] [PMID: 18801760]
[28]
Smolen J, Landewé RB, Mease P, et al. Efficacy and safety of certolizumab pegol plus methotrexate in active rheumatoid arthritis: The RAPID 2 study. A randomised controlled trial. Ann Rheum Dis 2009; 68(6): 797-804.
[http://dx.doi.org/10.1136/ard.2008.101659] [PMID: 19015207]
[29]
Emery P, Fleischmann RM, Strusberg I, et al. Efficacy and safety of subcutaneous golimumab in methotrexate -naïve patients with rheumatoid arthritis: Five-year results of a randomized clinical GO-BEFORE trial. Arthritis Care Res (Hoboken) 2016; 68(6): 744-52.
[http://dx.doi.org/10.1002/acr.22759] [PMID: 26474452]
[30]
Keystone E, Genovese MC, Klareskog L, et al. Golimumab in patients with active rheumatoid arthritis despite methotrexate therapy: 52-Week results of the GO-FORWARD study. Ann Rheum Dis 2010; 69(6): 1129-35.
[http://dx.doi.org/10.1136/ard.2009.116319] [PMID: 20444749]
[31]
Smolen JS, Kay J, Doyle MK, et al. Golimumab in patients with active rheumatoid arthritis after treatment with tumour necrosis factor alpha inhibitors (GO-AFTER study): A multicentre, randomised, double-blind, placebo-controlled, phase III trial. Lancet 2009; 374(9685): 210-21.
[http://dx.doi.org/10.1016/S0140-6736(09)60506-7] [PMID: 19560810]
[32]
Jones G, Sebba A, Gu J, et al. Comparison of tocilizumab monotherapy versus methotrexate monotherapy in patients with moderate to severe rheumatoid arthritis: The AMBITION study. Ann Rheum Dis 2010; 69(1): 88-96.
[http://dx.doi.org/10.1136/ard.2008.105197] [PMID: 19297346]
[33]
Emery P, Fleischmann R, Filipowicz-Sosnowska A, et al. The efficacy and safety of rituximab in patients with active rheumatoid arthritis despite methotrexate treatment: Results of a phase IIB randomized, double-blind, placebo-controlled, dose-ranging trial. Arthritis Rheum 2006; 54(5): 1390-400.
[http://dx.doi.org/10.1002/art.21778] [PMID: 16649186]
[34]
Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid arthritis classification criteria: An American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum 2010; 62(9): 2569-81.
[http://dx.doi.org/10.1002/art.27584] [PMID: 20872595]
[35]
Beeamy N, Buchanan WW. Clinical evaluation in the rheumatic disease. 14th ed. In: Koopman WJ, Ed. Arthritis and Allied Conditions. Philadelphia: Lipincott Wiliams and Wilkins 2001; pp. 1153-86.
[36]
van der Heijde DMFM, van ’t Hof M, van Riel PLCM, van de Putte LBA. Development of a disease activity score based on judgment in clinical practice by rheumatologists. J Rheumatol 1993; 20(3): 579-81.
[PMID: 8478878]
[37]
Prevoo ML, van ’t Hof MA, Kuper HH, van Leeuwen MA, van de Putte LB, van Riel PL. Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum 1995; 38(1): 44-8.
[http://dx.doi.org/10.1002/art.1780380107] [PMID: 7818570]
[38]
Smolen JS, Breedveld FC, Schiff MH, et al. A simplified disease activity index for rheumatoid arthritis for use in clinical practice. Rheumatology (Oxford) 2003; 42(2): 244-57.
[http://dx.doi.org/10.1093/rheumatology/keg072] [PMID: 12595618]
[39]
Larsen A, Dale K, Eek M. Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol Diagn (Stockh) 1977; 18(4): 481-91.
[http://dx.doi.org/10.1177/028418517701800415] [PMID: 920239]
[40]
Catherine A, Keeling C. Range of motion measurement of the hand. 5th ed. In: Mackin EJ, Callahan AD, Skieven TM, Schneider LH, Os-terrman AL, Eds. Rehabilitation of the Hand and Upper Extremity. St Louis, MO: Mosby Inc. 2002; pp. 169-82.
[41]
Fries JF, Spitz PW, Young DY, Spitz PW, Young DY. The dimensions of health outcomes: The health assessment questionnaire, disability and pain scales. J Rheumatol 1982; 9(5): 789-93.
[PMID: 7175852]
[42]
Küçükdeveci AA, Sahin H, Ataman S, Griffiths B, Tennant A. Issues in cross-cultural validity: Example from the adaptation, reliability, and validity testing of a Turkish version of the Stanford Health Assessment Questionnaire. Arthritis Rheum 2004; 51(1): 14-9.
[http://dx.doi.org/10.1002/art.20091] [PMID: 14872450]
[43]
Richards LG, Olson B, Palmiter-Thomas P. How forearm position affects grip strength. Am J Occup Ther 1996; 50(2): 133-8.
[http://dx.doi.org/10.5014/ajot.50.2.133] [PMID: 8808417]
[44]
Fess E. Grip strength. 2nd Ed. In: Casanova SJ, Ed. Clinical assessment recommendations. Chicago: American Society of Hand Therapists 1992; pp. 41-5.
[45]
Aoliciano PL. Clinical examination of the hand. In: Mackin EJ, Callahan AD, Skirven TM, Schneider LH, Osterrman AL, Eds. Rehabilitation of the hand and upper extremity. 5th ed. St Louis, MO: Mosby Inc 2002; pp. 120-43.
[46]
Hill T, Lewicki P. Statistics: Methods and applications: a comprehensive reference for science, industry, and data mining. Tulusa, OK, USA: StatSoft, Inc. 2006.
[47]
Sokal RR, Rohlf FJ. Biometry. In: The principles and practice of statistics in biological research. New York, USA: W.H. Freeman and Company 2012.
[48]
Horsten NC, Ursum J, Roorda LD, van Schaardenburg D, Dekker J, Hoeksma AF. Prevalence of hand symptoms, impairments and activity limitations in rheumatoid arthritis in relation to disease duration. J Rehabil Med 2010; 42(10): 916-21.
[http://dx.doi.org/10.2340/16501977-0619] [PMID: 21031287]
[49]
Dogu B, Sirzai H, Yilmaz F, Polat B, Kuran B. Effects of isotonic and isometric hand exercises on pain, hand functions, dexterity and quality of life in women with rheumatoid arthritis. Rheumatol Int 2013; 33(10): 2625-30.
[http://dx.doi.org/10.1007/s00296-013-2787-z] [PMID: 23739921]
[50]
Higgins SC, Adams J, Hughes R. Measuring hand grip strength in rheumatoid arthritis. Rheumatol Int 2018; 38(5): 707-14.
[http://dx.doi.org/10.1007/s00296-018-4024-2] [PMID: 29626222]
[51]
Bergstra SA, Murgia A, Te Velde AF, Caljouw SR. A systematic review into the effectiveness of hand exercise therapy in the treatment of rheumatoid arthritis. Clin Rheumatol 2014; 33(11): 1539-48.
[http://dx.doi.org/10.1007/s10067-014-2691-2] [PMID: 24952308]
[52]
Palamar D, Er G, Terlemez R, Ustun I, Can G, Saridogan M. Disease activity, handgrip strengths, and hand dexterity in patients with rheumatoid arthritis. Clin Rheumatol 2017; 36(10): 2201-8.
[http://dx.doi.org/10.1007/s10067-017-3756-9] [PMID: 28721628]
[53]
Dellhag B, Hosseini N, Bremell T, Ingvarsson PE. Disturbed grip function in women with rheumatoid arthritis. J Rheumatol 2001; 28(12): 2624-33.
[PMID: 11764207]
[54]
Sheehy C, Gaffney K, Mukhtyar C. Standardized grip strength as an outcome measure in early rheumatoid arthritis. Scand J Rheumatol 2013; 42(4): 289-93.
[http://dx.doi.org/10.3109/03009742.2012.747624] [PMID: 23311733]
[55]
Günther CM, Bürger A, Rickert M, Crispin A, Schulz CU. Grip strength in healthy caucasian adults: Reference values. J Hand Surg Am 2008; 33(4): 558-65.
[http://dx.doi.org/10.1016/j.jhsa.2008.01.008] [PMID: 18406961]
[56]
Dedeoğlu M, Gafuroğlu U, Yilmaz Ö, Bodur H. The relationship between hand grip and pinch strengths and disease activity damage, pain, and disability in patients with rheumatoid arthritis. Turk J Rheumatol 2013; 28(2): 69-77.
[http://dx.doi.org/10.5606/tjr.2013.2742]
[57]
Sarzi-Puttini P, Fiorini T, Panni B, Turiel M, Cazzola M, Atzeni F. Correlation of the score for subjective pain with physical disability, clinical and radiographic scores in recent onset rheumatoid arthritis. BMC Musculoskelet Disord 2002; 3(1): 18-26.
[http://dx.doi.org/10.1186/1471-2474-3-18] [PMID: 12133169]
[58]
Köybaşi M, Ayhau F, Borman P, Yorgaucioğlu R. Problems of self-care activities encountered in rheumatoid arthritis and their relationship with disease activity and hand deformity. Turk J Rheumatol 2011; 26(2): 89-93.
[http://dx.doi.org/10.5606/tjr.2011.014]
[59]
Eberhardt K, Sandqvist G, Geborek P. Hand function tests are important and sensitive tools for assessment of treatment response in patients with rheumatoid arthritis. Scand J Rheumatol 2008; 37(2): 109-12.
[http://dx.doi.org/10.1080/03009740701747129] [PMID: 18415767]
[60]
Adams J, Burridge J, Mullee M, Hammond A, Cooper C. Correlation between upper limb functional ability and structural hand impairment in an early rheumatoid population. Clin Rehabil 2004; 18(4): 405-13.
[http://dx.doi.org/10.1191/0269215504cr732oa] [PMID: 15180124]
[61]
Erol K, Gok K, Cengiz G, Ozgocmen S. Hand functions in systemic sclerosis and rheumatoid arthritis and influence on clinical variables. Int J Rheum Dis 2018; 21(1): 249-52.
[http://dx.doi.org/10.1111/1756-185X.13044] [PMID: 28322506]
[62]
Björk M, Thyberg I, Haglund L, Skogh T. Hand function in women and men with early rheumatoid arthritis. A prospective study over three years (the Swedish TIRA project). Scand J Rheumatol 2006; 35(1): 15-9.
[http://dx.doi.org/10.1080/03009740510026562] [PMID: 16467035]
[63]
Björk M, Gerdle B, Thyberg I, Peolsson M. Multivariate relationships between pain intensity and other aspects of health in rheumatoid arthritis-cross sectional and five year longitudinal analyses (the Swedish TIRA project). Disabil Rehabil 2008; 30(19): 1429-38.
[http://dx.doi.org/10.1080/09638280701623356] [PMID: 18923976]
[64]
Kuriya B, Arkema EV, Bykerk VP, Keystone EC. Efficacy of initial methotrexate monotherapy versus combination therapy with a biological agent in early rheumatoid arthritis: A meta-analysis of clinical and radiographic remission. Ann Rheum Dis 2010; 69(7): 1298-304.
[http://dx.doi.org/10.1136/ard.2009.118307] [PMID: 20421343]
[65]
Masiero S, Boniolo A, Wassermann L, Machiedo H, Volante D, Punzi L. Effects of an educational-behavioral joint protection program on people with moderate to severe rheumatoid arthritis: A randomized controlled trial. Clin Rheumatol 2007; 26(12): 2043-50.
[http://dx.doi.org/10.1007/s10067-007-0615-0] [PMID: 17404783]
[66]
Cima SR, Barone A, Porto JM, de Abreu DC. Strengthening exercises to improve hand strength and functionality in rheumatoid arthritis with hand deformities: A randomized, controlled trial. Rheumatol Int 2013; 33(3): 725-32.
[http://dx.doi.org/10.1007/s00296-012-2447-8] [PMID: 22565655]
[67]
Brorsson S, Hilliges M, Sollerman C, Nilsdotter A. A six-week hand exercise programme improves strength and hand function in patients with rheumatoid arthritis. J Rehabil Med 2009; 41(5): 338-42.
[http://dx.doi.org/10.2340/16501977-0334] [PMID: 19363566]
[68]
Buljina AI, Taljanovic MS, Avdic DM, Hunter TB. Physical and exercise therapy for treatment of the rheumatoid hand. Arthritis Rheum 2001; 45(4): 392-7.
[http://dx.doi.org/10.1002/1529-0131(200108)45:4<392::AID-ART353>3.0.CO;2-2] [PMID: 11501728]
[69]
Stenström CH, Minor MA. Evidence for the benefit of aerobic and strengthening exercise in rheumatoid arthritis. Arthritis Rheum 2003; 49(3): 428-34.
[http://dx.doi.org/10.1002/art.11051] [PMID: 12794800]
[70]
Flint-Wagner HG, Lisse J, Lohman TG, et al. Assessment of a sixteen-week training program on strength, pain, and function in rheumatoid arthritis patients. J Clin Rheumatol 2009; 15(4): 165-71.
[http://dx.doi.org/10.1097/RHU.0b013e318190f95f] [PMID: 19279507]
[71]
de Jong Z, Munneke M, Zwinderman AH, et al. Long term high intensity exercise and damage of small joints in rheumatoid arthritis. Ann Rheum Dis 2004; 63(11): 1399-405.
[http://dx.doi.org/10.1136/ard.2003.015826] [PMID: 15479889]
[72]
Rønningen A, Kjeken I. Effect of an intensive hand exercise programme in patients with rheumatoid arthritis. Scand J Occup Ther 2008; 15(3): 173-83.
[http://dx.doi.org/10.1080/11038120802031129] [PMID: 19180723]
[73]
Chim HW, Reese SK, Toomey SN, Moran SL. Update on the surgical treatment for rheumatoid arthritis of the wrist and hand. J Hand Ther 2014; 27(2): 134-41.
[http://dx.doi.org/10.1016/j.jht.2013.12.002] [PMID: 24530143]
[74]
Sebastin SJ, Chung KC. Reconstruction of digital deformities in rheumatoid arthritis. Hand Clin 2011; 27(1): 87-104.
[http://dx.doi.org/10.1016/j.hcl.2010.10.006] [PMID: 21176804]
[75]
Alderman AK, Arora AS, Kuhn L, Wei Y, Chung KC. An analysis of women’s and men’s surgical priorities and willingness to have rheumatoid hand surgery. J Hand Surg Am 2006; 31(9): 1447-53.
[http://dx.doi.org/10.1016/j.jhsa.2006.08.018] [PMID: 17095372]

Rights & Permissions Print Cite
Article Metrics
24
1
© 2024 Bentham Science Publishers | Privacy Policy