Dexterity, Visual Perception, and Activities of Daily

Living in Persons with Multiple Sclerosis

Janet L. Poole, PhD, OTR/L, FAOTA
Trisha Nakamoto, MOT, OTR/L
Tina McNulty, PhD, OTR/L
Janeen R. Montoya, OTR/L
Deedra Weill, OTR/L
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Kathy Dieruf, PhD, PT

Betty Skipper, PhD

ABSTRACT. The purposes of this study were to compare dexterity, visual perception,
and abilities to carry out activities of daily living (ADL) in persons with different multi-
ple sclerosis (MS) subtypes and to determine what relationships exist between the three
variables. Fifty-six persons with MS were administered tests of dexterity, visual per-
ception, and ADL ability. Demographic variables and scores on Kurtzke’s Expanded
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Disability Status Scale were also collected. Scores from the chronic-progressive group
were significantly higher than those of the benign and progressive-relapsing groups
for the Nine-Hole Peg Test–Left Hand, Grooved Peg Test, and Functional Status Index
(except Functional Status Index–Pain). There were no differences between the MS
groups for any demographic variables except on the Expanded Disability Status Scale.
Visual perception did not correlate with dexterity or ADL ability, and only dexterity
scores for the left hand correlated with ADL ability. Persons with the severer subtype
of MS were significantly impaired compared with the least severe group for dexterity
and ADL ability. Decreased dexterity was associated with needing more assistance
and having more perceived difficulty with ADL.

Janet L. Poole is a professor in the Occupational Therapy Graduate Program at the University of
New Mexico, Albuquerque, New Mexico.
Trisha Nakamoto is an occupational therapist at Providence Health Care, Olympia, Washington
Tina McNulty is an assistant professor in the Division of Occupational Therapy at the University
of Utah, Salt Lake City Utah.
Janeen R. Montoya is an occupational therapist at Rio Rancho Public School, Rio Rancho, New
Mexico.
Deedra Weill is an occupational therapist at Therapy Solutions for Kids in Portland, Oregon.
Kathy Dieruf is an associate professor in the Physical Therapy Program at the University of New
Mexico, Albuquerque, New Mexico.
Betty Skipper is a professor in the Department of Family and Community Medicine at the University
of New Mexico, Albuquerque, New Mexico.
Address correspondence to: Janet L. Poole, Occupational Therapy Graduate Program, University
of New Mexico, MSC 09 5240, Albuquerque, NM 87131-0001 (E-mail: jpoole@salud.unm.edu).
Occupational Therapy in Health Care, Vol. 24(2), 2010
Available online at http://informahealthcare.com/othc

C 2010 by Informa Healthcare USA, Inc. All rights reserved.
doi: 10.3109/07380571003681202 159
 160 OCCUPATIONAL THERAPY IN HEALTH CARE

KEYWORDS. Multiple sclerosis, visual perception, activities of daily living

INTRODUCTION

Multiple sclerosis (MS) is an inflammatory disease of the central nervous system

that involves demyelination and axonal damage (Burks & Johnson, 2000). Symptoms
include muscle weakness, spasticity, incoordination, loss of balance, sensory impair-
ment, and visual loss and visual-spatial deficits (Burks & Johnson, 2000). As shown in
Table 1, there are different subtypes used to describe the clinical course of MS. These
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include benign, relapsing-remitting, progressive-relapsing, and chronic-progressive, the

last of which consists of primary progressive and secondary progressive (Britell, Burks,
& Schapiro, 2001; Deshpande, Kremenchutzky, & Rice, 2006). With disease progres-
sion, the ability to perform activities of daily living (ADL) decreases. Several studies
have shown that persons with MS report difficulty with personal self-care, particu-
larly dressing, grooming, and bathing (Lexell, Iwarsson, & Lexell, 2006; Mosley, Lee,
Hughes, & Chatto, 2003), while other studies have reported difficulty with instrumen-
tal ADL such as mobility, work, home management activities, and leisure activities
(Doble, Fisk, Fisher, Ritvo, & Murray, 1994; Einarsson, Gottberg, Fredrikson, von
Koch, & Holmqvist, 2006; Finlayson, Impry, Nicolle, & Edwards, 1998; Mansson &
Lexell, 2004). While the progressive subtypes are recognized as the severer forms of
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MS, and the relapsing-remitting subtype is the most common, no studies have compared
ADL ability or the ability to perform daily tasks across subtypes.
Regardless, independence in both personal and instrumental ADL is reliant on hand
dexterity, and persons with MS have impaired dexterity compared with matched healthy
controls (Feys, Helsen, Lavrysen, Nuttin, & Ketelaer, 2003; Fraser & Stark, 2003;
Goodkin, Hertsgaard, & Seminary, 1988; Krishnan, de Freitas, & Slobodan, 2008;
van der Kamp et al., 1991). For example, Feys et al. (2003) showed that persons with
MS are almost four times slower compared with healthy controls on the Nine-Hole Peg
Test (NHPT), while Goodkin and colleagues (1988) reported that dexterity as measured
by the NHPT and Box and Blocks Test is markedly decreased in persons with MS. Hand

TABLE 1. Subtypes of MS and General Characteristics

Subtype Characteristics

Benign Very few attacks that are far apart with complete or
near-complete recovery
Relapsing-remitting Typically seen in younger patients; occurs in white and
gray matter and often involves both; relapses are clearly
defined—acute attack followed by recovery
Progressive-relapsing Overall progressive worsening from onset; defined, acute
relapses may or may not resolve
Chronic-progressive Steady and progressive worsening; no distinct relapses or
recovery
Primary-progressive Relapsing-remitting disease followed by progression of
Secondary-progressive the disease; occasional relapse, minor remission, or
plateau may or may not be present
 Poole et al. 161

dexterity has also been shown to deteriorate with MS progression (Feys, Duportail, Kos,
Van Asch, & Ketelaer, 2002; Goodkin et al., 1988).
This deterioration in dexterity has been reported to be associated with slowness
in visual-spatial processing (Halper et al., 2003; Jennekens-Schinkel, Lanser, van der
Velde, & Sanders, 1990; Lau, Chan, & Keung, 1998; van Donkelaar & Lee, 1994).
Using the Jebsen Test of Hand Function and the Rivermead Perception Assessment
Battery, Lau et al. (1998) found a correlation between the card-turning subtest (Jebsen
Test of Hand Function) and the shape-copying, word-copying, and cancellation subtests
(Rivermead Perception Assessment Battery), demonstrating that participants with poor
hand dexterity also performed poorly on visual-spatial tasks. While Lau et al. (1998),
showed a relationship between motor and visual perceptual function, they did not
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examine the impact these impairments had on subjects’ performance in ADL. Yet,
many tasks of daily living require both dexterity and visual-spatial processing (Doble
et al., 1994; Mansson & Lexell, 2004). Therefore, the purposes of the current study were
to determine and compare the relationship between hand dexterity, visual perception,
and perceived ADL ability. The research questions were as follows: (1) Does hand
dexterity, visual perception, and perceived ADL ability differ with disease subtype of
MS? (2) Are dexterity and visual perception related to perceived ADL ability?

METHODS

Participants
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A convenience sample of 56 persons diagnosed with definite or probable MS was

recruited on a volunteer basis from the MS clinic at a university hospital, as well as
through support groups throughout the metropolitan area of a southwestern city in the
United States. Participants included 45 women and 11 men, who ranged in age from
23 to 66 years (mean = 46.8 years). The majority of the participants were right-hand
dominant and had some type of visual correction. Participant characteristics can be found
in Table 2. Exclusion criteria included the following: (1) inadequate upper extremity
function to complete dexterity testing, (2) inadequate visual acuity to complete visual
perception testing, (3) the inability to comprehend written or verbal instructions, and
(4) other chronic diseases not due to MS. This study was approved by our institutional
human research review committee.

Instruments

To measure fine motor skills as well as eye–hand coordination, each participant

completed the NHPT (Mathiowetz, Weber, Kashman, & Volland, 1985; Oxford Grice
et al., 2003) and the Grooved Pegboard Test (GPT; Ruff & Parker, 1993). The score
for the NHPT is the time (in seconds) it takes to place and remove the nine pegs
from the pegboard. Adult norms are available for the commercially available NHPT,
and inter-rater reliability has been reported to be high (right: r = 0.98, r = 0.97;
left: r = 0.99, r = 0.99) (Oxford Grice et al., 2003). While the GPT also tests finger
dexterity, more complex visual-motor coordination is required. Pegs with a key along
one side must be rotated to coordinate with the hole before being inserted. The score
is the time (in seconds) it takes to place all 25 pegs into the holes. Original normative
values were included in the instruction manual provided by the Lafayette Instrument
 162 OCCUPATIONAL THERAPY IN HEALTH CARE

TABLE 2. Demographics of Study Population

Relapsing- Progressive- Chronic-

Total Benign remitting relapsing progressivea p
(n = 56) (n = 7) (n = 26) (n = 12) (n = 11) Value

Sex
Female 45 (80.4%) 1 (14.3%) 6 (23.1%) 1 (8.3%) 3 (27.3%)
Male 11 (19.6%) 6 (85.7%) 20 (76.9%) 11 (91.7%) 8 (72.7%) .69
Number with 27 (61.4%) 3 (50.0%) 15 (68.2%) 3 (42.9%) 7 (70.0%) .36
visual
correctionb
Hand dominance
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Right 51 (91.1%) 6 (85.7%) 24 (92.3%) 11 (91.7%) 10 (91.0%)

Left 5 (8.9%) 1 (14.3%) 2 (7.7%) 1 (8.3%) 1 (9.1%) .95
Mean age (SD); 46.8 (10.48); 42.25 (10.26); 44.88 (9.21); 49.77 (10.90); 51.56 (11.33); .15
range 23–66 23–57 26–60 29–66 30–64
Mean years with 11.38 (9.24); 9.88 (6.89); 9.13 (7.26); 12.81 (11.76); 18.33 (9.97); .13
MS (SD); range 0–37.5 0.5–23 0–24 0.5–37.5 4.0–37.0
Mean EDSS score 4.13 (2.08); 2.17 (0.58); 4.0 (2.09); 3.25 (1.21); 6.70 (0.76); .003
(SD); range 1.5–8.0 1.5–2.5 1.5–8.0 1.5–5.0 6.0–8.0

a
The chronic-progressive group includes subjects classified as having primary-progressive and secondary-progressive MS.
b
Data available for only 45 subjects.

Company (Trites, 1989) and were updated in 1993 by Ruff and Parker. The Motor-Free
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Visual Perception Test–Revised (MVPT-R) tests visual perception, with minimal use of
motor function (Colarusso & Hammill, 1996). Using a total of 40 items presented in a
multiple-choice format, five areas of visual perception are tested: spatial relationships,
visual discrimination, figure-ground, visual closure, and visual memory. In the current
study, participants had 15 s to respond to each item. Test–retest reliability were reported
to be 0.62 (Brown, Mullins, & Stagnitti, 2008), and correlations with other measures of
visual perception were reported to range from 0.72 to 0.79 (Su et al., 2000). Finally, the
Functional Status Index (FSI), an 18-item self-report questionnaire, was used to measure
daily living skills in five general categories: mobility, personal care, home chores, hand
activities, and social/role activities. In the FSI, each item is rated on a 4- to 5-point scale
for amount of assistance, amount of pain, and level of difficulty. Higher scores indicate
more assistance needed, higher levels of pain, or more difficulty performing an item.
Inter-observer intra-class correlation coefficients in the current study ranged from 0.64 to
0.89 (Jette, 1980, 1987). Criterion validity between the FSI and direct observation of nine
of the FSI activities ranged from 0.71 to 0.95 (Harris, Jette, Campion, & Cleary, 1986).
Demographic data (age, gender, hand dominance, length of time since disease onset,
MS form) were also collected. The Expanded Disability Status Scale (EDSS) score was
used to measure neurologic impairment (Kurtzke, 1983). Pyramidal, cerebellar, brain
stem, sensory, bowel and bladder, visual, cerebral, or mental functions were evaluated
by a neurologist, and a composite score was given on a numeric scale of 0 (normal) to
10 (death due to MS).

Procedures

After obtaining informed written consent, participants completed a demographics

questionnaire, and the NHPT and GPT were administered. Both were administered
 Poole et al. 163

according to standard procedures (Trites, 1989; Mathiowetz et al., 1985). Each test
was first administered to the participant’s dominant hand, followed by the nondominant
hand. One trial was conducted on each side; no practice was given. The MVPT-R was
administered next, followed by the FSI. Researchers were present to assist in completing
the FSI.

Data Analysis

Statistical analyses were done using SPSS statistical program for windows (SPSS
Inc., Chicago, IL, USA). A one-way analysis of variance (ANOVA) was used to compare
the differences between MS types in regard to the instruments used. Post hoc tests were
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used as needed. In order to assess relationships between dexterity, visual perception,

and functional status, Pearson product moment correlations were calculated. Significant
correlation levels were set at .05.

RESULTS

The MS type groups were similar with respect to all demographic variables except
for disease severity as measured by the EDSS (Table 2). The group with the chronic-
progressive subtype had a significantly higher EDSS score than the other three subtype
groups. Because of the large standard deviations for the times on the NHPT and GPT,
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a logarithmic transformation was performed on these times. The resulting geometric

means, 95% confidence intervals, and medians for the times are reported in Table 3, as
are the mean scores and standard deviations for visual perception and ADL ability by
MS subtype.
An ANOVA showed significant differences between MS types for dexterity and
functional ability. As seen in Table 3, scores from the chronic-progressive group were
significantly higher than the benign and progressive-relapsing groups for the NHPT–Left
Hand (NHPT-L), GPT, and FSI (except FSI–Pain or FSI-P). Their times were slower
on the dexterity tests, and they reported more disability and needing more assistance on
the FSI. For the NHPT–Right Hand (NHPT-R), the times for the chronic-progressive
group were significantly higher than the times for the progressive-relapsing group.
There were no significant correlations between the MVPT-R and any of the other
variables of demographics, dexterity, or ADL ability (Table 4). EDSS scores were
found to be significantly correlated with the NHPT, GPT, and FSI–Assistance (FSI-A)
and FSI–Difficulty (FSI-D). The dexterity measures correlated with each other, but
only the left-hand scores correlated significantly with the FSI-A and FSI-D, while the
GPT–Right Hand (GPT-R) approached significance with the FSI-A ( p = .61). Age and
disease duration were also significantly correlated to the GPT and FSI-D, suggesting
that dexterity and independence decrease with age and with disease duration.
There were no significant correlations between the MVPT-R and any of the other
variables of demographics, dexterity, or ADL ability (Table 4). EDSS scores were
found to be significantly correlated with the NHPT, GPT, and FSI-A and FSI-D. The
dexterity measures correlated with each other, but only the left-hand scores correlated
significantly with the FSI-A and FSI-D, while the GPT-R approached significance with
the FSI-A ( p = .61). Age and disease duration were also significantly correlated to the
GPT and FSI-D, suggesting that dexterity and independence decrease with age and with
disease duration.
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164
TABLE 3. Participant Scores for the NHPT, GPT, MVPT-R, and FSI

Mean (SD)

Benign Relapsing-remitting Progressive-relapsing Chronic-progressivea p Value

NHPT-Rb,c 21.39 (18.51, 24.73) 22.74 (19.11, 27.05) 22.09 (20.30, 24.05) 32.77 (20.80, 51.64) .029
NHPT-Lb,d 20.25 (17.99, 22.81) 29.85 (22.07, 40.36) 22.19 (20.45, 24.07) 31.55 (23.31, 42.71) .004
GPT-Rb,d 80.34 (52.48, 123.01) 99.73 (77.17, 128.88) 87.93 (76.64, 100.87) 145.33 (92.75, 227.70) .014
GPT-Lb,d 79.78 (56.77, 112.13) 129.03 (96.31, 172.85) 94.25 (78.14, 113.69) 154.29 (106.37, 223.81) .010
MVPT-R 37.5 (3.16) 36.4 (4.52) 37.5 (1.66) 36.3 (3.16) .73
FSI-Ae 1.06 (0.08) 1.30 (0.40) 1.71 (0.62) 1.75 (0.50) .006
FSI-P 1.18 (0.21) 1.53 (0.69) 1.33 (0.36) 1.30 (0.39) .44
FSI-Df 1.30 (0.33) 1.69 (0.59) 1.80 (0.47) 2.11 (0.51) .039

Note: Nine-Hole Peg Test–Right Hand (NHPT-R); Nine-Hole Peg Test–Left Hand (NHPT-L); Grooved Peg Test–Right Hand (GPT-R); Grooved Peg Test–Left Hand (GPT-L);
Motor–Free Visual Perception Test–Revised (MVPT-R); Functional Status Index–Assistance (FSI-A); Functional Status Index–Pain (FSI-P); and Functional Status Index–
Difficulty (FSI-D).
a
The chronic-progressive group includes subjects classified as having primary-progressive or secondary-progressive MS.
b
Numbers represent geometric means and 95% confidence intervals.
c
The chronic-progressive group was significantly slower than the progressive-relapsing group.
d
The chronic-progressive group was significantly slower than the benign and progressive-relapsing groups.
e
The chronic-progressive and progressive-relapsing groups needed significantly more assistance than the benign group.
f
The chronic-progressive group report significantly more difficulty than the benign group.
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TABLE 4. Correlations Between Dexterity, Visual Perception, Daily Living Skills, and Selected Demographic Variables

Years with
Age MS NHPT-R NHPT-L GPT-R GPT-L MVPT-R EDSS FSI-A FSI-P FSI-D

Age 1.0
Years with MS 0.48b 1.0
NHPT-R −0.14 0.06 1.0
NHPT-L −0.00 0.31a 0.74b 1.0
GPT-R 0.36b 0.84b 0.83b 0.28a 1.0
GPT-L 0.30a 0.55b 0.71b 0.72b 0.56b 1.0
MVPT-R 0.05 0.00 −0.05 −0.00 0.10 0.04 1.0
EDSS 0.09 0.56b 0.42a 0.63b 0.51b 0.55b –0.12 1.0
FSI-A 0.12 0.29 0.22 0.48b 0.29 0.50b –0.15 0.67b 1.0
FSI-P 0.08 −0.15 –0.10 –0.09 –0.17 –0.15 –0.12 0.03 0.30a 1.0
FSI-D 0.35a 0.34a 0.22 0.33a 0.24 0.52b –0.14 0.60b 0.75b 0.48b 1.0

Note: Nine-Hole Peg Test–Right Hand (NHPT-R); Nine-Hole Peg Test–Left Hand (NHPT-L); Grooved Peg Test–Right Hand (GPT-R); Grooved Peg Test–Left Hand (GPT-L); Motor-Free Visual
Perception Test–Revised (MVPT-R); Expanded Disability Status Scale (EDSS); Functional Status Index–Assistance (FSI-A); Functional Status Index–Pain (FSI-P); and Functional Status
Index–Difficulty (FSI-D).
a
Correlation is significant at the .05 level (two-tailed).
b
Correlation is significant at the .01 level (two-tailed).

165
 166 OCCUPATIONAL THERAPY IN HEALTH CARE

DISCUSSION

The purposes of the current study were to compare dexterity, visual perception, and
perceived ADL abilities in MS subtypes and to examine the relationships between them.
Our sample had an average of three errors on the MVPT-R and an average EDSS score
of 4.0, suggesting mild visual perceptual deficits and low levels of disease activity.
In addition, participants either were independent or used assistive devices for daily
activities and/or experienced no to mild levels of pain and difficulty according to the
FSI. Dexterity scores on the NHPT and GPT, however, were up to three times lower
than the norms from healthy controls. These results are similar to those found by Feys
et al. (2003), whose study group took an average of 88.8 s to complete the NHPT,
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almost four times longer than the control group. The large standard deviations for some
scores indicate variations within each group. Our MS subtype groups were similar in
age and length of time with MS. Even though members of the group with chronic-
progressive MS had the highest difficulty and assistance scores on the FSI, their scores
were only significantly different from the scores for the benign group. Thus, in our
sample, the only significant ADL differences were between the group with the mild
and severe forms of MS. These findings could be due to the mild ADL limitations
and relatively mild neurological involvement of our sample or to the deterioration of
ADL abilities being progressive over time and associated with other factors besides
MS subtype. Another explanation could be the small sample sizes for most of the MS
levels.
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Our results indicate that visual perception was not significantly correlated with dex-
terity or perceived ADL in persons with mild visual perceptual impairments. These
results are similar to those found previously, where there were either weak or no cor-
relations between the MVPT-R and fine motor ability (Halper et al., 2003; Leonard,
Foxcroft, & Kroukamp, 1988; Rao et al., 1991), supporting the idea that the MVPT-R
does not require dexterity. Lau et al. (1998) were not able to find significant correlations
between visual perception and dexterity; however, this was because of the required mo-
tor component of their assessments. They suggested further studies correlating motor
and visual perceptual function using measurements requiring minimal motor demands
such as the NHPT. Results from Lau et al. (1998) appear to support the use of the MVPT
to measure visual perception. Both the NHPT and the GPT were found to be signifi-
cantly correlated with EDSS score, but only the left-hand scores correlated with level of
assistance and perceived difficulty on the FSI. Ozakbas, Cagiran, Ormeci, and Idiman
(2004) found similar results, where the NHPT was moderately correlated with EDSS
score (r = 0.51). This finding is somewhat surprising, given the EDSS is most sensi-
tive to motor impairments based on gait and lower-extremity dysfunction rather than
upper-extremity dysfunction (Doble et al., 1994). In our study, as NHPT and GPT times
increased (slower performance), so did assistance and difficulty levels. Because fine
motor control is such an integral part of our lives in general, this relationship would be
expected. Similarly, Provinciali, Ceravolo, Bartolini, Logullo, and Danni (1999) found
that as EDSS scores increased, motor abilities decreased. Although our sample had
slower dexterity times for both hands compared with a normative sample, our findings
that only the left-hand dexterity scores correlated with ability and assistive needed for
daily tasks is interesting. Perhaps when the dominant hand has decreased dexterity, the
role of the nondominant hand becomes more important to assist in the performance of
daily tasks.
 Poole et al. 167

Average pain levels were reported as absent or mild and were not significantly
correlated with dexterity or visual perception, which is surprising given that the National
Multiple Sclerosis Society (NMSS) suggests that 55% of people with MS will experience
some type of pain during the progression of their disease (NMSS, 2003). One possible
reason may be the time frame in which the FSI is based, as the participant is instructed
to think of events during the past 7 days versus a more extensive amount of time, such as
a year.

Significance
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The high degree of symptom variability in people with MS leads to a great amount
of difficulty in predicting disease course. Performance scores on the NHPT and GPT
support the conclusion that people with MS require more time when completing tasks
requiring dexterity. Understanding that dexterity corresponds to disease severity and
ADL ability provides a greater awareness of future changes in ADL performance and
potential adaptations. The correlations between the NHPT and the GPT show that these
tests are related but still evaluate separate skills and are justified in being used to assess
dexterity in persons with MS.
Those persons with MS who do not display a high degree of motor dysfunction
may still unknowingly suffer from visual perceptual symptoms. As the majority of
people with MS develop symptoms during working years, awareness of dysfunction is
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a necessity in order to provide the proper adaptations and expectations of a person’s

workload (Rao et al., 1991).

Limitations

This study has several limitations. The overall sample size is small, especially within
MS subgroups. The number of participants placed in the relapsing-remitting and chronic-
progressive groups is similar to that found in the general population; however, our
progressive-relapsing group is larger than the 5% reported by the NMSS (2003). Also,
the male-to-female ratio is not representative of the 1:2 or 1:3 ratios that have been
reported in the general population. More aggressive recruitment of men with MS could
be done in future studies. Regardless, the demographics of our four groups were very
similar. A larger study with participants with severer visual perceptual impairments
would provide more data regarding the relationships between visual perception and
dexterity. In addition, when we began the study, the third edition of the MVPT had
not been available, which has additional items that may provide more insight into the
visual perceptual deficits of persons with MS. We also only measured ADL ability. An
examination of work status, instrumental ADL, and quality of life may provide a more
concrete understanding of the impact MS has on lives, rather than generalizations and
inferences.
In addition, future studies may consider using the Multiple Sclerosis Functional Com-
posite as has been suggested by previous studies (Balcer, 2001; Miller, Rudick, Cutter,
Baier, & Fischer, 2000; Rudick, Cutter, & Reingold, 2002). The Multiple Sclerosis
Functional Composite has been found to be more sensitive than the EDSS and has also
shown strong correlations with quality of life measures.
 168 OCCUPATIONAL THERAPY IN HEALTH CARE

CONCLUSION

People with MS experiencing difficulty with dexterity appear to then have higher
assistance requirements and perceived difficulty when performing activities such as
dressing, home chores, and mobility. Those classified as chronic-progressive were found
to be different when compared with the benign group for dexterity and ADL ability.
The overall EDSS score was significantly correlated to the FSI’s assistance and diffi-
culty domains, suggesting that as disease level increases, assistance requirements and
perceived difficulty in completing daily tasks do so as well.
Declaration of interest: The authors report no conflict of interest. The authors alone
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are responsible for the content and writing of this paper.

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Received: 07/28/2009
Revised: 01/29/2010
Accepted: 02/05/2010
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