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The Influence of Emotional and Cognitive Factors on Limb Laterality Discrimination in Women with Fibromyalgia Syndrome: A Cross-Sectional Study Secondary Analysis

Víctor Riquelme-Aguado
Antonio Gil-Crujera
Josué Fernández-Carnero
Ferran Cuenca-Martínez
Guillermo Baviano Klett
1,3 and
Francisco Gómez Esquer
Department of Basic Health Sciences, Rey Juan Carlos University, 28933 Madrid, Spain
Escuela Internacional de Doctorado, Rey Juan Carlos University, 28933 Madrid, Spain
Grupo de Investigación Emergente de Bases Anatómicas, Moleculares y del Desarrollo Humano de la Universidad Rey Juan Carlos (GAMDES), 28922 Alcorcón, Spain
Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Rey Juan Carlos University, 28933 Madrid, Spain
Grupo Multidisciplinar de Investigación y Tratamiento del Dolor, Grupo de Excelencia Investigadora URJC-Banco de Santander, 28922 Madrid, Spain
La Paz Hospital Institute for Health Research, IdiPAZ, 28029 Madrid, Spain
Motion in Brains Research Group, Institute of Neuroscience and Movement Sciences (INCIMOV), Centro Su-Perior de Estudios Universitarios La Salle, Universidad Autonóma de Madrid, 28049 Madrid, Spain
Grupo de Investigación de Dolor Musculoesqueletico y Control Motor, Universidad Europea de Madrid, 28670 Madrid, Spain
Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, University of Valencia, 46010 Valencia, Spain
Author to whom correspondence should be addressed.
Appl. Sci. 2023, 13(3), 1894;
Submission received: 16 November 2022 / Revised: 27 January 2023 / Accepted: 29 January 2023 / Published: 1 February 2023
(This article belongs to the Section Applied Biosciences and Bioengineering)


Previous scientific evidence has shown that patients with fibromyalgia syndrome (FMS) have alterations in the body schema. There have also been findings regarding the influence of psychological factors on pain, as well as evidence that patients with FMS have difficulty performing laterality discrimination tasks. The main objective of this study was to evaluate whether emotional and cognitive factors influence the limb laterality discrimination task in women with FMS. Seventeen of the participants were healthy female controls, and the other seventeen were women diagnosed with FMS. The main outcome measures were laterality discrimination, anxiety symptoms, depression symptoms, pain catastrophizing, and fear-related movement. The main analysis showed that patients with FMS had longer reaction times for laterality discrimination in hands (hand 20 images, p < 0.031; hands 50 images p < 0.013). In the secondary analysis, FMS patients showed emotional (anxiety (p < 0.0001); depression (p < 0.0001)) and cognitive (pain catastrophizing (p < 0.0001); fear-related movement (p < 0.0001)) disorders compared with healthy subjects. There was no correlation between limb laterality discrimination and psychological variables. In conclusion, patients with FMS showed impaired laterality discrimination, but psychological variables were not influenced. This could be due to the implicit nature of the task.

1. Introduction

International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in such terms” [1]. Three dimensions are included in the current concept of pain in order to represent the different sources of modulation of the pain experience (sensory-discriminative, motivational-affective, and cognitive-evaluative) [2]. Chronic pain does not protect biological function, and it is a major part of the disease process. When symptoms last longer than 3 months, pain is considered chronic. This can occur along with other psychological symptoms, such as frequent anxiety, depression, pain catastrophizing, or fear-related movement [1,2]. In addition, the study of pain in the field of neuroscience has given us a better understanding of different clinical entities characterized by the presence of “nociplastic pain”, this being a recent term applied to describe the pain of patients with alterations in the nociceptive system, despite no clear evidence of actual or potential tissue damage that would lead to activation of peripheral nociceptors, nor evidence of disease or injury to the somatosensory system that would be causing the pain [3]. Emotional factors, such as anxiety and depression, and cognitive factors, such as pain catastrophizing and fear-related movement, can influence the experience of pain and are considered risk factors for pain chronification [4,5,6].
A complex chronic pain, in terms of the mechanisms responsible for the disease, is fibromyalgia syndrome (FMS). FMS is a highly prevalent chronic pain condition characterized by chronic widespread musculoskeletal pain as the main symptom, and is associated with the presence of tender points in multiple locations. FMS is a complex multidimensional disorder, given that patients can have other concomitant symptoms such as fatigue, unrefreshing sleep, stiffness, depression, anxiety, or cognitive dysfunction [7,8,9,10,11,12]. Several alterations have been identified in patients with FMS in the nociceptive system (transmission, processing, and modulation of pain) [13,14,15,16,17,18,19]. These changes can alter the body schema. Previous research has shown that these patients suffer from more frequent falls and a lack of balance [20]. They may also perceive increased body size and decreased surrounding space during pain exacerbations, as well as deficits in tactile acuity [21,22,23,24].
On the other hand, variables corresponding to the emotional-affective sphere (such as anxiety and depression) and cognitive factors (pain catastrophizing and fear-related movement) also play an important role in the pain experienced by patients with FMS. Pain catastrophizing has been associated with pain severity and disability. This construct of pain has been shown to decrease pain acceptance, which, in turn, may aggravate the symptoms of FMS [25]. Anxiety and depression have been proposed as precipitating and/or perpetuating factors of this condition and are inversely related to quality of life among FMS patients [26]. In this regard, it has been suggested that the higher the levels of pain catastrophizing, anxiety, and depression, the greater the patient’s sensitivity to non-painful stimuli and difficulty in coping with the painful process [27]. In addition, fear-related movement has been reported consistently in individuals with FMS, as they show higher pain intensity and reduced physical functioning [28,29]. These emotional and cognitive factors described above have been accentuated in recent years in patients with FMS since the health crisis of the COVID-19 disease began in 2020, as has been shown by important longitudinal epidemiological studies, translating into an exacerbation of the painful symptoms of these patients [30,31]. Finally, in FMS patients, negatively biased cognitions about their bodies and heightened awareness of internal body signals may be related to the inability of incoming sensory pathways to adequately update negatively biased somatic representations of body parts, which are stored as long-term memories [32].
Limb laterality discrimination is a cognitive task that allows evaluating interoception of body schema (sense of the physiological condition of the body) [33]. The task consists of discriminating whether a part of the body belongs to the right or left side. This process requires the participant to perform a mental rotation of the internal representation of the body part to be identified. During laterality discrimination, observers imagine their own hand moving toward the orientation of the stimulus they are to identify. This implies that the participants must carry out a process of implicit motor imagery [34]. The complex mechanisms of pain can influence the state of the body schema of populations suffering from chronic pain. The notion of the body schema is unconscious, and these alterations may be linked to a deterioration in the cortical representation of a painful part of the body (for example, in chronic pain, the cortical representation of the affected part suffers changes in position, size, or shape) or absence of this representation [35,36,37]. In addition, the nerve pathways that transmit information can also be altered in patients with chronic pain. Thus, the sensory pathway of the posterior cord of the medial lemniscus, related to movement planning, may be influenced by chronic pain, resulting in movement planning that is different from that of healthy people [38]. Furthermore, the pyramidal motor pathway is affected by incoming information, which can lead to alterations in pain processing [39].
In the area of pain study and treatment, limb laterality discrimination has been widely used in different populations suffering from some type of chronic pain condition [37,40,41,42,43,44,45,46,47,48,49]. Despite its broad use in the field of pain neuroscience, there are no standardized protocols for limb discrimination tasks, given that previous research has shown significant heterogeneity in the applied methodologies and in the characteristics of the study populations [50]. Moreover, very few investigations evaluating laterality discrimination studied the emotional and cognitive aspects presented by the patients [51,52,53].
Laterality discrimination in FMS patients has only been investigated in two previous studies, with FMS patients showing an impairment of this ability compared to healthy subjects [54,55]. However, in none of these investigations did the emotional and cognitive aspects presented by patients with FMS establish a correlation between these and the laterality discrimination task. To the best of our knowledge of the current scientific literature, to date, no publication has described how psychological variables can influence the limb laterality discrimination in FMS patients. The main objective of this study was to assess the status of body schema using limb laterality discrimination tasks in women with FMS compared to healthy subjects. The secondary aim was to evaluate how emotional and cognitive factors influence the limb laterality discrimination task in patients with FMS and healthy subjects.

2. Materials and Methods

This study was a cross-sectional study conducted according to the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement.

2.1. Participants

The study sample comprised seventeen women with a prior formal diagnosis of FMS who were recruited from the fibromyalgia association “AFINSYFACRO” in Móstoles, Spain and seventeen healthy women who served as controls recruited from a local support group through advertisements and informative presentations in the facilities of the Rey Juan Carlos University. This was intended to ensure that they had no relationship of any kind with the subjects who belonged to the fibromyalgia association. Data were collected from August 2022 to October 2022. The study protocol was approved by the Ethical Review Board of the Rey Juan Carlos University (2605202012920) in accordance with the Declaration of Helsinki, and all participants provided written informed consent before participating. The inclusion criteria for FMS patients in this study were: (1) medical diagnosis of fibromyalgia; (2) more than 12 weeks on pain; (3) speaking and understanding Spanish correctly. The study excluded FMS patients with: (1) cognitive inability to understand and correctly complete any of the measurement variables; (2) previous experience with treatments or other investigations in which the recognition of the laterality of different parts of the human body has been used. The inclusion criteria for the control participants were: (1) no pain (NPRS = 0); (2) speak and understand Spanish correctly. We excluded participants with: (1) previous episode of musculoskeletal pain in the last week; (2) presence of rheumatologic disease. A flowchart is shown in Figure 1.

2.2. Pain and Clinical Status

Pain and clinical status were assessed by using self-administered questionnaires. FMS patients provided an overall measure of pain severity on a numeric pain rating scale (NPRS), and the impact of ongoing pain and daily function was evaluated by the Spanish version of the Fibromyalgia Impact Questionnaire (FIQ). This questionnaire has been validated and adapted to the Spanish population with a sensitivity of 85.6% (95% CI: 83.1–88.1) and a specificity of 73.2% (95% CI: 68.4–78) [56,57].

2.3. Left/Right Judgment Test (LRJT)

A series of 20 and 50 images representing left hands or right hands and a series of 20 and 50 images representing left feet and right feet, with different rotations and seen from palmar or dorsal views, were shown on the screen of an electronic device using software with an installed application. The order of appearance and the sequential images displayed were random. The images were shown for a maximum duration of 10 s or until the answer was made. Patients were instructed to indicate hand or foot side as quickly and accurately as possible by pressing the appropriate key on the screen of the electronic device: “Left” for the left and “Right” for the right. Participants saw an example image to familiarize themselves with the test and were instructed not to move their limbs during the test. The reaction time (s) and the correct hits (%) were recorded as result measurements. Application software collected the reaction time and the hit percentage data. The reliability of the Recognise online application has previously been established in populations with and without pain [42]. The intraclass correlation coefficient (ICC) response time for “feet” was ICC = 0.63–0.75, and for “trunk” ICC = 0.51–0.91. The accuracy of the laterality recognition answers was ICC = 0.61–0.77 for “feet” and ICC = 0.69–0.71 for “trunk” [49]. The internal and external validity were established before the application was online. Trials were conducted using a cluster of images tested with the letters “L” for “left” and “R” for “right”. The application was tested three times, and the internal validity was 100% [45]. “Left” and “right” were included as factors in the analysis because the study conducted by Saimpont et al. [58] performed a similar separation in their research on hands.

2.4. Anxiety

Anxiety was measured with the validated Spanish version of the Hospital Anxiety and Depression Scale (HADS), especially with the anxiety subscale. This subscale consists of seven items, with a score ranging from 0 to 3 for each. A total score of more than 10 points indicates anxiety, whereas a score ranging from 8–10 represents a borderline case and a score of less than 8 points represents no significant anxiety [59]. This test has shown an excellent reliability (ICC = 0.85) [60].

2.5. Depression

Depression was evaluated by the validated Spanish version of the Beck Depression Inventory—Second Edition (BDI-II) [61], which is a widely used 21-item self-report inventory that has been proven to be highly accurate for measuring the severity of depression in patients with chronic pain [62,63] Each of the 21 items scores from 0 to 3, with a maximum score of 63 points. A score of 0 to 13 points indicates that there is minimal depression, 14 to 19 points indicates mild depression, 20 to 28 points indicate moderate depression, and 29 or more points indicate severe depression [61]. It has shown good reliability (ICC between 0.73 and 0.86) [64].

2.6. Pain Catastrophizing

  • Pain catastrophizing was measured with the validated Spanish version of the Pain Catastrophizing Scale (PCS). This is a self-administered scale consisting of 13 items with a score ranging from 0 “Not at all” to 4 “All the time.” It presents three dimensions: (1) helplessness corresponds to questions 1 to 5 and 12 and refers to the person’s belief about their capability to influence their pain; (2) magnification corresponds to questions 6, 7, and 13 and refers to exaggeration of the threatening properties of the painful stimulus; (3) rumination corresponds to questions 8 to 11 and refers to the patients’ inability to stop thinking of their pain and to avoid the idea.
A total score is yielded (ranging from 0–52), whereby higher scores are representative of greater pain catastrophizing. The reliability of the scale is excellent (ICC = 0.94) [65].

2.7. Fear-Related Movement (Kinesiophobia)

  • The Spanish version of Tampa Kinesiophobia scale (TSK-11) was used to measure the fear that a patient has of movement. It consists of 11 items, each with 1 of 4 response options, where “strongly disagree” scores 1 point and “strongly agree” scores 4 points. Therefore, the total score will vary between a minimum of 11 and a maximum of 44. A high score means a greater fear of movement/injury, that is, high levels of fear-related movement [66]. The TSK-11 has been shown to be consistent, reliable, and appropriate to assess fear of movement in patients with FMS within a clinical context (ICC = 0.85) [66,67].

2.8. Data Analysis

The data analysis was performed with the Statistics Package for Social Science (SPSS 25.00, IBM Chicago, IL, USA). A 95% confidence interval (95% CI) was employed, and all values with a p-value lower than 0.05 were considered to be statistically significant. The Chi-square test was used to compare the differences between nominal variables (such as profession or marital status). Each group comprised seventeen participants; normality tests were performed and no statistical differences were found that would determine an abnormal distribution (The Shapiro–Wilk and Kolmogorov–Smirnov tests were used). Student’s t-test for independent samples was used as a statistical test to compare continuous variables between groups. The effect size (Cohen’s d) was then calculated to compare the study variables. According to Cohen’s method, the effect was considered small (0.20–0.49), medium (0.50–0.79), or large (>0.8). The relationship between LRJT and psychological variables (depression, anxiety, catastrophizing, and fear-related movement), was analyzed using with the Spearman Rho correlation coefficient. For statistical analysis, the significance level for all tests was p < 0.05.

3. Results

3.1. Baseline Clinical Status of FMS Patients

Seventeen participants were healthy female controls (with a mean age of 49.71 ± 8.50 years), and seventeen patients were women diagnosed with FMS (with a mean age of 51.29 ± 7.22 years). According to the Fibromyalgia Impact Questionnaire (FIQ), patients had, on average, mild to moderate symptoms and moderate to severe function deficits, with 86.88 ± 3.28. The mean pain intensity was 6/10 (SD ± 2). In relation to the sociodemographic variables shown in Table 1, there were no statistically significant differences between healthy subjects and patients.

3.2. Impairment of Limb Laterality Discrimination

FM patients had longer reaction times (hands, 20 images: t = 2.251, p < 0.031, d = 0.69; hands, 50 images: t = 2.621, p < 0.013, d = 0.64). The Student’s t-test showed statistical significance for reaction time taken to judge the laterality of hands, with a moderate effect size. The recording of the right/left laterality judgment task measurements was used to count the right/left recognition hit scores (% successes) and the reaction time for the response. The reaction time for hand images when 20 and 50 were shown to the healthy volunteers was a mean of 2.11 s and 2.37 s, respectively (SD: 0.54 s and 0.45 s, respectively). In the group of FMS patients, reaction time was longer for 20 hand images, at 2.80 s (SD: 1.15 s), and for 50 hand images it was 3.01 s (SD: 0.90 s). There were statistically significant differences for both tasks (hands, 20: t = 2.251; p < 0.01; hands, 50: t = 2.621; p < 0.13). For the rest of the laterality discrimination measurement variables, no statistically significant differences were found. Data are shown in Table 2.

3.3. Emotional and Cognitive Factors

Patients with FMS had higher scores on the HADS anxiety subscale, indicative of the presence of moderate-to-severe anxiety symptoms compared to healthy controls. The independent sample Student’s t-test revealed significant inter-group differences (t = 3.405; p < 0.0001, d = 3.25), with a high effect size. Patients with FMS had higher scores on the BDI-II, at levels indicative of a depressive disorder with moderate or severe symptoms. There were statistically significant differences between patients and healthy subjects on the BDI-II (t = 14.184; p < 0.0001, d = 28.58), with a high effect size. Patients with FMS showed cognitive characteristics of pain catastrophism, obtaining higher scores on the PCS compared to the controls. The independent sample Student´s t-test revealed significant inter-group differences (t = 14.207; p < 0.0001, d = 19.05), with a high effect size. In the three dimensions of pain catastrophizing, statistically significant differences were also obtained between groups; these were helplessness (t = 11.361; p < 0.0001, d = 9.05); magnification (t = 5.712; p < 0.0001, d = 3.17); and rumination (t = 10.135; p < 0.0001, d = 6.82). FMS patients showed negative cognitive beliefs regarding fear of movement/reinjury, obtaining higher scores on the TSK-11 compared to the control group (t = 6.512; p < 0.0001, d = 17.23), with a high effect size. There were statistically significant differences between patients and healthy subjects on the TSK-11. Data are shown in Table 3.

3.4. Correlation Analysis

The bivariate relationships between the psychological variables (depression, anxiety, catastrophism, and fear-related movement) and the reaction time and laterality recognition ability of the patients were examined. No statistically significant correlations were found between psychological variables, reaction time, and the percentage of correct identifications of hand and foot images. The results can be seen in Table 4.

4. Discussion

The main objective of this study was to assess the status of body schema of women with FMS compared to healthy subjects using limb laterality discrimination tasks. The secondary aim was to evaluate the influence of emotional and cognitive factors on the limb laterality discrimination task in patients with FMS and healthy subjects. This study showed that the ability to discriminate limbs from hands was impaired in terms of reaction time in patients with FMS, and these patients had higher rates of psychological disorders than the healthy subjects. In addition, the psychological variables were correlated with the laterality discrimination task. The statistical analysis determined that these variables did not influence the performance of the task.

4.1. Limb Laterality Discrimination and Psychological Variables in Fibromyalgia Pain Syndrome

According to the current scientific literature, there are only two studies that have evaluated laterality discrimination in patients with FMS. In both studies, the results showed that patients with FMS had an impaired ability to discriminate laterality [54,55]. In one of the former investigations, they found an impaired ability to perform two-point discrimination, which is also indicative of alterations in the body schema [54]. In the other recent investigation carried out by our group, limb laterality discrimination was correlated with somatosensory variables related to pain (pressure pain threshold and conditioned pain modulation) [55].
Despite the remarkable relevance of emotional and cognitive factors to the experience of pain, the previous research did not use standardized measures to evaluate these variables, which may influence the clinical statuses of patients with FMS and its potential influence on laterality discrimination. In this investigation, the study of emotional and cognitive aspects and their influence on limb laterality discrimination in patients with FMS was conscientiously deepened. With regard to psychological variables, our results are consistent with the results of other investigations in which anxiety, depression [26], pain catastrophizing [25,68,69], and fear-related movement [28,29,67] were measured in patients with FMS. The results demonstrate the presence of emotional and cognitive disorders in this population.
Subsequently, regarding limb laterality discrimination, our results are in line with previous studies on patients with FMS [54,55]. In the present study, patients with FMS took more time to discriminate the side of each limb. According to the nature of the task, this extra time needed to discriminate laterality is required to correct an initial error in the judgment of this task [34]. Another hypothesis suggests that the increase in reaction time is related to a protective process due to the prediction and avoidance of pain during movement planning in people with these traits (given that the recognition of laterality and the movements executed activate related areas in the brain) [40]. Nevertheless, the statistical analysis of correlation conducted by the present study ruled out this hypothesis, since none of the cognitive (pain catastrophizing and fear-related movement) or emotional (anxiety and depression) factors were correlated with the ability to discriminate the laterality of limbs. On the other hand, the inability to discriminate the laterality of the hands, with no significant differences found for the feet, may be owing to the hand being one of the body regions with the largest area of representation in both the somatosensory and motor cortex, according to the somatotopic maps established by Penfield [70,71]
Some previous publications on other chronic pain conditions which studied the laterality discrimination task and psychological variables have found a relationship between them, whereas others have not [51,52,53]. Elsig et al. [51] carried out a study on patients with neck pain that correlated the laterality discrimination task with the Fear Avoidance Beliefs Questionnaire, without finding a statistically significant association. Lee et al. [52] conducted a study in patients with complex regional pain syndrome (CRPS), where subjects only showed longer RTs for the upper lip lift than other types of facial expressions. This reflects a deficit in mental rotation tasks, especially for lower-facial-region pain expressions in CRPS, which may be related to the psychosocial aspects of pain. However, they did not further study the comprehensive intra- and interpersonal influences of these aspects further (they used the BDI scale to assess depression). In the research by Pedler et al. [53] in populations with neck pain and whiplash-associated disorders (WAD), they found no correlation between laterality discrimination and the post-traumatic stress symptoms scale. In this study, the laterality discrimination ability of patients with WAD was not impaired. Our study is the first to delve into the study of the relationship between psychological variables (depression, anxiety, fear of movement, and catastrophizing) and the laterality discrimination task in patients with FMS by performing a statistical correlation analysis.

4.2. Why Do Psychological Variables Not Influence Limb Laterality Discrimination? A Neurophysiological Explanation

According to the current scientific literature, relationships have been found between psychological variables and functional alterations in brain activity. Studies had found elevated catastrophizing to be associated with reduced left amygdala connectivity with the supramarginal gyrus and increased left amygdala connectivity with the hippocampus, dorsal striatum, paracingulate, and motor regions. It was concluded that resting-state functional connectivity between the left amygdala (a core emotion hub) and the inferior parietal lobe (involved in appraisal and integration of bodily signals, as well as attentional reorienting) explains associations between daily-life relevant catastrophizing and threat/safety learning [72]. In addition, catastrophizing has been found to affect the relationship between clinical pain and resting-state functional connectivity among the anterior cingulate cortex (ACC), dorsolateral prefrontal cortex (dlPFC), insula, and S1 [73]. With regard to fear-related movement, studies using fMRI showed that greater fear-related movement was positively associated with greater activity in the cerebello-frontal network [74]. Increased functional connectivity between the right dlPFC and the right anterior insular cortex (aIC) is also significantly associated with increased TSK [75]. Negative emotional stimuli (anxiety or depression) activate a broad network of brain regions, including the medial prefrontal (mPFC) and ACC cortices [76]. During limb laterality discrimination, the participants must accomplish a process of implicit motor imagery (the patients are not asked to carry out imagined movements; therefore, the participants are not aware of carrying out this process of motor imagery). Neuroimaging studies using positron emission tomography have shown that this process involves the activation of different brain areas. Immediately after the presentation of the visual stimulus, the attentional process involves an activation of the ACC and the attentional parietal areas contralateral to the stimulated hemisphere. The visual process activates occipital areas contralateral to the stimulated hemisphere. During the process of implicit motor imagery, blood flow increases (without being activated) in primary motor and somatosensory areas similar to those that are activated when there is a real movement or an explicit motor imagery process. These areas were activated during the process of implicit motor imagery. In the left hemisphere, without differentiating one extremity form another, these were the supplementary motor area, the superior premotor cortex (Brodmann area 6), and the inferior parietal cortex (Brodmann area 40); in the right hemisphere, without differentiating one member from another, these were the superior premotor cortex, the insula, the superior parietal cortex (Brodmann area 7), and the inferior occipitotemporal cortex (Brodmann area 37) [34]. It is pertinent to emphasize that, even though brain areas with altered function are activated in patients with cognitive factors such as pain catastrophism or fear-related movement, this is not related to a better or worse performance of laterality discrimination. This likely happens owing to the implicit nature of the task, as the patient is not consciously carrying out this motor imagery process.

4.3. Limitations

The first limitation is that the evaluators who carried out the measurements were not blinded and knew the group to which the participants belonged. The second limitation is that the medications the patients were taking were not assessed, as this could have influenced the results when judging laterality. Finally, the sample size of this study was reduced.

4.4. Future Research Lines

We suggest that future research should focus on clinical trials that determine the efficacy of therapies based on motor imagery for the treatment of pain and the improvement of the body schema of patients with FMS.

5. Conclusions

This study showed that patients with FMS have selective impairment of left/right discrimination and greater psychological disorders compared to healthy subjects. No correlation was found between psychological variables and hand and foot laterality discrimination in FMS patients. The results are in line with previous reports which suggested the presence of altered body schema, central sensitization, and psychological disorders in patients with FMS.

Author Contributions

Conceptualization, V.R.-A., A.G.-C. and F.G.E.; methodology, V.R.-A., A.G.-C., F.G.E. and J.F.-C.; data curation, V.R.-A., A.G.-C., F.G.E. and J.F.-C.; writing—original draft preparation, V.R.-A., A.G.-C., F.G.E., F.C.-M., G.B.K. and J.F.-C.; writing—review and editing, V.R.-A., A.G.-C., F.G.E., F.C.-M., G.B.K. and J.F.-C.; supervision, A.G.-C. and F.G.E.; project administration, V.R.-A., A.G.-C. and F.G.E. All authors have read and agreed to the published version of the manuscript.


This research received no external funding.

Institutional Review Board Statement

The study was approved by the Ethical Review Board of the Rey Juan Carlos University (2605202012920) in accordance with the Declaration of Helsinki.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Not applicable.


We would like to acknowledge the fibromyalgia association for all their support: “AFINSYFACRO” in Móstoles, Spain.

Conflicts of Interest

The authors declare no conflict of interest.


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Figure 1. Study design. The following flowchart shows how the participants are distributed in the FMS study group and in the control group of healthy individuals. The discarded cases also shown, as they either did not meet the selection criteria or abandoned the investigation.
Figure 1. Study design. The following flowchart shows how the participants are distributed in the FMS study group and in the control group of healthy individuals. The discarded cases also shown, as they either did not meet the selection criteria or abandoned the investigation.
Applsci 13 01894 g001
Table 1. Descriptive statistics in demographic measures (n = 34).
Table 1. Descriptive statistics in demographic measures (n = 34).
(n = 30)
Pain-Free Controls
(n = 30)
p Value Independent
Samples Student’s t-Test
Age51.29 ± 7.2249.71 ± 8.500.56
Pain (NPRS)6.00 ± 2.00-
FIQ86.88 ± 3.28-
Data are presented as means (SD). Patients in the FMS sample presented high clinical pain intensity on the numeric pain rating scale (NPRS) and high levels of impact of the disease, measured with the Fibromyalgia Impact Questionnaire (FIQ). The FIQ and NPRS were administered only to FMS participants.
Table 2. Group comparison of right/left judgment performance between FM and pain-free controls.
Table 2. Group comparison of right/left judgment performance between FM and pain-free controls.
(n = 17)
Pain-Free Controls
(n = 17)
p Value
Student’s t-test
ACC hands
(20 images)
84.85 ± 9.5787.64 ± 6.920.377
ACC hands
(50 images)
84.41 ± 7.1188.82 ± 6.820.074
RT hands
(20 images)
2.80 ± 1.152.11 ± 0.540.031 *
RT hands
(50 images)
3.01 ± 0.902.37 ± 0.450.013 *
ACC feet
(20 images)
89.55 ± 7.7689.85 ± 4.870.896
ACC feet
(50 images)
87.11 ± 8.1289.29 ± 6.590.397
RT feet
(20 images)
2.58 ± 1.272.00 ± 0.410.087
RT feet
(50 images)
2.72 ± 1.142.25 ± 0.580.137
This table shown a group comparison of right/left judgment performance. ACC = accuracy in %, RT = reaction time in seconds, FM: fibromyalgia. Results are displayed as mean ± SD. * indicates values with a p-value lower than 0.05 (statistically significant).
Table 3. Between-group comparison of psychological variables.
Table 3. Between-group comparison of psychological variables.
(n = 17)
Pain-Free Controls
(n = 17)
p Value Independent
Samples Student’s t-Test
Anxiety11.12 ± 2.547.88 ± 2.970.002 *
Depression38.35 ± 8,019.76 ± 2.190.000 *
Pain catastrophizing33.82 ± 3.4314.76 ± 4.330.000 *
Helplessness16.06 ± 2.197.00 ± 2.440.000 *
Magnification6.65 ± 1.693.47 ± 1.540.000 *
Rumination11.12 ± 1.53 4.29 ± 2.310.000 *
Fear-related movement31.76 ± 3.7314.53 ± 10.250.000 *
This table shows differences between groups in psychological variables of anxiety, depression, and pain catastrophism (including the three dimensions: helplessness, magnification, and rumination). * indicates values with p-values inferior to 0.05 (statistically significant). FMS patients showed elevated levels of anxiety and depression symptoms and negative cognitive distortions regarding pain catastrophizing and fear-related movement compared to healthy subjects.
Table 4. Correlation coefficients between performance on the lateral limb discrimination and psychological variables.
Table 4. Correlation coefficients between performance on the lateral limb discrimination and psychological variables.
MeasuresAnxietyDepressionPain CatastrophizingFear-Related Movement
ACC hands
(20 images)
ACC hands
(50 images)
RT hands
(20 images)
RT hands
(50 images)
ACC feet
(20 images)
ACC feet
(50 images)
RT feet
(20 images)
RT feet
(50 images)
This table shows the correlation coefficients between performance on the lateral recognition test and psychological variables. ACC = accuracy, RT = reaction time. No correlation was found between limb laterality discrimination and psychological variables.
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Riquelme-Aguado, V.; Gil-Crujera, A.; Fernández-Carnero, J.; Cuenca-Martínez, F.; Klett, G.B.; Esquer, F.G. The Influence of Emotional and Cognitive Factors on Limb Laterality Discrimination in Women with Fibromyalgia Syndrome: A Cross-Sectional Study Secondary Analysis. Appl. Sci. 2023, 13, 1894.

AMA Style

Riquelme-Aguado V, Gil-Crujera A, Fernández-Carnero J, Cuenca-Martínez F, Klett GB, Esquer FG. The Influence of Emotional and Cognitive Factors on Limb Laterality Discrimination in Women with Fibromyalgia Syndrome: A Cross-Sectional Study Secondary Analysis. Applied Sciences. 2023; 13(3):1894.

Chicago/Turabian Style

Riquelme-Aguado, Víctor, Antonio Gil-Crujera, Josué Fernández-Carnero, Ferran Cuenca-Martínez, Guillermo Baviano Klett, and Francisco Gómez Esquer. 2023. "The Influence of Emotional and Cognitive Factors on Limb Laterality Discrimination in Women with Fibromyalgia Syndrome: A Cross-Sectional Study Secondary Analysis" Applied Sciences 13, no. 3: 1894.

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