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Cavaliere C, Loperfido A, Ciofalo A, Di Michele L, Begvarfaj E, Bellocchi G, Bugani M, de Vincentiis M, Greco A, Millarelli S, Plath M, Sculco E, Masieri S. Real-Life Evidence of Mepolizumab Treatment in Chronic Rhinosinusitis with Nasal Polyps: A Multicentric Study. J Clin Med 2024; 13:3575. [PMID: 38930104 PMCID: PMC11204559 DOI: 10.3390/jcm13123575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 06/14/2024] [Accepted: 06/16/2024] [Indexed: 06/28/2024] Open
Abstract
Background: The introduction of biological drugs in the management of chronic rhinosinusitis with nasal polyps (CRSwNP) is allowing new and increasingly promising therapeutic options. This manuscript aims to provide a multicenter trial in a real-life setting on Mepolizumab treatment for severe uncontrolled CRSwNP with or without comorbid asthma. Methods: A retrospective data analysis was jointly conducted at the Otolaryngology-Head and Neck Surgery departments of La Sapienza University and San Camillo Forlanini Hospital in Rome. Both institutions participated by sharing clinical information on patients with CRSwNP treated with Mepolizumab. Patients were evaluated before starting Mepolizumab, at six months and at twelve months from the first drug administration. During follow-up visits, patients underwent endoscopic evaluation, quality of life assessment, nasal symptoms assessment, and blood tests to monitor mainly neutrophils, basophils, eosinophils, and IgG, IgA, and IgE assay. Results: Twenty patients affected by CRSwNP and treated with Mepolizumab were enrolled (12 females and 8 males with a mean age of 63.7 years). Sixteen patients (80%) had concomitant asthma. During follow-up, a gradual improvement in nasal polyp score, quality of life and nasal symptoms, assessed by SNOT-22 and VAS and loss of smell measured by olfactory VAS, was found. Regarding blood tests, eosinophils decreased gradually, while other blood parameters showed no statistically significant changes. Conclusions: Mepolizumab has been shown to be effective in the therapeutic management of patients with CRSwNP. Further studies are needed to support our findings and better understand the underlying immune pathways to predict patients' response to biological treatment in CRSwNP.
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Affiliation(s)
- Carlo Cavaliere
- Department of Sense Organs, Sapienza University, 00185 Rome, Italy; (A.C.)
| | - Antonella Loperfido
- Otolaryngology Unit, San Camillo Forlanini Hospital, 00152 Rome, Italy; (A.L.)
| | - Andrea Ciofalo
- Department of Sense Organs, Sapienza University, 00185 Rome, Italy; (A.C.)
| | - Loreta Di Michele
- Department of Pulmonary Interstitial Diseases, San Camillo Forlanini Hospital, 00152 Rome, Italy;
| | - Elona Begvarfaj
- Department of Sense Organs, Sapienza University, 00185 Rome, Italy; (A.C.)
| | - Gianluca Bellocchi
- Otolaryngology Unit, San Camillo Forlanini Hospital, 00152 Rome, Italy; (A.L.)
| | - Marcella Bugani
- Department of Sense Organs, Sapienza University, 00185 Rome, Italy; (A.C.)
| | | | - Antonio Greco
- Department of Sense Organs, Sapienza University, 00185 Rome, Italy; (A.C.)
| | - Stefano Millarelli
- Otolaryngology Unit, San Camillo Forlanini Hospital, 00152 Rome, Italy; (A.L.)
| | - Michaela Plath
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Eleonora Sculco
- Department of Translational and Precision Medicine, Sapienza University, 00185 Rome, Italy;
| | - Simonetta Masieri
- Department of Oral and Maxillofacial Sciences, Sapienza University, 00185 Rome, Italy
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Ishikawa C, Takeno S, Okamoto Y, Kawasumi T, Kakimoto T, Takemoto K, Nishida M, Ishino T, Hamamoto T, Ueda T, Tanaka A. Oncostatin M's Involvement in the Pathogenesis of Chronic Rhinosinusitis: Focus on Type 1 and 2 Inflammation. Biomedicines 2023; 11:3224. [PMID: 38137445 PMCID: PMC10740885 DOI: 10.3390/biomedicines11123224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
OBJECTIVES The cytokine oncostatin M (OSM) elicits pathogenic effects involving disruption of the epithelial barrier function as a part of immunological response networks. It is unclear how these integrated cytokine signals influence inflammation and other physiological processes in the pathology of chronic rhinosinusitis (CRS). We investigated the expression and distribution of OSM and OSM receptor (OSMR) in CRS patients' sinonasal specimens, and we compared the results with a panel of inflammatory cytokine levels and clinical features. PATIENTS AND METHODS We classified CRS patients as eosinophilic (ECRS, n = 36) or non-eosinophilic (non-ECRS, n = 35) based on the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis phenotypic criteria and compared their cases with those of 20 control subjects. We also examined OSM's stimulatory effects on cytokine receptor expression levels using the human bronchial epithelium cell line BEAS-2B. RESULTS RT-PCR showed that the OSM mRNA levels were significantly increased in the CRS patients' ethmoid sinus mucosa. The OSM mRNA levels were positively correlated with those of TNF-α, IL-1β, IL-13, and OSMR-β. In BEAS-2B cells, OSM treatment induced significant increases in the OSMRβ, IL-1R1, and IL-13Ra mRNA levels. CONCLUSIONS OSM is involved in the pathogenesis of CRS in both type 1 and type 2 inflammation, suggesting the OSM signaling pathway as a potential therapeutic target for modulating epithelial stromal interactions.
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Affiliation(s)
- Chie Ishikawa
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (C.I.); (Y.O.); (T.K.); (T.K.); (K.T.); (M.N.); (T.I.); (T.H.); (T.U.)
| | - Sachio Takeno
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (C.I.); (Y.O.); (T.K.); (T.K.); (K.T.); (M.N.); (T.I.); (T.H.); (T.U.)
| | - Yukako Okamoto
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (C.I.); (Y.O.); (T.K.); (T.K.); (K.T.); (M.N.); (T.I.); (T.H.); (T.U.)
| | - Tomohiro Kawasumi
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (C.I.); (Y.O.); (T.K.); (T.K.); (K.T.); (M.N.); (T.I.); (T.H.); (T.U.)
| | - Takashi Kakimoto
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (C.I.); (Y.O.); (T.K.); (T.K.); (K.T.); (M.N.); (T.I.); (T.H.); (T.U.)
| | - Kota Takemoto
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (C.I.); (Y.O.); (T.K.); (T.K.); (K.T.); (M.N.); (T.I.); (T.H.); (T.U.)
| | - Manabu Nishida
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (C.I.); (Y.O.); (T.K.); (T.K.); (K.T.); (M.N.); (T.I.); (T.H.); (T.U.)
| | - Takashi Ishino
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (C.I.); (Y.O.); (T.K.); (T.K.); (K.T.); (M.N.); (T.I.); (T.H.); (T.U.)
| | - Takao Hamamoto
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (C.I.); (Y.O.); (T.K.); (T.K.); (K.T.); (M.N.); (T.I.); (T.H.); (T.U.)
| | - Tsutomu Ueda
- Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (C.I.); (Y.O.); (T.K.); (T.K.); (K.T.); (M.N.); (T.I.); (T.H.); (T.U.)
| | - Akio Tanaka
- Department of Dermatology, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan;
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Loperfido A, Ciofalo A, Cavaliere C, Begvarfaj E, Cascone F, Alfonzo G, Cadeddu R, Millarelli S, Bellocchi G, Greco A, de Vincentiis M, Masieri S. Dupilumab's Impact on Blood Parameters in Nasal Polyposis: 18-Month Follow-Up in Real Life. J Immunol Res 2023; 2023:4027701. [PMID: 37745203 PMCID: PMC10516700 DOI: 10.1155/2023/4027701] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/30/2023] [Accepted: 08/25/2023] [Indexed: 09/26/2023] Open
Abstract
Background Dupilumab represents the first approved biological for severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP). Objective Aim of this paper is to provide a multicentric real-life study about treatment with dupilumab for CRSwNP with a special focus on blood parameters and IgE, IgG, and IgA. Method A retrospective data collection was jointly conducted at the Otolaryngology departments of San Camillo Forlanini Hospital and University of Rome "La Sapienza" from December 2020 to January 2023. Results A total of 130 patients were included in the study. Monitoring our patients for 18 months, we observed a reduction in nasal polyposis and an improvement in symptoms and their impact on quality of life. Regarding blood tests, a transient increase in blood eosinophils was found in most cases. Total IgE showed a gradual decrease in values. IgG and IgA also showed a slight reduction of values, while remaining within normal ranges. Conclusion To the best of our knowledge, this is the first study to evaluate the impact of dupilumab on several blood parameters in patients receiving treatment for CRswNP. Further studies are needed to confirm our results and to understand the underlying immunological mechanisms.
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Affiliation(s)
| | - Andrea Ciofalo
- Department of Sense Organs, Sapienza University, Rome, Italy
| | - Carlo Cavaliere
- Department of Sense Organs, Sapienza University, Rome, Italy
| | - Elona Begvarfaj
- Department of Sense Organs, Sapienza University, Rome, Italy
| | | | - Giacomo Alfonzo
- Department of Sense Organs, Sapienza University, Rome, Italy
| | - Rosalba Cadeddu
- Department of Sense Organs, Sapienza University, Rome, Italy
| | | | | | - Antonio Greco
- Department of Sense Organs, Sapienza University, Rome, Italy
| | | | - Simonetta Masieri
- Department of Oral and Maxillofacial Sciences, Sapienza University, Rome, Italy
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Ryu G, Lee E, Park SI, Park M, Hong SD, Jung YG, Kim HY. The Mechanism of Action and Clinical Efficacy of Low-Dose Long-Term Macrolide Therapy in Chronic Rhinosinusitis. Int J Mol Sci 2023; 24:ijms24119489. [PMID: 37298439 DOI: 10.3390/ijms24119489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/12/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
Various chronic inflammatory airway diseases can be treated with low-dose, long-term (LDLT) macrolide therapy. LDLT macrolides can be one of the therapeutic options for chronic rhinosinusitis (CRS) due to their immunomodulatory and anti-inflammatory actions. Currently, various immunomodulatory mechanisms of the LDLT macrolide treatment have been reported, as well as their antimicrobial properties. Several mechanisms have already been identified in CRS, including reduced cytokines such as interleukin (IL)-8, IL-6, IL-1β, tumor necrosis factor-α, transforming growth factor-β, inhibition of neutrophil recruitment, decreased mucus secretion, and increased mucociliary transport. Although some evidence of effectiveness for CRS has been published, the efficacy of this therapy has been inconsistent across clinical studies. LDLT macrolides are generally believed to act on the non-type 2 inflammatory endotype of CRS. However, the effectiveness of LDLT macrolide treatment in CRS is still controversial. Here, we reviewed the immunological mechanisms related to CRS in LDLT macrolide therapy and the treatment effects according to the clinical situation of CRS.
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Affiliation(s)
- Gwanghui Ryu
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Eunkyu Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Song I Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang 10380, Republic of Korea
| | - Minhae Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Sang Duk Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Yong Gi Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Hyo Yeol Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
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Luo C, Zhu Y, Zhou J, Sun X, Zhang S, Tan S, Li Z, Lin H, Zhang W. Increased CYR61 expression activates CCND1/c-Myc pathway to promote nasal epithelial cells proliferation in chronic rhinosinusitis with nasal polyps. Clin Immunol 2023; 247:109235. [PMID: 36681101 DOI: 10.1016/j.clim.2023.109235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/03/2023] [Accepted: 01/09/2023] [Indexed: 01/20/2023]
Abstract
PURPOSE Chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) is a chronic sinonasal inflammatory disease characterized histologically by hyperplastic nasal epithelium and epithelial cells proliferation. Cysteine-rich angiogenic inducer 61 (CYR61) acts as a positive regulator of cell cycle process. Cyclin D1 (CCND1) and c-Myc play key roles in the processes of cell cycle and cell growth. The purpose of our research was to explore the expression and roles of CYR61, CCND1 and c-Myc in CRSwNP. METHODS FeaturePlot and vlnPlot functions embedded in the seurat package (version 4.1.1) of R software (version 4.2.0) were applied to explore the cellular distribution of CYR61, CCND1 and c-Myc in the single-cell RNA sequencing (scRNA-seq) dataset of nasal tissue samples. CYR61, CCND1 and c-Myc immunolabeling and mRNA levels in nasal tissue samples were assessed by immunohistochemistry and real-time PCR. Co-localization of CYR61, CCND1 and c-Myc with basal epithelial cell marker P63 was assayed using double-label immunofluorescence staining. Furthermore, we collected and cultured human nasal epithelial cells (HNEC) to assess the regulation and role of CYR61 in vitro study. RESULTS CYR61, CCND1 and c-Myc were primarily expressed by nasal epithelial cells. Significant upregulation of CYR61, CCND1 and c-Myc positive cells and increased levels of CYR61, CCND1 and c-Myc mRNA were found in nasal polyps in comparison to control samples. Of note, CYR61 mRNA and protein levels were altered by SEB, LPS, IFN-γ, IL-13, IL-17A and TGF-β1 in HNEC. In addition, CYR61 intervention could increase CCND1 and c-Myc mRNA and protein levels to promote HNEC proliferation, and siRNA against ITGA2 (si-ITGA2) could reverse CYR61 induced upregulation of CCND1 and c-Myc mRNA and protein levels in HNEC and cell proliferation of HNEC. CONCLUSIONS CYR61, CCND1 and c-Myc were primarily expressed by epithelial cells in nasal mucosa. CYR61, CCND1 and c-Myc expression levels were increased in CRSwNP compared with controls. CYR61 could interact with ITGA2 to enhance HNEC proliferation via upregulating CCND1 and c-Myc levels in the HNEC, leading to hyperplastic nasal epithelium in CRSwNP.
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Affiliation(s)
- Chunyu Luo
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Otolaryngological Institute, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Ying Zhu
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Otolaryngological Institute, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Jiayao Zhou
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Otolaryngological Institute, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Xiwen Sun
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Otolaryngological Institute, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Shiyao Zhang
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Otolaryngological Institute, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Shaolin Tan
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Otolaryngological Institute, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Postgraduate Training Base of Shanghai Sixth People's Hospital, Jinzhou Medical University, Shanghai, China
| | - Zhipeng Li
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Otolaryngological Institute, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Hai Lin
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Otolaryngological Institute, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China.
| | - Weitian Zhang
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Otolaryngological Institute, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China.
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Naghdi S, Ansari NN, Varedi M, Fathali M, Zarrin M, Kashi-Alashti M, HasanNia F. Use of low-level laser therapy for patients with chronic rhinosinusitis: a single-blind, sham-controlled clinical trial. Lasers Med Sci 2022; 38:5. [PMID: 36538169 DOI: 10.1007/s10103-022-03684-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/22/2022] [Indexed: 12/24/2022]
Abstract
Chronic rhinosinusitis (CRS) is one of the most common conditions all over the world. The purpose of this study was to investigate the effects of low-level laser therapy (LLLT) in patients with CRS. Fourteen adult patients with CRS participated in this single-blind, sham-controlled clinical trial (12 male, mean age 40 years). Patients received five successive sessions of sham laser followed by five successive sessions of real laser after 2 days. Ga-Al-As laser of 830 nm in a continuous mode at a power output of 30 mW and energy dose of 1 J was applied on the cheeks and the forehead for the maxillary and frontal sinuses, respectively. Laser was delivered on six points over each sinus, each point for 33 s. Four measurements were taken. The total symptom score (TSS) was calculated as the primary outcome measure. The effects of LLLT on TSS were evaluated by using repeated measure ANOVA. The percentage improvement of real laser and sham laser was compared by Wilcoxon signed ranked test. Cohen's d was used to calculate the effect size. Total symptom score significantly improved after real laser (p = 0.015, Cohen's d = 0.69). The percentage improvement for real laser (34.12 ± 46.43) was significantly better than the sham laser (5.02 ± 37.34, Z = - 2.23, p = 0.026). No significant improvements were observed after sham laser. This study indicates that five-session active LLLT when compared with sham is effective in the treatment of CRS symptoms.
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Affiliation(s)
- Soofia Naghdi
- Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Sciences, Enghelab Ave, Pich-E-Shemiran, Zip: 11489, Tehran, Iran.
- Research Center for War-Affected People, Tehran University of Medical Sciences, Tehran, Iran.
| | - Noureddin Nakhostin Ansari
- Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Sciences, Enghelab Ave, Pich-E-Shemiran, Zip: 11489, Tehran, Iran
- Research Center for War-Affected People, Tehran University of Medical Sciences, Tehran, Iran
| | - Mitra Varedi
- Epidemiology and Cancer Control Department, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Mojtaba Fathali
- Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Sciences, Enghelab Ave, Pich-E-Shemiran, Zip: 11489, Tehran, Iran
| | - Milad Zarrin
- Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Sciences, Enghelab Ave, Pich-E-Shemiran, Zip: 11489, Tehran, Iran
| | - Mina Kashi-Alashti
- Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Sciences, Enghelab Ave, Pich-E-Shemiran, Zip: 11489, Tehran, Iran
| | - Fatemeh HasanNia
- Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Sciences, Enghelab Ave, Pich-E-Shemiran, Zip: 11489, Tehran, Iran
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