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Liu Y, Suvithayasiri S, Kim JS. Comparative Efficacy of Clinical Interventions for Sacroiliac Joint Pain: Systematic Review and Network Meta-analysis With Preliminary Design of Treatment Algorithm. Neurospine 2023; 20:997-1010. [PMID: 37798994 PMCID: PMC10562251 DOI: 10.14245/ns.2346586.293] [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: 05/25/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE We aimed to identify the most effective clinical treatment method for sacroiliac joint (SIJ)-related pain based on the systematic review and network meta-analysis (NMA) to evaluate the comparative efficacy of clinical interventions for sacroiliac joint pain by pooling the randomized controlled trials (RCTs). METHODS Our team conducted a systematic review and NMA of RCTs to determine the most effective clinical treatment for SIJ-related pain. We searched the PubMed (MEDLINE), Web of Science, Cochrane Library, and Scopus databases for RCTs until February 2023. The PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines were followed. Pairwise and network meta-analyses were conducted using a random effects model. RESULTS Based on the search strategy and inclusion criteria, our systematic review and NMA included 9 randomized studies with 652 participants. Research has mainly focused on various radiofrequency sources, but their number is still low. In the network analysis, according to the NMA and mean ranking probabilities for the improvement of pain intensity (PI) and quality of life (QoL), sacroiliac joint fusion and cooled radiofrequency were associated with high treatment rank for improving PI and QoL in patients with sacroiliac joint pain. CONCLUSION This NMA suggest that SIJ fusion and cooled radiofrequency could be potential options for improving the QoL and relieving pain in patients with SIJ-related pain. Comparison studies of outcomes between these 2 procedures with solid methodology and a low risk of bias would be very beneficial to identify the optimal treatment option for this challenging disease.
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Affiliation(s)
- Yanting Liu
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Siravich Suvithayasiri
- Department of Orthopedics, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Jin-Sung Kim
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Aktaş İ, Sarı K, Ünlü Özkan F, Nedim Kahraman A, Vural A, Akgün K. Magnetic resonance imaging/ultrasound fusion-guided sacroiliac joint corticosteroid injection in patients with axial spondyloarthritis. Turk J Phys Med Rehabil 2023; 69:116-120. [PMID: 37201011 PMCID: PMC10186019 DOI: 10.5606/tftrd.2022.8858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 08/04/2021] [Indexed: 05/20/2023] Open
Abstract
Local glucocorticoid injections are used in the treatment of isolated sacroiliitis in patients with spondyloarthritis. Sacroiliac joint injections can be performed intraarticularly or periarticularly. Since the accuracy of blind injections is low, fluoroscopy, magnetic resonance imaging, computed tomography, or ultrasonography guidance are used to increase the accuracy of sacroiliac joint injections. Currently, imaging fusion software is successfully used in sacroiliac joint interventions with three-dimensional anatomic information added to ultrasonography. Herein, we present two cases of sacroiliac joint corticosteroid injections under ultrasonography-magnetic resonance imaging fusion guidance.
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Affiliation(s)
- İlknur Aktaş
- Department of Physical Medicine and Rehabilitation, University of Health Sciences, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Türkiye
| | - Kemal Sarı
- Department of Physical Medicine and Rehabilitation, University of Health Sciences, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Türkiye
| | - Feyza Ünlü Özkan
- Department of Physical Medicine and Rehabilitation, University of Health Sciences, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Türkiye
| | - Ahmet Nedim Kahraman
- Department of Radiology, University of Health Sciences, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Türkiye
| | - Ahmet Vural
- Department of Radiology, University of Health Sciences, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Türkiye
| | - Kenan Akgün
- Department of Physical Medicine and Rehabilitation, Istanbul University-Cerrahpaşa Cerrahpaşa Faculty of Medicine, Istanbul, Türkiye
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Ramírez Huaranga MA, Castro Corredor D, Plasencia Ezaine AE, Paulino Huertas M, Arenal Lopez R, Fernández JA, Ramos Rodríguez CC. First Spanish study on the effectiveness of ultrasound-guided sacroiliac joint injection in patients with spondylarthritis. Rheumatol Adv Pract 2022; 6:rkac036. [PMID: 35663153 PMCID: PMC9154057 DOI: 10.1093/rap/rkac036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/23/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objective
To assess clinical improvement after ultrasound-guided injection of corticosteroids into the sacroiliac joint of patients with spondyloarthritis.
Methods
Observational, descriptive, retrospective study of patients with spondyloarthritis and sacroiliitis who received an ultrasound-guided injection into the sacroiliac joint between June 1, 2020 and May 31, 2021. Means were compared using the t test for the variables VAS, BASDAI, ASDAS, CRP, and ESR before and after the procedure. We evaluated the association between these variables and the clinical response using the odds ratio.
Results
We analyzed 32 patients with spondyloarthritis (age 42.69 ± 8.19 years; female sex, 56.25%) with a VAS score of 7.88 ± 0.79, BASDAI of 5.43 ± 1.48, and ASDAS of 3.27 ± 0.86 before the procedure. At 2–3 months, 75% of patients had improved: VAS 3.81 ± 2.33 (–4.07, p < 0.0001) and BASDAI 3.24 ± 1.6 (–2.19, p < 0.0001). At 5–6 months, 59.37% had improved: VAS 4.63 ± 2.31 (–3.25, p < 0.0001), BASDAI 3.57 ± 1.67 (–1.86, p < 0.0001), and ASDAS 2.27 ± 0.71 (–1.0, p < 0.0001). Bone marrow oedema resolved in 87.5% of cases compared with the previous magnetic resonance scan. No significant association was identified with the clinical response to the injection.
Conclusions
Ultrasound-guided injection of corticosteroids into the sacroiliac joint of patients with spondyloarthritis and active sacroiliitis leads to an improvement in symptoms that is maintained at 5–6 months. The procedure is effective, safe, inexpensive, and easy to apply.
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Affiliation(s)
| | - David Castro Corredor
- Rheumatology Department, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | | | - Marco Paulino Huertas
- Rheumatology Department, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Rocío Arenal Lopez
- Interventional Rheumatology, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
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2022 French Society for Rheumatology (SFR) recommendations on the everyday management of patients with spondyloarthritis, including psoriatic arthritis. Joint Bone Spine 2022; 89:105344. [PMID: 35038574 DOI: 10.1016/j.jbspin.2022.105344] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Update the French Society for Rheumatology (SFR) recommendations on the everyday management of patients with spondyloarthritis, including psoriatic arthritis. METHODS Following standardized procedures, a systematic literature review was done by four supervised rheumatology residents based on questions defined by a task force of 16 attending rheumatologists. The findings were reviewed during three working meetings that culminated in each recommendation receiving a grade and the level of agreement among experts being determined. RESULTS Five general principles and 15 recommendations were developed. They take into account pharmacological and non-pharmacological measures along with treatment methods based on the dominant phenotype present (axial, articular, enthesitis/dactylitis) and the extra-articular manifestations (psoriasis, inflammatory bowel disease, uveitis). NSAIDs are the first-line pharmacological treatment in the various presentations. Conventional synthetic disease modifying antirheumatic drugs (csDMARDs) are not indicated in the axial and isolated entheseal forms. If the response to conventional treatment is not adequate, targeted therapies (biologics, synthetics) should be considered; the indications depend on the clinical phenotype and presence of extra-articular manifestations. CONCLUSION This update incorporates recent data (published since the prior update in 2018) and the predominant clinical phenotype concept. It aims to help physicians with the everyday management of patients affected by spondyloarthritis, including psoriatic arthritis.
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Nam B, Kim TH, Lee SW, Kim H, Kim YJ, Jun JB, Lee S. Efficacy and Safety of Intra-articular Sacroiliac Glucocorticoid Injections in Ankylosing Spondylitis. J Clin Rheumatol 2022; 28:e26-e32. [PMID: 33298816 DOI: 10.1097/rhu.0000000000001584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND/AIMS To assess the efficacy and safety of intra-articular sacroiliac glucocorticoid injection in ankylosing spondylitis (AS). METHODS Patients with AS undergoing fluoroscopy-guided intra-articular sacroiliac glucocorticoid injection were enrolled between 2012 and 2018. Efficacy was assessed by numeric pain rating scale, acute phase reactants, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index, and Ankylosing Spondylitis Disease Activity Score (ASDAS). Patients who started biologics within 3 months despite the intervention were compared with those not starting biologics, hence: the nonbiologic group. RESULTS A total of 96 patients were treated, with a total of 107 injections. After intervention, there were significant decreases in numeric pain rating scale (7.8 ± 1.8 vs. 3.3 ± 2.2, p < 0.001) and acute phase reactants level (erythrocyte sedimentation rate [ESR] 23.0 mm/h [10.0-47.0 mm/h] vs. 13.0 mm/h [4.0-27.0 mm/h], p < 0.001; C-reactive protein [CRP] 1.0 mg/dL [0.2-2.7 mg/dL] vs. 0.2 mg/dL [0.2-0.9 mg/dL], p < 0.001). Disease activity scores also decreased for BASDAI (6.2 ± 1.8 vs. 4.5 ± 2.5, p = 0.001), Bath Ankylosing Spondylitis Functional Index (5.5 [4.1-7.0] vs. 1.8 [0.5-4.1], p = 0.001), ASDAS-CRP (2.9 ± 1.0 vs. 2.3 ± 1.3, p = 0.046), and ASDAS-ESR (3.7 ± 1.1 vs. 2.4 ± 1.3, p < 0.001). However, 12 patients (12.5%) started biologics within 3 months. These patients showed higher ESR (91.0 mm/h [IQR 21.0-113.0 mm/h] vs. 21.5 mm/h [IQR 9.5-43.0 mm/h], p = 0.010), CRP (8.0 mg/dL [IQR 1.11-17.1 mg/dL] vs. 0.8 mg/dL [IQR 0.2-1.8 mg/dL], p = 0.002), BASDAI (7.4 ± 1.2 vs. 5.9 ± 1.8, p = 0.027), and ASDAS-CRP (4.0 ± 0.5 vs. 2.8 ± 1.0, p = 0.004) than the nonbiologic group. There was no serious adverse event. CONCLUSIONS Intra-articular sacroiliac glucocorticoid injection can be a safe and effective treatment option for active sacroiliitis in AS.
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Affiliation(s)
| | | | - Sung Won Lee
- Department of Rheumatology, Soon Chun Hyang University Hospital, Cheonan
| | - Hyunah Kim
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University
| | - Yun Jin Kim
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University
| | - Jae-Bum Jun
- From the Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases
| | - Seunghun Lee
- Department of Radiology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
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Dhir V, Mishra D, Samanta J. Glucocorticoids in spondyloarthritis-systematic review and real-world analysis. Rheumatology (Oxford) 2021; 60:4463-4475. [PMID: 33748829 DOI: 10.1093/rheumatology/keab275] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/20/2021] [Accepted: 03/10/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE The objective of this study was to identify and summarize the efficacy and safety of systemic glucocorticoids (GCs) and local injections of GC in SpA. METHODS PubMed (Medline) and EMBASE were searched with pre-defined keywords for relevant articles in English reporting randomized controlled trials (RCTs), non-randomized interventional studies and non-randomized observational studies of the efficacy of GC in SpA, with five or more patients, for inclusion in a systematic literature review. Local injections of GC included IA and entheseal injections, but excluded SI joint injections. RESULTS Out of 9657 records identified, there were 14 studies on the use of systemic GCs in SpA (364 patients), including two RCTs of oral prednisolone. On pooling data from two placebo-controlled RCTs (≤24 weeks), BASDAI 50 was 4.2 times more likely (95% CI: 1.5, 11.5) and Ankylosing Spondylitis Assessment Group (ASAS) 20 was twice more likely (95% CI: 1.1, 3.64) to occur in patients on high-dose oral prednisolone (± taper). Pulsed GCs led to dramatic improvements that lasted a few weeks to a few months. There were no deaths or major adverse events. There were 10 studies (560 patients) on local GCs in SpA. IA injection was effective in achieving a sustained response in 51.5-90% of joints at 6 months. Entheseal injections led to reduced pain and improved US parameters. CONCLUSION There were limited studies on either systemic or local injections of GCs in SpA. However, there was good evidence of efficacy with the use of high-dose systemic GCs in the short term (≤6 months) in SpA. Both IA and entheseal injections seemed safe and effective.
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Affiliation(s)
- Varun Dhir
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Debasish Mishra
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Joydeep Samanta
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Kokar S, Kayhan Ö, Şencan S, Gündüz OH. The Role of Sacroiliac Joint Steroid Injections in the Treatment of Axial Spondyloarthritis. Arch Rheumatol 2021; 36:80-88. [PMID: 34046572 PMCID: PMC8140859 DOI: 10.46497/archrheumatol.2021.8043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 05/25/2020] [Indexed: 02/02/2023] Open
Abstract
Objectives
This study aims to investigate the effects of fluoroscopy-guided sacroiliac joint steroid injection in patients with acute bilateral sacroiliitis diagnosed with axial spondyloarthritis (axSpA) and how those injections affect the current need for nonsteroidal anti-inflammatory drug (NSAID) usage. Patients and methods
We retrospectively evaluated 43 patients (28 males, 15 females; mean age, 31.7±6.3 years; range, 18 to 44 years) fulfilling the Assessment of SpondyloArthritis international Society 2009 criteria for axSpA between June 2015 and May 2016. One group included 22 patients (injection group) treated with sacroiliac joint steroid injection (triamcinolone acetonide) and the other group included 21 patients (non-injection group) not receiving the injection. All 43 patients in both groups were treated with indomethacin peroral. Pre-treatment, first week and first, third and sixth month follow-up examinations were evaluated. Results
A ≥50% reduction in the numeric rating scale score compared with the baseline was considered as significant pain relief. The mean pain relief rates in patients receiving injections were higher at all inspections. This difference was statistically significant at first week (p<0.05). When groups were compared, no difference was found in the Bath Ankylosing Spondylitis Disease Activity Index scores (p>0.05). There was no statistically significant difference between the two groups when indomethacin dose was evaluated cumulatively for six months (p>0.05). Conclusion Fluoroscopy-guided sacroiliac joint steroid injections can be recommended in patients with active sacroiliitis, particularly in those with severe axial pain, for rapid analgesia in the initial term. It was concluded that steroid injections applied to the sacroiliac joint did not affect disease activity. It is noteworthy that there is a trend to reduce the use of NSAIDs in patients receiving these injections, although it does not make a statistically significant difference in the long term.
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Affiliation(s)
- Serdar Kokar
- Department of Physical Medicine and Rehabilitation, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Önder Kayhan
- Department of Physical Medicine and Rehabilitation, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Savaş Şencan
- Department of Physical Medicine and Rehabilitation, Division of Pain Management Section, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Osman Hakan Gündüz
- Department of Physical Medicine and Rehabilitation, Division of Pain Management Section, Marmara University Faculty of Medicine, Istanbul, Turkey
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Falowski S, Sayed D, Pope J, Patterson D, Fishman M, Gupta M, Mehta P. A Review and Algorithm in the Diagnosis and Treatment of Sacroiliac Joint Pain. J Pain Res 2020; 13:3337-3348. [PMID: 33335420 PMCID: PMC7737553 DOI: 10.2147/jpr.s279390] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 10/19/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction The sacroiliac joint (SIJ) has been estimated to contribute to pain in as much as 38% of cases of lower back pain. There are no clear diagnostic or treatment pathways. This article seeks to establish a clearer pathway and algorithm for treating patients. Methods The literature was reviewed in order to review the biomechanics, as well as establish the various diagnostic and treatment options. Diagnostic factors addressed include etiology, history, physical exam, and imaging studies. Treatment options reviewed include conservative measures, as well as interventional and surgical options. Results Proposed criteria for diagnosis of sacroiliac joint dysfunction can include pain in the area of the sacroiliac joint, reproducible pain with provocative maneuvers, and pain relief with a local anesthetic injection into the SIJ. Conventional non-surgical therapies such as medications, physical therapy, radiofrequency denervation, and direct SI joint injections may have some limited durability in therapeutic benefit. Surgical fixation can be by a lateral or posterior/posterior oblique approach with the literature supporting minimally invasive options for improving pain and function and maintaining a low adverse event profile. Conclusion SIJ pain is felt to be an underdiagnosed and undertreated element of LBP. There is an emerging disconnect between the growing incidence of diagnosed SI pathology and underwhelming treatment efficacy of medical treatment. This has led to an increase in SI joint fixation. We have created a clearer diagnostic and treatment pathway to establish an algorithm for patients that can include conservative measures and interventional techniques once the diagnosis is identified.
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Affiliation(s)
- Steven Falowski
- Neurosurgical Associates of Lancaster, Lancaster, PA 17601, USA
| | | | - Jason Pope
- Evolve Restorative Center, Santa Rosa, CA, USA
| | | | - Michael Fishman
- Center for Interventional Pain and Spine, Lancaster, PA, USA
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Wendling D. Reply to Aktaş et al. "Local sacroiliac injections in the treatment of spondyloarthritis. What is the evidence?" Joint Bone Spine 2020. DOI:10.1016/j.jbspin.2020.105083. Joint Bone Spine 2020; 88:105094. [PMID: 33157232 DOI: 10.1016/j.jbspin.2020.105094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/23/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Daniel Wendling
- Department of Rheumatology, University Teaching Hospital, CHRU de Besançon, boulevard Fleming, 25030 Besançon, France; EA4266, EPILAB, université Bourgogne-Franche-Comté, 25030 Besançon, France.
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Aktas İ, Unlu Ozkan F, Sari K. Comment on "Local sacroiliac injections in the treatment of spondyloarthritis. What is the evidence?" by Wendling et al. Joint Bone Spine 2020; 87:209-213. Joint Bone Spine 2020; 88:105083. [PMID: 33115665 DOI: 10.1016/j.jbspin.2020.105083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/23/2020] [Indexed: 11/16/2022]
Affiliation(s)
- İlknur Aktas
- University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital, PM&R Clinic , Istanbul, Turkey
| | - Feyza Unlu Ozkan
- University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital, PM&R Clinic , Istanbul, Turkey
| | - Kemal Sari
- University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital, PM&R Clinic , Istanbul, Turkey.
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