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Berkani S, Courties A, Eymard F, Latourte A, Richette P, Berenbaum F, Sellam J, Louati K. Time to Total Knee Arthroplasty after Intra-Articular Hyaluronic Acid or Platelet-Rich Plasma Injections: A Systematic Literature Review and Meta-Analysis. J Clin Med 2022; 11:3985. [PMID: 35887749 PMCID: PMC9322631 DOI: 10.3390/jcm11143985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 02/05/2023] Open
Abstract
Intra-articular (IA) hyaluronic acid (HA) and platelet-rich plasma (PRP) injections are increasingly being prescribed for knee osteoarthritis (KOA). However, failure of the medical treatment may result in total knee arthroplasty (TKA). We wondered if IA HA or PRP injections (intervention) may delay the time to TKA (outcome) among KOA patients (population), compared to KOA patients not receiving these injections (comparator). For this systematic literature review (SLR) and meta-analysis, we selected observational studies with at least one group of patients receiving IA HA or PRP and with TKA data available. The main outcome was time from the diagnosis of KOA to TKA. We included 25 articles in the SLR (2,824,401 patients) and four in the meta-analysis. The mean strengthening the reporting of observational studies in epidemiology (STROBE) score was 63%. For patients receiving versus not receiving HA injections, the delay between a declared diagnosis of KOA to TKA was increased by 9.8 months (95% CI (8.2-11.4)). As compared with standard of care, the effect size of HA injections for this outcome was 0.57 (95% CI (0.36-0.76)). Only one study described a median time from PRP injections to TKA of 4.1 years (range 0.3-14.7). IA HA injections were associated with increased time to TKA. Causality cannot be concluded because of missing confounder factors as comorbidities. Data were insufficient to conclude any effect of PRP injections on TKA delay.
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Affiliation(s)
- Sabryne Berkani
- Rheumatology Department, Inserm UMRS_938, (AP-HP) Saint-Antoine Hospital, Sorbonne Université, 75012 Paris, France; (S.B.); (A.C.); (F.B.)
| | - Alice Courties
- Rheumatology Department, Inserm UMRS_938, (AP-HP) Saint-Antoine Hospital, Sorbonne Université, 75012 Paris, France; (S.B.); (A.C.); (F.B.)
| | - Florent Eymard
- Rheumatology Department, AP-HP Henri Mondor Hospital, 94000 Créteil, France;
| | - Augustin Latourte
- Rheumatology Department, Inserm U1132, DMU Locomotion, AP-HP Lariboisière Hospital, Université de Paris, 75010 Paris, France; (A.L.); (P.R.)
| | - Pascal Richette
- Rheumatology Department, Inserm U1132, DMU Locomotion, AP-HP Lariboisière Hospital, Université de Paris, 75010 Paris, France; (A.L.); (P.R.)
| | - Francis Berenbaum
- Rheumatology Department, Inserm UMRS_938, (AP-HP) Saint-Antoine Hospital, Sorbonne Université, 75012 Paris, France; (S.B.); (A.C.); (F.B.)
| | - Jérémie Sellam
- Rheumatology Department, Inserm UMRS_938, (AP-HP) Saint-Antoine Hospital, Sorbonne Université, 75012 Paris, France; (S.B.); (A.C.); (F.B.)
| | - Karine Louati
- Rheumatology Department, Inserm UMRS_938, (AP-HP) Saint-Antoine Hospital, Sorbonne Université, 75012 Paris, France; (S.B.); (A.C.); (F.B.)
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Research on the Effectiveness of Probabilistic Stochastic Convolution Neural Network Algorithm in Physical Education Teaching Evaluation. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2022:4921846. [PMID: 35528362 PMCID: PMC9068316 DOI: 10.1155/2022/4921846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/28/2022] [Accepted: 04/01/2022] [Indexed: 11/17/2022]
Abstract
In practice, PE teaching evaluation based on probabilistic convolutional neural network still faces some practical problems. At present, the existing research mainly focuses on how to improve the accuracy of PE (physical education) teaching evaluation, but ignores the balance between accuracy and speed of the model, which is the key to achieve efficient PE teaching estimation. Aiming at the problem of optimization contradiction existing in the traditional probabilistic stochastic convolution neural network regression method, a position adaptive probabilistic stochastic convolution neural network regression method was proposed. Firstly, the basic principle of probabilistic and random convolution neural network regression method is given. Secondly, the contradiction and reasons between hot trial regression and coordinated regression are analyzed. It is found that the process heat will return to the optimization with irreconcilable contradiction with the coordinates due to the lack of learning parameters when the hot trial transforms the coordinates. The optimization contradiction will make the model tonot obtain the exact coordinates of the nodes. Then, based on the above analysis, the learnable parameters are introduced into the Softmax function, and the position adaptive Softmax model is proposed. Combining the model with the probabilistic stochastic convolution neural network regression method, the position adaptive probabilistic stochastic convolution neural network integral regression method is obtained. In order to reduce the training cost of this method, a simplified training strategy is proposed. Finally, the simulation software MATLAB is used for verification, and the functions of sample maintenance, probabilistic stochastic convolution neural network training, and neural network evaluation are realized. The experimental data show that the probabilistic stochastic convolutional neural network is feasible for teaching quality evaluation, meets the accuracy requirements, and indeed provides a convenient and practical tool for PE teaching quality evaluation.
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Webner D, Huang Y, Hummer CD. Intraarticular Hyaluronic Acid Preparations for Knee Osteoarthritis: Are Some Better Than Others? Cartilage 2021; 13:1619S-1636S. [PMID: 34044600 PMCID: PMC8808930 DOI: 10.1177/19476035211017320] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE This literature review summarizes evidence on the safety and efficacy of intraarticular hyaluronic acid (IAHA) preparations approved in the United States for the treatment of osteoarthritis of the knee. DESIGN A systematic literature search was performed in PubMed, Ovid MEDLINE, and SCOPUS databases. Only studies in which clinical outcomes of individual IAHA preparations alone could be assessed when compared to placebo, no treatment, other standard knee osteoarthritis treatments, and IAHA head-to-head studies were selected. RESULTS One hundred nine articles meeting our inclusion criteria were identified, including 59 randomized and 50 observational studies. Hylan G-F 20 has been the most extensively studied preparation, with consistent results confirming efficacy in placebo-controlled studies. Efficacy is also consistently reported for Supartz, Monovisc, and Euflexxa, but not for Hyalgan, Orthovisc, and Durolane. In the head-to-head trials, high-molecular-weight (MW) Hylan G-F 20 was consistently superior to low MW sodium hyaluronate preparations (Hyalgan, Supartz) up to 20 weeks, whereas one study reported that Durolane was noninferior to Supartz. Head-to-head trials comparing high versus medium MW preparations all used Hylan G-F 20 as the high MW preparation. Of the IAHA preparations with strong evidence of efficacy in placebo-controlled studies, Euflexxa was found to be noninferior to Hylan G-F 20. There are no direct comparisons to Monovisc. One additional IAHA preparation (ie, Synovial), which has not been assessed in placebo-controlled studies, was also noninferior to Hylan G-F 20. CONCLUSION IAHA efficacy varies widely across preparations. High-quality studies are required to assess and compare the safety and efficacy of IAHA preparations.
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Affiliation(s)
- David Webner
- Crozer-Keystone Health System,
Springfield, PA, USA,David Webner, Crozer-Keystone Health
System, 196 W. Sproul Road, Suite 110, Springfield, PA 19064, USA.
| | - Yili Huang
- Northwell Health, Zucker School of
Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Mordin M, Parrish W, Masaquel C, Bisson B, Copley-Merriman C. Intra-articular Hyaluronic Acid for Osteoarthritis of the Knee in the United States: A Systematic Review of Economic Evaluations. CLINICAL MEDICINE INSIGHTS. ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2021; 14:11795441211047284. [PMID: 34840501 PMCID: PMC8619730 DOI: 10.1177/11795441211047284] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/30/2021] [Indexed: 01/02/2023]
Abstract
Background: The economic impact of intra-articular hyaluronic acid (IAHA) for the treatment of knee pain associated with osteoarthritis (OA) has been evaluated in the United States, but not systematically summarized. Objective: We reviewed the literature to determine the economic impact of IAHA for pain associated with knee OA in the United States. Methods: A literature review was performed in PubMed (including MEDLINE and MEDLINE In-Process), Embase, the Cochrane Database of Systematic Reviews, and National Health Service Economic Evaluation Database and was limited to English language human studies published from January 2000 to October 2020. Results: The literature search identified 215 unique abstracts; of these, 47 were selected for full-text review and 21 studies met the inclusion criteria. Intra-articular hyaluronic acid injections delayed progression to total knee arthroplasty (TKA), and repeated courses of treatment successfully delayed TKA by more than 5 years. Intra-articular hyaluronic acid was found to reduce the use of pain medications overall and reduce the number of patients receiving opioid prescriptions by 6% (P < .001). Several studies showed that IAHA is more cost-effective in treating pain associated with knee OA compared with conventional care with nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, and corticosteroids, and several authors concluded that IAHA should be the dominant treatment strategy. Conclusions: Current studies suggest that IAHA may reduce the use of pain medications, such as NSAIDs and opioids, and impact time to TKA procedures, thus potentially decreasing overall treatment costs of knee OA over time. Furthermore, IAHA was determined to be cost-effective against NSAIDs, corticosteroids, analgesics, and conservative treatment. As the safety and efficacy of IAHA for knee OA have been well established, the findings from our literature review may be used to inform future economic evaluations.
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Affiliation(s)
- Margaret Mordin
- Market Access and Outcomes Strategy, RTI Health Solutions, Ann Arbor, MI, USA
| | - William Parrish
- Department of Medical Affairs, DePuy Synthes, Raynham, MA, USA
| | - Catherine Masaquel
- Market Access and Outcomes Strategy, RTI Health Solutions, Ann Arbor, MI, USA
| | - Brad Bisson
- Department of Medical Affairs, DePuy Synthes, Raynham, MA, USA
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Peck J, Slovek A, Miro P, Vij N, Traube B, Lee C, Berger AA, Kassem H, Kaye AD, Sherman WF, Abd-Elsayed A. A Comprehensive Review of Viscosupplementation in Osteoarthritis of the Knee. Orthop Rev (Pavia) 2021; 13:25549. [PMID: 34745480 DOI: 10.52965/001c.25549] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/03/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose of Review The purpose of this systematic review is to discuss emerging evidence in the field of viscosupplementation for chronic knee pain secondary to Osteoarthritis (OA). This review focuses on types of viscosupplementation that are clinically available currently, evidence to support their use, contraindications, and adverse events. Recent Findings OA, also known as degenerative joint disease, is the most common form of arthritis in the United States, affecting 54.4 million, or 22.7% of the adult population. The knee is the most common joint affected in OA, with up to 41% involvement, 30% in the hands, and 19% in the hips. The pathophysiology of OA is complex, with contributing factors including mechanical stress to the joint, as well as many person-specific factors such as genetic susceptibility, ethnicity, nutrition, and sex. Treatment modalities include weight control, exercise, non-steroidal and steroidal anti-inflammatory drugs, opioids, intra-articular platelet-rich plasma, placebo, corticosteroid injection, intra-articular viscosupplementation, and surgery. Viscosupplementation consists of injection of hyaluronic acid (HA) into affected joints, intending to restore the physiologic viscoelasticity in the synovial fluid (SF) in the absence of inflammation. HA has also been shown to downregulate pro-inflammatory factors, such as PGE2 and NFkB, and proteases and proteinases known to break down the joint matrix.The contraindications for HA injection are similar to any other injection therapy, and adverse events are usually mild, local, and transient. Viscosupplementation (VS) is effective over placebo and more effective than NSAIDs and corticosteroids in pain reduction and improved functionality; however, guidelines recommend neither for nor against its use, demonstrating variability in the existing evidence base.Current VS options divide primarily into native vs. cross-linked and low-molecular-weight vs. high-molecular-weight. Current treatment options include Hylan g-f-20, Sodium Hyaluronate preparations (Suparts Fx, Euflexxa, Gelsyn-3, Durolane, Hyalgen), single-use agents (Gel-One, Synvisc-One, Monovisc), and Hyaluronan (Orthovisc, Monovisc, Hymovic). They share a common safety profile, and all have evidence supporting their efficacy. Their specific details are reviewed here. Summary OA is the most common form of arthritis. It is a chronic, debilitating illness with a high impact on the functionality and quality of life of a significant part of the population in the western world. Treatments include medical management, physical therapy, activity modification, injection, and surgery. VS effectively reduces pain, increases functionality, and delays surgery in the knee to treat osteoarthritis. While previous studies have demonstrated variable results, more evidence is becoming available generally supportive of the benefit of VS in the treatment of knee OA.
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Affiliation(s)
| | - Annabel Slovek
- Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix
| | - Paulo Miro
- University of Arizona College of Medicine-Phoenix, AZ
| | - Neeraj Vij
- University of Arizona College of Medicine-Phoenix, AZ
| | - Blake Traube
- University of Arizona College of Medicine-Phoenix, AZ
| | - Christopher Lee
- Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, AZ
| | - Amnon A Berger
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | | | | | - Alaa Abd-Elsayed
- University of Wisconsin School of Medicine and Public Health, Madison, WI
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Liao FY, Lin CL, Lo SF, Chang CC, Liao WY, Chou LW. Efficacy of Acupoints Dual-Frequency Low-Level Laser Therapy on Knee Osteoarthritis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2020; 2020:6979105. [PMID: 33029170 PMCID: PMC7532399 DOI: 10.1155/2020/6979105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/30/2020] [Accepted: 08/04/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Knee osteoarthritis (OA) presented with knee pain and limitation of mobility is common, and it may become a chronic problem resulting in major loss of function, with related impaired activity of daily living. Current traditional therapy for knee OA includes pharmacological treatment and physiotherapy, but the efficacies are limited. An alternative noninvasive treatment low-level laser therapy (LLLT) applied to acupoints is still contradictory and the efficacy needs to be assessed. METHODS AND MATERIALS We conduct the randomized double-blind control study to investigate the efficacy of a dual-frequency LLLT (combines red light (780 nm) and near-infrared light (830 nm)) in patients suffering knee OA. Participates were randomly assigned into active laser therapy (ALT) and placebo laser therapy (PLT) groups. Subjects in the ALT group were separately treated by laser apparatus at the three acupoints (SP9, SP10, and EX-LE2) on their knee joints under continuous radiation for 15 min at the maximum intensity, three times per week for four weeks. The PLT group used laser apparatus of the same model according to similar procedures without laser light emission. Outcome Measurements including visual analog scale (VAS), pain pressure threshold (PPT), and Lequesne index were used. RESULTS A total of 30 subjects with two-sided knee OA in both groups completed the experiment. Statistically significant decreases were observed in the Lequesne index (5.27 ± 3.26 vs. 10.83 ± 3.83), conscious VAS 4 weeks after treatment (moving: 2.87 ± 1.13 vs. 5.67 ± 1.72; resting: 0.33 ± 0.62 vs. 2.67 ± 1.29), and the increase was noted in PPT (21.23 ± 1.82 kg vs. 13.02 ± 1.46 kg) in the ALT group compared with the PLT group. CONCLUSION It appears that the knee OA pain and disability can be decreased after a dual-frequency LLLT applied to acupoints (SP9, SP10, and EX-LE2). The clinical efficacy of LLLT is highly related to the therapeutic settings of the laser apparatus; hence, more clinical trials with diffident parameter settings are needed to be further clarified.
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Affiliation(s)
- Fang-Yin Liao
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung 40432, Taiwan
| | - Chien-Lin Lin
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung 40432, Taiwan
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung 40433, Taiwan
| | - Sui-Foon Lo
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung 40432, Taiwan
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung 40433, Taiwan
| | - Chun-Ching Chang
- Department of Rehabilitation, New Bodhi Hospital, Taichung 41222, Taiwan
| | - Wen-Yen Liao
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung 40432, Taiwan
| | - Li-Wei Chou
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung 40432, Taiwan
- Department of Physical Therapy and Graduate Institute of Rehabilitation Science, China Medical University, Taichung 40433, Taiwan
- Department of Physical Medicine and Rehabilitation, Asia University Hospital, Asia University, Taichung 41350, Taiwan
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Shahabi S, Rezapour A, Arabloo J. Economic evaluations of physical rehabilitation interventions in older adults with hip and/or knee osteoarthritis: a systematic review. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2019. [DOI: 10.1080/21679169.2019.1672785] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Saeed Shahabi
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Aziz Rezapour
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Jalal Arabloo
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
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Hayes AJ, Melrose J. Glycosaminoglycan and Proteoglycan Biotherapeutics in Articular Cartilage Protection and Repair Strategies: Novel Approaches to Visco‐supplementation in Orthobiologics. ADVANCED THERAPEUTICS 2019. [DOI: 10.1002/adtp.201900034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Anthony J. Hayes
- Bioimaging Research HubCardiff School of BiosciencesCardiff University Cardiff CF10 3AX Wales UK
| | - James Melrose
- Graduate School of Biomedical EngineeringUNSW Sydney Sydney NSW 2052 Australia
- Raymond Purves Bone and Joint Research LaboratoriesKolling Institute of Medical ResearchRoyal North Shore Hospital and The Faculty of Medicine and HealthUniversity of Sydney St. Leonards NSW 2065 Australia
- Sydney Medical SchoolNorthernRoyal North Shore HospitalSydney University St. Leonards NSW 2065 Australia
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Bernetti A, Mangone M, Villani C, Alviti F, Valeo M, Grassi MC, Migliore A, Viora U, Adriani E, Quirino N, Fioravanti A, Paoloni M. Appropriateness of clinical criteria for the use of SYmptomatic Slow-Acting Drug for OsteoArthritis (SYSADOA). A Delphi Method Consensus initiative among experts in Italy. Eur J Phys Rehabil Med 2019; 55:658-664. [PMID: 31106560 DOI: 10.23736/s1973-9087.19.05633-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Osteoarthritis (OA) is a theme currently representing an emerging topic for its increasing incidence. It is well known that it is a chronic disease that could lead to important long-lasting disability; this generates increasing costs for the health care system. OA treatment options vary: localization, etiology, grading and symptomatology should be considered before choosing the most adequate therapy. Currently, a modern approach to managing OA involves SYmptomatic Slow-Acting Drug for OsteoArthritis (SYSADOAs). However, while all preparations may claim to deliver a therapeutic level of glucosamine or chondroitin, not all of them are supported by clinical evidence. Recently the European Society for Clinical and Economic aspects of Osteoporosis, Osteoarthritis and musculoskeletal diseases (ESCEO), produced an evidenced based document providing practitioners with the latest clinical and economic information, thereby allowing them to optimize the management of knee OA. According to this report, only crystalline glucosamine sulphate and the pharmaceutical-grade chondroitin sulphate are considered as effective in the first line approach to treating knee OA as an alternative drug to acetaminophen. However, some OA guidelines do not agree are not concordant in recommending the use of SYSADOA, perhaps because they are generally considered as a class and distinctions among formulations are not made. AIM Aim of this study was to identify the main aspects involved in patient selection, the choice of therapeutic agents and the safety profile in using SYSADOA. DESIGN Delphi method Consenus Statement. POPULATION Italian Physicians having expertise in Osteoarthritis management. METHODS A committee of 11 experts from Italian universities, public hospitals, territorial services, research institutes and patient associations was set up. Sixty-three clinicians from a large number of Italian medical centers specialized in osteoarthritis management took part in a Delphi process which was aimed at obtaining consensus statements among the participants. RESULTS Large consensus was obtained for statements grouped under the following main themes: treatment indications; drug/medical devices choice; treatment efficacy. CONCLUSIONS Results from the Italian consensus on appropriateness of OA therapies in osteoarthritis seems to be in line with the stepwise approach proposed by the ESCEO algorithm, where crystalline glucosamine sulphate shows greater clinical efficacy than other glucosamine-based formulations, according to several independent meta-analyses. CLINICAL REHABILITATION IMPACT This study may be used as a practical reference tool to help Italian physicians treat osteoarthritis patients using SYSADOA.
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Affiliation(s)
- Andrea Bernetti
- Department of Physical Medicine and Rehabilitation, Sapienza University, Rome, Italy -
| | - Massimiliano Mangone
- Department of Physical Medicine and Rehabilitation, Sapienza University, Rome, Italy
| | - Ciro Villani
- Department of Orthopedic Science, Sapienza University, Rome, Italy
| | - Federica Alviti
- Department of Physical Medicine and Rehabilitation, Sapienza University, Rome, Italy
| | - Massimo Valeo
- Department of Orthopedic Science, Sapienza University, Rome, Italy
| | - Maria C Grassi
- Vittorio Erspamer Department of Physiology and Pharmacology, Sapienza University, Rome, Italy.,Unit of Drug Addiction and Clinical Pharmacology, Umberto I University Hospital, Sapienza University, Rome, Italy
| | | | - Ugo Viora
- Associazione Nazionale Malati Reumatici Onlus (ANMAR), Rome, Italy
| | - Ezio Adriani
- Department of Orthopedics and Traumatology, Sport Clinique, Rome, Italy
| | | | - Antonella Fioravanti
- Unit of Rheumatology, Department of Medicine, Surgery and Neurosciences, Le Scotte Polyclinic, University of Siena, Siena, Italy
| | - Marco Paoloni
- Department of Physical Medicine and Rehabilitation, Sapienza University, Rome, Italy
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