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Original Clinical Article
Standing and walking age in children with idiopathic
clubfoot: French physiotherapy versus Ponseti method
A. Zanardi1
V. Fortini2
C. N. Abati1
C. Bettuzzi1
G. Salvatori1
E. Prato2
S. Di Giacinto1
M. Lampasi1
Abstract
Purpose A mild delay in gross motor milestones and walk-
ing age has been reported in infants with clubfoot. The influ-
ence of different treatments on motor development has been
poorly investigated. Some parents and physical therapists
express concern that the Ponseti method (PM) and its con-
straints (abduction brace, casts) would affect development
more than the French physical therapy method (FM) due to
greater immobilization and lesser stimulation.
The purpose of this study was to evaluate achievement of
three motor milestones (pull-to-standing, cruising and inde-
pendent walking) in two groups of clubfoot patients treated
at two experienced institutes respectively with the PM and FM.
Methods In all, 52 consecutive infants (full-term at birth,
mean age at beginning of treatment 24.3 days (sd 10), mean
Dimeglio score 12 (sd 3.4)) were prospectively enrolled (26
patients per centre) and followed up to walking age record-
ing milestones.
Results The two groups were not different in terms of age at
the beginning of treatment (p = 0.067) and rate of tenoto-
my. Age at tenotomy was significantly lower in the PM group
(p=0.000). Severity (p = 0.004) and number of bilateral cases
(p=0.012) were higher in the PM group. A non- significant
difference was found for age of achievement of pull-to-standing
(p = 0.109), cruising (p = 0.253) and independent ambulation
1 Department of Paediatric Orthopaedics and Traumatology, Anna
Meyer Children’s Hospital, Florence, Italy
2 Department of Paediatric Rehabilitation, Anna Meyer Children’s
Hospital, Florence, Italy
Correspondence should be sent to M. Lampasi, Anna Meyer
Children’s Hospital, Chief of the Depar tment of Paediatric
Orthopaedics and Traumatology, Viale Pieraccini 24, 50139,
Florence, Italy.
E-mail: manuele.lampasi@gmail.com
(p = 0.349) between the two groups. Overall, milestones
were achieved approximately two months later than normal
population. Sex, severity, laterality and need of tenotomy were
not found to significantly influence milestones.
Conclusion Our results confirmed that infants with clubfoot
are expected to have a minimum delay in motor develop-
ment. Infants treated with the PM and those treated with the
FM did not show significant differences in gross motor mile-
stones achievement at walking age.
Level of evidence: Level II – Prospective comparative thera-
peutic studies
Cite this article: Zanardi A, Fortini V, Abati CN, Bettuzzi C,
Salvatori G, Prato E, Di Giacinto S, Lampasi M. Standing and
walking age in children with idiopathic clubfoot: French
physiotherapy versus Ponseti method. JChild Orthop 2019;13.
DOI: 10.1302/1863-2548.13.190097
Keywords: clubfoot; Ponseti method; walking age; gross
motor milestones; French method
Introduction
Congenital talipes equinovarus or clubfoot is one of the
most common congenital birth defects, with a reported
incidence of one to two per 1000 newborns.1 The aeti-
ology is not completely understood and is considered
multifactorial, with a combination of environmental and
genetic factors (mostly genes related to limb patterning
and development of muscle and blood vessels) supposed
to play a role in the pathogenesis.1
In about 20% to 25% of cases, the deformity is asso-
ciated with syndromic conditions (distal arthrogrypo-
sis, congenital myotonic dystrophy, myelomeningocele,
amniotic band sequence or other genetic syndromes
such as trisomy 18 or chromosome 22q11 deletion syn-
drome) or is secondary to an underlying pathology.1,2 This
pathology is not always evident at birth; in some cases the
pathology is suspected and can be diagnosed in the first
years of growth, for example in case of repeated relapses
or delay in motor development.3,4
At the beginning of treatment, many parents are con-
cerned about possible delay in gross motor development
of their child, which could be due to clubfoot pathology
or to the treatment performed (immobilization, lack of
stimulation, surgery).
STANDING AND WALKING AGE IN IDIOPATHIC CLUBFEET
J Child Orthop 2019;13.
A few papers have demonstrated a minimum delay
in clubfoot patients5-7 but how different treatments may
influence gross motor development has been poorly
investigated. Among conservative methods for treatment
that have gained worldwide diffusion, the Ponseti method
(PM) and the French physical therapy method (FM) share
similar principles of trying to limit extensive surgery as
much as possible, but with different means (serial manip-
ulation/casting, percutaneous Achilles tenotomy and foot
abduction orthosis in the former, physiotherapy, taping
and splinting in the latter).
Some parents and physical therapists express con-
cern that the PM with its constraint (abduction brace,
casts) would affect development more than the FM due
to greater immobilization and lesser stimulation. This
is especially true in some regional areas where the FM
was traditionally applied before the wide diffusion of
the PM.
The purpose of this two-institution study was to eval-
uate gross motor milestones in two groups of clubfoot
patients: the first group was treated according to the
FM at one institution (group FM); the second group was
treated according to the PM in a different centre (group
PM). A comparison between the two groups and with
data reported in the literature for a non-affected popula-
tion was performed.
Materials and methods
We performed an analysis on prospectively collected data
from two centres. Infants consecutively treated for idio-
pathic congenital clubfeet between January 2011 and
December 2015 at two institutes were enrolled.
Inclusion criteria were: full-term (gestation ≥ 37
weeks), no previous clubfoot treatment and age ≤ 90 days
at beginning of treatment. Patients with postural defor-
mities, benign feet (Dimeglio grade I) and non-idiopathic
clubfoot were excluded.
All infants with conditions that could have determined
delay of motor development were excluded from the
analysis: orthopaedic conditions requiring physiother-
apy or immobilization (torticollis, hip dysplasia, etc),
lack of respect of the treatment protocol until the time
of independent ambulation or patients who underwent
casts or interventions for relapses before independent
ambulation.
Severity of the deformity was determined at presenta-
tion using Dimeglio score (DimS):8 midfoot rotation, hind-
foot varus, forefoot adduction and equinus were each
given 0 to 4 points based on reducibility on the relative
plane; pejorative items (posterior crease, medial crease,
cavus and muscular abnormality) were each scored as
1 if present and 0 if absent. The sum of these elements
constitutes a total on a 20-point scale, where a higher
score indicates a more severe deformity. This score has
been shown to have a high interobserver reliability.8 The
evaluation was performed by orthopaedic surgeons or
physical therapists experienced with the score.
For infants with bilateral clubfoot, the more severe of
the two scores was used for the analysis.7
Intervention protocols
Treatment was performed differently at the two institu-
tions according to local protocols by teams with large
experience in managing clubfoot with their respective
method.
At the first institute patients were treated according to
the FM, including physiotherapy, taping and splinting to
maintain correction. For this method, different descrip-
tions and modifications have been reported.9 The pro-
tocol used in this study, introduced in the regional area
of the institute after formal training of the orthopaedic
and physiotherapist staff by Dr Raphael Seringe in 2004,
involved initial intensive physiotherapy about three times
a week by an experienced (on average ten years of prac-
tice in the field of clubfoot, 25 patients treated per year)
physical therapist; at each session, gentle mobilization
and stretching of contracted tissues, stimulation and
strengthening of weakened muscles were performed
and lastly taping was applied, fixing the foot on a rigid
plastic plate with a non-elastic strapping; finally, parents
were instructed on how to promote psychomotor devel-
opment of their children. In addition, an above-knee pos-
terior splint with the knee in 90° flexion and the foot in
a corrective position was applied, which was worn full
time (23 hours/day) until six months of age and then
progressively reduced to night and naptime use (12 to
14 hours/day) at the age of 12 months; once walking
was achieved, it was used only at night. After walking
age, taping ended and physiotherapy continued two
to three times per week up to 30 to 36 months of age.
Open Achilles tenotomy was performed by a single expe-
rienced (about 20 years of practice in the field of club-
foot, 25 patients treated per year) orthopaedic surgeon
in cases of limited dorsiflexion (lesser than 10°), plantar
convexity appearance or radiographic evidence of equi-
nus of the calcaneus on lateral radiographs at about four
months of age.
At the second institute, treatment was performed
according to the method described by Ponseti10 by a sin-
gle experienced (about ten years of practice in the field
of clubfoot, 25 patients treated per year) orthopaedic sur-
geon. The method included weekly sessions of manipu-
lation and above-knee casting until complete abduction
was achieved and then percutaneous Achilles tenotomy
was performed if the foot could not be dorsiflexed to 15°
STANDING AND WALKING AGE IN IDIOPATHIC CLUBFEET
J Child Orthop 2019;13.
at that time. After the last cast, the foot abduction brace
was applied: the brace regimen included 23 hours a day
for three months, then reduced to 18 hours a day and then
removed gradually, one hour a day until a use of 12 hours
a day. After walking age, the brace was worn at night and
naptime until about four to five years of age.
Gross motor milestones analysis
Parents were asked to record on a sheet provided the age
at which their child achieved three gross motor milestones:
pull-to-standing, cruising and independent ambulation
(ten steps without support). At each visit clinic, the valid-
ity of the parental report was supported by observation of
the infant by the physician and/or physical therapist until
independent walking.
Statistical analysis
Mean age at beginning of treatment, mean severity, rate
of tenotomy and mean age of achievement of milestones
were calculated.
The two-sample t-test was used to compare the mean
results for the two groups. A p-value < 0.05 was consid-
ered statistically significant.
The 50th, 75th and 90th percentiles for the age of
achievement were determined.
Analysis was performed using two-sample t-tests to
evaluate if sex, severity at presentation, laterality or need
of tenotomy could have influenced age of achievement of
the three milestones.
Results
Overall, 52 infants were included in the study: 40 male
patients, 12 female patients, 27 unilateral and 25 bilateral.
Mean age at beginning of treatment was 24.3 days (
10). Mean DimS severity was 12 ( 3.4).
Mean age at last follow-up was 48 months ( 14). In
no case a disorder that could have caused clubfoot defor-
mity was suspected.
Results of mean age of achievement of milestones are
reported in Table 1. By 18 months, all patients were walk-
ing without assistance.
FM and PM group
At the first institute (FM) 26 consecutive infants (19 male,
seven female, 18 unilateral, eight bilateral) were included.
Mean age at beginning of treatment was 22.2 days (
8.7). Mean DimS severity was 10.8 ( 3.1) (Table 2).
Tenotomy was performed in 80.8% of cases at mean age
of 127 days ( 32). Correction was described as complete
after tenotomy in all cases but in five patients at the time
of independent walking some residual deformity was evi-
dent (two cavus, two varus, one limited dorsiflexion).
At the second institute (PM) 26 consecutive infants
(21 male, five female, nine unilateral, 17 bilateral) were
enrolled. Mean age at beginning of treatment was 26.4
days ( 10.8). Mean DimS severity was 13.3 ( 3.2)
(Table 1). A mean of 4.8 casts (2 to 7; including post-
tenotomy cast) was performed. Tenotomy was performed
in 84.6% of cases at a mean age of 77 days ( 12).
None of the infants in the PM group had any formal
physiotherapy prior to walking age. Initial correction of
the deformity was achieved in all patients.
FM versus PM group
Mean age at the beginning of treatment was slightly dif-
ferent (FM 22.2 days, PM 26.4 days) between the two
groups but the difference did not reach statistical signif-
icance (p= 0.067). DimS was significantly higher in the
PM group (13.3) than in the FM group (10.8; p = 0.004).
The PM group included a significantly higher number
of bilateral cases (65.4% versus 30.8% in the FM group;
Table 1 Age, presented as months (sd) (where sd is reported), of achievement of motor milestones in clubfoot and normal infants
(from present study and the literature)
Clubfoot Normal
Present study
(combined)
Sala
et al6 (PM)
Zionts
et al7 (PM)
Garcia et al5
(combined)
Capute et al14 Davis et al15 WHO12
Pull-to-stand 10.1 (1.6) 9.0 (1.9) NR 10.1 8 .1 8.5 NR
Cruising 11.4 (1.4) 10.2 (2.0) NR NR 8.8 NR NR
Independent ambulation 14.4 (1.7) 13.9 (2.2) 14.5 (2.6) 13.9 11. 7 12.2 12.1 (1.8)
PM, Ponseti method; WHO, World Health Organization; NR, not reported
Table 2 Comparison between the French physical therapy method (FM)
and the Ponseti method (PM) group in the present study: characteristics
of patients and treatment and age of achievement of motor milestones
FM PM p-value*
(FM versus PM)
Age at beginning, days (sd)22.2 (8.7) 26.4 (10.8) 0.067
Severity (DimS), score (sd)10.8 (3.1) 13.3 (3.2) 0.004**
Bilateral cases, % 30.8 65.4 0.012**
Tenotomy, % 80.8 84.6 0.500
Age at tenotomy, days (sd)127 (32) 77 (12) 0.000*
Pull-to-stand, mths (sd)10.4 (1.7) 9.8 (1.5) 0.109
Cruising, mths (sd)11.6 (1.5) 11.3 (1.4) 0.253
Independent ambulation, mths (sd)14.5 (1.8) 14.3 (1.6) 0.349
* raw 1-2-5-6-7-8: two-sample-t-test; for raw 3-4: chi-squared test
**significant
STANDING AND WALKING AGE IN IDIOPATHIC CLUBFEET
J Child Orthop 2019;13.
p=0.012). The rate of tenotomy was similar (p = 0.500).
Age at tenotomy was significantly lower in the PM group
(77 days ( 12)) than in the FM group (127 days ( );
p = 0.000).
The results of the mean age of achievement of mile-
stones are reported in Table 2. Comparison of the age
in the two groups showed a non-significant difference
between the two groups for pull-to-standing (p=0.109),
cruising (p = 0.253) and independent ambulation
(p=0.349).
The 50th, 75th and 90th percentiles for the age of
achievement of the three milestones are reported in
Table3, along with data reported in the literature for nor-
mal infants.11-15
Factors influencing milestones
An analysis was performed in the overall sample and in
the two groups to understand if patient or treatment fac-
tors could have influenced achievement of milestones.
Sex (male versus female), severity at presentation (DimS
≤ 14 points versus ≥ 15 points), laterality (unilateral versus
bilateral cases) and need of tenotomy (performed versus
not performed) were not found to significantly influence
age of achievement of standing, cruising and indepen-
dent ambulation in the FM group, PM group and overall
sample.
Discussion
Gross motor development and achievement of indepen-
dent ambulation may be delayed in infants with idiopathic
clubfoot, as suggested by a few recent papers.5-7
Zionts et al7 evaluated walking age in 94 patients and
found that the mean age of independent walking was
14.5 months, about two months later than infants with-
out clubfoot. Sala et al6 analyzed gross motor milestones
in a sample of 36 patients from rolling prone to supine
to independent ambulation and found that delays were
at most 1.5 months, except for walking age, which was
approximately two months. Garcia et al5 used the Alberta
Infant Motor Scale to evaluate motor performance on a
group of 26 clubfoot patients treated with different meth-
ods (PM 12 infants, FM nine infants or both five infants)
and found a mild delay in attainment of motor skills at
nine and 12 months of age in comparison with a group of
normally developing infants.
These findings were confirmed in our study. Clubfoot
patients in our study achieved pull-to-standing, cruising
and independent ambulation approximately two months
later than non-affected children: data for non-affected
infants described in earlier studies11-15 are reported for
comparison in the tables. Slight differences among club-
foot papers may be attributed to different inclusion criteria
(for example, we have excluded patients that experienced
relapse, included by Zionts et al7) or different brace pro-
tocol. Our regimen included 23 hours/day for three
months, then reduced to 18 hours/day and then removed
gradually, one hour a day until a use of 12 hours/day. The
regimen used by Sala et al6 and Zionts et al7 included 23
hours/day for three months and then direct use at night
and at naptime. In fact, different brace protocols have
been described in the literature.16
The motor delay found in our study was mild, with all
patients walking by 18 months, which is similar to the
results of other authors (90% of patients walking at 18
months for Zionts et al,7 25 out of 26 patients in Garcia
et al,5 “almost all” in Sala et al6). On the one hand this
information can help to reassure parents and on the other
hand can alert us that greater delays can be hardly attrib-
uted to clubfoot (in the absence of relapses or complica-
tions) and should be investigated with the suspicion of
underlying conditions determining clubfoot and motor
delay. Yet, a clear cut-off cannot be established.
Table 3 Percentiles of age of achievement of motor milestones in clubfoot and normal infants (from present study and the literature)
Clubfoot Normal
Present
study (FM)
Present
study (PM)
Present study
(combined)
Sala
et al6Zionts
et al7Frankenburg
et al11 WHO12 Neligan and
Prudham13
Pull-to-stand 50% 10 10 10 8.8 NR 8.4 7.4*NR
75% 11. 5 10.5 11 10.5 NR 9.1 8.4*NR
90% 13 12 13 11. 2 NR 9.7 9.4*NR
Cruising 50% 11 11 11 NR NR NR 9** NR
75% 13 12 13 NR NR NR 10** NR
90% 13 13 13 NR NR NR 11** NR
Independent
ambulation
50% 14 14 14 13.8 14 12.3*** 12 12.8
75% 15 16 15.5 15 16.5 13.6*** 13.1 14.2
90% 18 16.5 17 17.7 18 14.9*** 14.4 15.8
*standing with assistance
**walking with assistance
***walk well
FM, French physical therapy method; PM, Ponseti method; WHO, World Health Organization; NR, not reported
STANDING AND WALKING AGE IN IDIOPATHIC CLUBFEET
J Child Orthop 2019;13.
It has been suggested that the motor delay in infants
with clubfoot could be secondary to clubfoot pathology
itself or to the treatment.5,6
As for pathology, an underlying mild motor develop-
ment dysfunction related to clubfoot has been hypoth-
esized.5 This could be the effect of one or more of the
multifactorial components hypothesized for clubfoot aeti-
ology that would also negatively affect gross motor skills
(for example, neuromyogenic imbalances).5
Andriesse et al17 analyzed motor ability at seven years
of age in a group of 20 children treated for clubfoot by
assessing the Movement Assessment Battery for Children,
which includes items for the main motor skills (manual
dexterity, ball skills and balance, coordination, visual-
spatial perception, etc). They found an increased preva-
lence of motor impairment, with no relationship with foot
status, laterality or the extent of surgery and suggested
that other factors besides function may play a role.
As regards treatment, a possible cause for delay is the
containment used to treat the deformity that is different
according to the method used.
In the PM the use of long-leg casts initially and then
foot abduction brace does not permit typical patterns
of kicking in the early months of life.5 Both feet are con-
strained and connected with a bar even if the deformity is
unilateral. In the FM the constraints are different: taping
and splinting are used without using a bar connecting
lower extremities and massage, stretching and active facil-
itation are performed by parents and therapists.
This lesser constraint and greater stimulation is sup-
posed to provide a better facilitation to motor develop-
ment, but no study has evaluated this aspect and our
findings did not confirm it; infants treated with the FM
achieved the three gross motor milestones analyzed at a
similar age in comparison with the PM group.
The characteristics of treatment performed in the two
groups in the present study are similar to earlier descrip-
tions for the two methods.9,10,1 8,19 In the PM group, a mean
of 4.8 casts was performed (four to seven reported in
the literature)6 and Achilles tenotomy was performed in
84.6% of cases (63% to 91% in earlier studies).6 In the FM
group the percentage of tenotomy (80.8%) was higher
than that reported in previous studies (17% to 32%).19,20
Yet, more recent studies on the FM9,18,20 have suggested
that early Achilles tenotomy in the FM may improve the
final results and decrease the recourse to surgery.
The two groups were similar in terms of age at the
beginning of treatment and the percentage of tenot-
omy performed. Age at tenotomy was significantly lower
in the PM group and could have played a role. On the
other hand, the PM group showed a more severe mean
DimS and a higher percentage of bilateral cases. Infants
with bilateral involvement have been supposed to repre-
sent a subgroup with more severe clinical expression in
comparison with unilateral cases.21,22 Despite theoretical
advantages of the FM group in terms of lesser severity and
constraints, no superiority in motor milestones achieve-
ment was found.
To our knowledge, comparison between FM and PM
in terms of motor development at walking age was pre-
viously performed only by Garcia et al,5 that similarly
reported no difference in gross motor development in
the two groups, but the sample size was very small (nine
patients for the PM and seven for the FM evaluated at 15
months of age).
As regards other factors possibly influencing motor
milestones, Zionts et al7 reported that motor develop-
ment, particularly walking age, was influenced by severity
of the deformity. This finding was not confirmed by our
study. This difference is likely due to different criteria of
inclusion of patients: the authors included in the analysis
patients with relapses requiring treatments. In contrast,
we have excluded these patients since it seemed obvious
that a patient requiring longer period of immobilization
and treatment would have revealed delay as shown by
Zionts et al,7 while our interest was in patients undergo-
ing the basic treatment. By excluding these patients, no
difference was found in relation to deformity severity, as
reported by Garcia et al.5
The strength of our study is that it represents a pro-
spective analysis of consecutive cases treated in two cen-
tres experienced with the respective method (no bias of
patient and treatment selection).
One of the main limitations is that data collection was
partially performed by parents. We believe that data are to
be considered accurate since parental reports were regu-
larly verified by physicians and therapists at the visits, that
are planned frequently (approximately every one to two
months) at that age. In addition, the reliability of parental
recall of developmental milestones of children has been
analyzed by Majnemer and Rosenblatt:23 the mean dis-
crepancy was found to be less than 0.4 months at three to
five years after occurrence of beginning of walking.
Analysis of results at final follow-up and of patients
showing relapses after walking age lies outside the pur-
pose of this study and was deliberately not performed.
We acknowledge that the overall mean gross motor devel-
opment for each method is clearly influenced by the rate
of relapses, re-interventions and relative immobilizations.
A comparison of results between the two treatments has
been performed in very few papers.19,20,24 In a single-
centre study (with parent-selected treatment), Richards
et al24 compared results of the FM and PM and found
that initial correction rates were equal (95% and 94.4%,
respectively), relapses occurred in 29% and 37% of cases,
respectively, and outcomes were comparable at a mean
follow-up of 4.3 years. Chotel et al19 in a two-institution
study reported higher rates of extensive surgery in the FM
STANDING AND WALKING AGE IN IDIOPATHIC CLUBFEET
J Child Orthop 2019;13.
group (19% of feet) with lower clinical results at a mean
follow-up of 5.5 years; in particular, they found that results
for mild deformities were similar, but results for intermedi-
ate and severe clubfeet were better in the PM group.
In general, the FM has been reported to have less repro-
ducible results,19 that largely depend on the experience,
skill and motivation of physical therapists.25 This implies
the necessity to develop a network of specialized physio-
therapists and the need for geographic proximity of the
patient to the competent physiotherapist. Other limiting
factors of the FM in comparison with the PM may be the
need for cooperation of families to assiduous physiother-
apy and the cost/time requirement, not covered by all
healthcare systems.19
In this paper, only gross motor development until inde-
pendent ambulation was analyzed and nothing can be
said about further development in the two groups. In a
recent paper, Zapata et al26 analyzed gross motor function
at ten years of age of children treated with either method
and found that patients in the FM group scored higher
on running speed/agility, body coordination and strength
and agility. They concluded that it could be beneficial to
incorporate physiotherapy during the maintenance phase
of PM to maximize functional outcomes. Recently, a new
hybrid protocol combining the advantages of the PM and
FM has been proposed by Dimeglio and Canavese.9
In conclusion, our results have confirmed that infants
with clubfoot are expected to have a minimum delay in
motor development and this finding could be used to
reassure parents. Infants treated with the PM and those
treated with the FM did not show significant differences
in gross motor milestones achievement at walking age.
Further studies are needed to evaluate gross motor devel-
opment at longer follow-up.
Received 24 June 2019; accepted after revision 2 August 2019.
COMPLIANCE WITH ETHICAL STANDARDS
FUNDING STATEMENT
No benets in any form have been received or will be received from a commercial
party related directly or indirectly to the subject of this article.
OA LICENCE TEXT
This article is distributed under the terms of the Creative Commons Attribution-Non
Commercial 4.0 International (CC BY-NC 4.0) licence (https://creativecommons.org/
licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribu-
tion of the work without further permission provided the original work is attributed.
ETHICAL STATEMENT
Ethical approval: All procedures performed in studies involving human partic-
ipants were in accordance with the ethical standards of the institutional and/or
national research committee and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards. This article does not contain any
studies with animals performed by any of the authors.
Informed consent: Not required for this work.
ICMJE CONFLICT OF INTEREST STATEMENT
None declared.
ACKNOWLEDGEMENTS
The authors wish to thank Dr Salvatore De Masi (Clinical Trial Oce, AOU Meyer,
Florence) and Prof Giancarlo Bettuzzi for statistical analysis, Drs Alessandro Pagliazzi
and Alessandra Novembri for their contribution in the treatment and follow-up of
patients of FM group.
AUTHOR CONTRIBUTIONS
AZ, ML: Data acquisition, Analysis and interpretation of data, Ideation and writing
of the manuscript.
VF, CNA, CB, GS, EP, SDG: Data acquisition, Critical revision of the manuscript.
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