Rheumatology International

, Volume 38, Issue 12, pp 2167–2182 | Cite as

Expert recommendations on the psychological needs of patients with rheumatoid arthritis

  • Leticia Leon
  • Marta Redondo
  • Antonio Fernández-Nebro
  • Susana Gómez
  • Estíbaliz Loza
  • María Montoro
  • Rosario Garcia-Vicuña
  • María GalindoEmail author



To establish feasible and practical recommendations for the management of the psychological needs of patients with rheumatoid arthritis (RA) from the moment of diagnosis through the course of the disease.


A nominal group meeting was held with an RA expert team including rheumatologists and psychologists, at which a guided discussion addressed the most important psychological and emotional needs in RA. Based on the comments collected, and a literature review, a matrix document of recommendations for telematics discussion was prepared, as well as a Delphi survey to test agreement with these recommendations. Agreement was defined if at least 80% of participants voted ≥ 7 (from 1, totally disagree to 10, totally agree). For each recommendation, the level of evidence and grading of recommendations was established following the Oxford criteria, and the degree of agreement through the Delphi.


Thirteen recommendations were established, addressing several key processes: (1) identification of psychological problems and needs in patients with RA, and a guideline for their management in daily practice; (2) communication with patients; (3) referral criteria to mental health professionals.


These recommendations are intended to help health care professionals openly address the psychological aspects of patients in daily practice to follow and treat them properly.


Rheumatoid arthritis Psychological issues Recommendations 



To Milena Gobbo Montoya, Jose Bernardo Negrón, Rebeca Pardo Cebrián, Javier García González, Elisa Trujillo Martín, Blanca Estela Hernández Cruz, Ana Ortiz García, Cristina Lajas Petisco, José Manuel Rodríguez Heredia, Ana Pérez Gómez, María Victoria Hernández, Teresa Otón-Sánchez, María Jesús García de Yébenes, Loreto Carmona, the LIRE and ConArtritis.

Author contribution

Maria Galindo, Estíbaliz Loza and Maria Montoro participated in the study design. All of the authors took part in the rest of the study phases, contributed in this article discussion and reviewed the final version.


This research was funded by Pfizer. Estibaliz Loza, from the institute of musculoskeletal health (Instituto de Salud Musculoesquelética, INMUSC), which in turn was funded by Pfizer, and helped in methodological coordination.

Compliance with ethical standards

Conflict of interest

Authors report no conflicts of interest.


  1. 1.
    Redondo MM, León Mateos L, Pérez Nieto MA, JJ JA, Abasolo Alcazar L (2008) El dolor en los pacientes con artritis reumatoide: variables psicológicas relacionadas e intervención. Clínica y Salud 19:359–378Google Scholar
  2. 2.
    Balsa A, Lojo-Oliveira L, Alperi-Lopez M, Garcia-Manrique M, Ordonez-Canizares C, Perez L, Ruiz-Esquide V, Corrales A, Narvaez J, Rey-Rey J, Rodriguez-Lozano C, Ojeda S, Munoz-Fernandez S, Nolla JM, Garcia-Torron J, Gamero F, Garcia-Vicuna R, Hernandez-Cruz B, Campos J, Rosas J, Garcia-Llorente JF, Gomez-Centeno A, Caliz R, Sanmarti R, Bermudez A, Abasolo-Alcazar L, Fernandez-Nebro A, Rodriguez-Rodriguez L, Marras C, Gonzalez-Gay MA, Hmamouchi I, Martin-Mola E (2017) Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring in clinical practice: the spanish cohort of the COMORA study. Reumatol Clin. CrossRefPubMedGoogle Scholar
  3. 3.
    Covic T, Cumming SR, Pallant JF, Manolios N, Emery P, Conaghan PG, Tennant A (2012) Depression and anxiety in patients with rheumatoid arthritis: prevalence rates based on a comparison of the Depression, Anxiety and Stress Scale (DASS) and the hospital, Anxiety and Depression Scale (HADS). BMC Psychiatry 12:6. CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Matcham F, Rayner L, Steer S, Hotopf M (2013) The prevalence of depression in rheumatoid arthritis: a systematic review and meta-analysis. Rheumatology 52(12):2136–2148. CrossRefPubMedGoogle Scholar
  5. 5.
    Creed F (1990) Psychological disorders in rheumatoid arthritis: a growing consensus? Ann Rheum Dis 49(10):808–812CrossRefGoogle Scholar
  6. 6.
    Walsh JD, Blanchard EB, Kremer JM, Blanchard CG (1999) The psychosocial effects of rheumatoid arthritis on the patient and the well partner. Behav Res Ther 37(3):259–271CrossRefGoogle Scholar
  7. 7.
    Young LD (1992) Psychological factors in rheumatoid arthritis. J Consult Clin Psychol 60(4):619–627CrossRefGoogle Scholar
  8. 8.
    Goes ACJ, Reis LAB, Silva MBG, Kahlow BS, Skare TL (2017) Rheumatoid arthritis and sleep quality. Revista Brasileira de Reumatologia 57(4):294–298. CrossRefPubMedGoogle Scholar
  9. 9.
    Guo G, Fu T, Yin R, Zhang L, Zhang Q, Xia Y, Li L, Gu Z (2016) Sleep quality in Chinese patients with rheumatoid arthritis: contributing factors and effects on health-related quality of life. Health Qual Life Outcomes 14(1):151. CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Hari A, Rostom S, Lahlou R, Bahiri R, Hajjaj-Hassouni N (2015) Sexual function in Moroccan women with rheumatoid arthritis and its relationship with disease activity. Clin Rheumatol 34(6):1047–1051. CrossRefPubMedGoogle Scholar
  11. 11.
    Hashimoto A, Sato H, Nishibayahi Y, Shiino Y, Kutsuna T, Ishihara Y, Hoshi K, Fujimori J, Tsuboi S, Kondo H, Akizuki M, Moroi Y, Yoshida S (2002) [A multicenter cross-sectional study on the health related quality of life of patients with rheumatoid arthritis using a revised Japanese version of the arthritis impact measurement scales version 2 (AIMS 2), focusing on the medical care costs and their associative factors]. Ryumachi 42(1):23–39PubMedGoogle Scholar
  12. 12.
    Leon L, Jover JA, Loza E, Zunzunegui MV, Lajas C, Vadillo C, Fontsere O, Rodriguez-Rodriguez L, Martinez C, Fernandez-Gutierrez B, Abasolo L (2013) Health-related quality of life as a main determinant of access to rheumatologic care. Rheumatol Int 33(7):1797–1804. CrossRefPubMedGoogle Scholar
  13. 13.
    Vangeli E, Bakhshi S, Baker A, Fisher A, Bucknor D, Mrowietz U, Ostor AJ, Peyrin-Biroulet L, Lacerda AP, Weinman J (2015) A systematic review of factors associated with non-adherence to treatment for immune-mediated inflammatory diseases. Adv Ther 32(11):983–1028. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Matcham F, Scott IC, Rayner L, Hotopf M, Kingsley GH, Norton S, Scott DL, Steer S (2014) The impact of rheumatoid arthritis on quality-of-life assessed using the SF-36: a systematic review and meta-analysis. Seminars Arthritis Rheumat 44(2):123–130. CrossRefGoogle Scholar
  15. 15.
    Matcham F, Norton S, Scott DL, Steer S, Hotopf M (2016) Symptoms of depression and anxiety predict treatment response and long-term physical health outcomes in rheumatoid arthritis: secondary analysis of a randomized controlled trial. Rheumatology 55(2):268–278. CrossRefPubMedGoogle Scholar
  16. 16.
    Matcham F, Davies R, Hotopf M, Hyrich KL, Norton S, Steer S, Galloway J (2018) The relationship between depression and biologic treatment response in rheumatoid arthritis: an analysis of the British Society for Rheumatology Biologics Register. Rheumatology. CrossRefPubMedGoogle Scholar
  17. 17.
    Leon L, Jover JA, Candelas G, Lajas C, Vadillo C, Blanco M, Loza E, Perez MA, Redondo M, Abasolo L (2009) Effectiveness of an early cognitive-behavioral treatment in patients with work disability due to musculoskeletal disorders. Arthritis Rheum 61(7):996–1003. CrossRefPubMedGoogle Scholar
  18. 18.
    Arends RY, Bode C, Taal E, van de Laar MA (2016) The longitudinal relation between patterns of goal management and psychological health in people with arthritis: the need for adaptive flexibility. Br J Health Psychol 21(2):469–489. CrossRefPubMedGoogle Scholar
  19. 19.
    Coulter A, Entwistle VA, Eccles A, Ryan S, Shepperd S, Perera R (2015) Personalised care planning for adults with chronic or long-term health conditions. Cochrane Database Syst Rev (3):CD010523.
  20. 20.
    Howick J, Chalmers I, Paul Glasziou P, Greenhalgh T, Carl Heneghan C, Liberati A, Moschetti I, Phillips B, Thornton H (2018) Explanation of the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) levels of evidence (background document). Accessed 1 Nov 2017
  21. 21.
    Suarez-Almazor ME (2004) Patient-physician communication. Curr Opin Rheumatol 16(2):91–95CrossRefGoogle Scholar
  22. 22.
    Gafvels C, Hagerstrom M, Nordmark B, Wandell PE (2012) Psychosocial problems among newly diagnosed rheumatoid arthritis patients. Clin Rheumatol 31(3):521–529. CrossRefPubMedGoogle Scholar
  23. 23.
    Leblanc-Trudeau C, Dobkin PL, Carrier N, Cossette P, de Brum-Fernandes AJ, Liang P, Masetto A, Boire G (2015) Depressive symptoms predict future simple disease activity index scores and simple disease activity index remission in a prospective cohort of patients with early inflammatory polyarthritis. Rheumatology 54(12):2205–2214. CrossRefPubMedGoogle Scholar
  24. 24.
    Evers AW, Kraaimaat FW, Geenen R, Jacobs JW, Bijlsma JW (2003) Pain coping and social support as predictors of long-term functional disability and pain in early rheumatoid arthritis. Behav Res Ther 41(11):1295–1310CrossRefGoogle Scholar
  25. 25.
    Leon L, Redondo M, Garcia-Vadillo A, Perez-Nieto MA, Rodriguez-Rodriguez L, Jover JA, Gonzalez-Alvaro I, Abasolo L (2016) Influence of patient personality in the treatment of rheumatoid arthritis. Rheumatol Int 36(11):1549–1555. CrossRefPubMedGoogle Scholar
  26. 26.
    Evers AW, Kraaimaat FW, Geenen R, Bijlsma JW (1997) Determinants of psychological distress and its course in the first year after diagnosis in rheumatoid arthritis patients. J Behav Med 20(5):489–504CrossRefGoogle Scholar
  27. 27.
    Guillem-Mesado A, de Andres C, Lopez-Longo J, Gimenez-Roldan S (1998) [Information about the diagnosis: a subjective experience of patients with multiple sclerosis and rheumatoid arthritis]. Rev Neurol 26(149):25–28PubMedGoogle Scholar
  28. 28.
    Lindgren S, Storli SL, Wiklund-Gustin L (2014) Living in negotiation: patients’ experiences of being in the diagnostic process of COPD. Int J Chron Obstruct Pulmon Dis 9:441–451. CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Salt E, Rowles GD, Reed DB (2012) Patient’s perception of quality patient–provider communication. Orthop Nurs 31(3):169–176. CrossRefPubMedGoogle Scholar
  30. 30.
    Sheppard J, Kumar K, Buckley CD, Shaw KL, Raza K (2008) ‘I just thought it was normal aches and pains’: a qualitative study of decision-making processes in patients with early rheumatoid arthritis. Rheumatology 47(10):1577–1582. CrossRefPubMedGoogle Scholar
  31. 31.
    Powley L, McIlroy G, Simons G, Raza K (2016) Are online symptoms checkers useful for patients with inflammatory arthritis? BMC Musculoskelet Disord 17(1):362. CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Strand V, Khanna D (2010) The impact of rheumatoid arthritis and treatment on patients’ lives. Clin Exp Rheumatol 28(3 Suppl 59):S32-40PubMedGoogle Scholar
  33. 33.
    Cadena J, Vinaccia S, Perez A, Rico MI, Hinojosa R, Anaya JM (2003) The impact of disease activity on the quality of life, mental health status, and family dysfunction in colombian patients with rheumatoid arthritis. J Clin Rheumatol 9(3):142–150. CrossRefPubMedGoogle Scholar
  34. 34.
    Verstappen SM (2015) Rheumatoid arthritis and work: The impact of rheumatoid arthritis on absenteeism and presenteeism. Best Pract Res Clin Rheumatol 29(3):495–511. CrossRefPubMedGoogle Scholar
  35. 35.
    Sandberg EH, Sharma R, Sandberg WS (2012) Deficits in retention for verbally presented medical information. Anesthesiology 117(4):772–779. CrossRefPubMedGoogle Scholar
  36. 36.
    Warmington K, Flewelling C, Kennedy CA, Shupak R, Papachristos A, Jones C, Linton D, Beaton DE, Lineker S (2017) Telemedicine delivery of patient education in remote Ontario communities: feasibility of an Advanced Clinician Practitioner in Arthritis Care (ACPAC)-led inflammatory arthritis education program. Open Access Rheumatol 9:11–19. CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Cottrell JE, Jonas M, Bergsten U, Blaas E, de la Torre Aboki J, Howse C, Korandova J, Lofman P, Logtenberg C, Lupton T, Mallon C, Oliver S, Pickles D, Bulinckx L (2013) The nurse’s role in addressing unmet treatment and management needs of patients with rheumatoid arthritis: Delphi-based recommendations. Int J Nurs Knowl 24(2):66–76. CrossRefPubMedGoogle Scholar
  38. 38.
    Haraoui B, Bensen W, Thorne C, Wade J, Deamude M, Prince J, Legare J (2014) Treating rheumatoid arthritis to target: a Canadian patient survey. J Clin Rheumatol 20(2):61–67. CrossRefPubMedGoogle Scholar
  39. 39.
    Strand V, Wright GC, Bergman MJ, Tambiah J, Taylor PC (2015) Patient expectations and perceptions of goal-setting strategies for disease management in rheumatoid arthritis. J Rheumatol 42(11):2046–2054. CrossRefPubMedGoogle Scholar
  40. 40.
    Funahashi K, Matsubara T (2012) What RA patients expect of their treatment–discussion over the result of our survey. Clin Rheumatol 31(11):1559–1566. CrossRefPubMedGoogle Scholar
  41. 41.
    Flurey CA, Morris M, Pollock J, Richards P, Hughes R, Hewlett S (2014) A Q-methodology study of flare help-seeking behaviours and different experiences of daily life in rheumatoid arthritis. BMC Musculoskelet Disord 15:364. CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Bazzichi L, Maser J, Piccinni A, Rucci P, Del Debbio A, Vivarelli L, Catena M, Bouanani S, Merlini G, Bombardieri S, Dell’Osso L (2005) Quality of life in rheumatoid arthritis: impact of disability and lifetime depressive spectrum symptomatology. Clin Exp Rheumatol 23(6):783–788PubMedGoogle Scholar
  43. 43.
    Sociedad Española de Reumatología (2011) Guía de práctica clínica para el manejo de la artritis reumatoide. Accessed 1 Nov 2017
  44. 44.
    Herrero MJ, Blanch J, Peri JM, De Pablo J, Pintor L, Bulbena A (2003) A validation study of the hospital anxiety and depression scale (HADS) in a Spanish population. Gener Hosp Psychiatry 25(4):277–283CrossRefGoogle Scholar
  45. 45.
    Costa TF, Silva CR, Muniz LF, Mota LM (2015) Prevalence of sexual dysfunction among female patients followed in a Brasilia Cohort of early rheumatoid arthritis. Rev Bras Reumatol 55(2):123–132. CrossRefPubMedGoogle Scholar
  46. 46.
    Lin MC, Lu MC, Livneh H, Lai NS, Guo HR, Tsai TY (2017) Factors associated with sexual dysfunction in Taiwanese females with rheumatoid arthritis. BMC Womens Health 17(1):12. CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Leon L, Abasolo Alcazar L (2016) Relaciones de pareja y enfermedad reumática. EP Health Marketing, SL. Accessed 1 Nov 2017
  48. 48.
    Royuela Rico A, Macías Fernández JA (1997) Propiedades clinimetricas de la versión castellana del cuestionario de Pittsburgh. 9 (2):81–94Google Scholar
  49. 49.
    Kool MB, van Middendorp H, Lumley MA, Schenk Y, Jacobs JW, Bijlsma JW, Geenen R (2010) Lack of understanding in fibromyalgia and rheumatoid arthritis: the Illness Invalidation Inventory (3*I). Ann Rheum Dis 69(11):1990–1995. CrossRefPubMedGoogle Scholar
  50. 50.
    Bouhouche L, Rostom S, Idrissi ZM, Bahiri R, Hajjaj-Hassouni N (2017) Perceptions in rheumatoid arthritis: comparative study between patients and their close families. J Clin Rheumatol 23(5):262–266. CrossRefPubMedGoogle Scholar
  51. 51.
    Riemsma RP, Taal E, Rasker JJ (2000) Perceptions about perceived functional disabilities and pain of people with rheumatoid arthritis: differences between patients and their spouses and correlates with well-being. Arthritis Care Res 13(5):255–261CrossRefGoogle Scholar
  52. 52.
    Kool MB, van de Schoot R, Lopez-Chicheri Garcia I, Mewes R, Da Silva JA, Vangronsveld K, Wismeijer AA, Lumley MA, van Middendorp H, Bijlsma JW, Crombez G, Rief W, Geenen R (2014) Measurement invariance of the Illness Invalidation Inventory (3*I) across language, rheumatic disease and gender. Ann Rheum Dis 73(3):551–556. CrossRefPubMedGoogle Scholar
  53. 53.
    Martinez Lopez JA, Garcia Vivar ML, Caliz R, Freire M, Galindo M, Hernandez MV, Lopez Longo FJ, Martinez Taboada V, Pego Reigosa JM, Rubio E, Trujillo E, Vela-Casasempere P (2017) Recommendations for the evaluation and management of patients with rheumatic autoimmune and inflammatory diseases during the reproductive age, pregnancy, postpartum and breastfeeding. Reumatol Clin 13(5):264–281. CrossRefPubMedGoogle Scholar
  54. 54.
    Castaneda S, Martin-Martinez MA, Gonzalez-Juanatey C, Llorca J, Garcia-Yebenes MJ, Perez-Vicente S, Sanchez-Costa JT, Diaz-Gonzalez F, Gonzalez-Gay MA, Group CPC (2015) Cardiovascular morbidity and associated risk factors in Spanish patients with chronic inflammatory rheumatic diseases attending rheumatology clinics: Baseline data of the CARMA Project. Seminars Arthritis Rheumat 44(6):618–626. CrossRefGoogle Scholar
  55. 55.
    Nyhall-Wahlin BM, Petersson IF, Nilsson JA, Jacobsson LT, Turesson C, group Bs (2009) High disease activity disability burden and smoking predict severe extra-articular manifestations in early rheumatoid arthritis. Rheumatology 48(4):416–420. CrossRefPubMedGoogle Scholar
  56. 56.
    Wolfe F (2000) The effect of smoking on clinical, laboratory, and radiographic status in rheumatoid arthritis. J Rheumatol 27(3):630–637PubMedGoogle Scholar
  57. 57.
    Manfredsdottir VF, Vikingsdottir T, Jonsson T, Geirsson AJ, Kjartansson O, Heimisdottir M, Sigurdardottir SL, Valdimarsson H, Vikingsson A (2006) The effects of tobacco smoking and rheumatoid factor seropositivity on disease activity and joint damage in early rheumatoid arthritis. Rheumatology 45(6):734–740. CrossRefPubMedGoogle Scholar
  58. 58.
    Saevarsdottir S, Wedren S, Seddighzadeh M, Bengtsson C, Wesley A, Lindblad S, Askling J, Alfredsson L, Klareskog L (2011) Patients with early rheumatoid arthritis who smoke are less likely to respond to treatment with methotrexate and tumor necrosis factor inhibitors: observations from the Epidemiological Investigation of Rheumatoid Arthritis and the Swedish Rheumatology Register cohorts. Arthritis Rheum 63(1):26–36. CrossRefPubMedGoogle Scholar
  59. 59.
    Daien CI, Hua C, Combe B, Landewe R (2017) Non-pharmacological and pharmacological interventions in patients with early arthritis: a systematic literature review informing the 2016 update of EULAR recommendations for the management of early arthritis. RMD Open 3(1):e000404. CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Combe B, Landewe R, Daien CI, Hua C, Aletaha D, Alvaro-Gracia JM, Bakkers M, Brodin N, Burmester GR, Codreanu C, Conway R, Dougados M, Emery P, Ferraccioli G, Fonseca J, Raza K, Silva-Fernandez L, Smolen JS, Skingle D, Szekanecz Z, Kvien TK, van der Helm-van Mil A, van Vollenhoven R (2017) 2016 update of the EULAR recommendations for the management of early arthritis. Ann Rheum Dis 76(6):948–959. CrossRefPubMedGoogle Scholar
  61. 61.
    Matheson L, Harcourt D, Hewlett S (2010) Your whole life, your whole world, it changes: partners’ experiences of living with rheumatoid arthritis. Musculoskelet Care 8(1):46–54. CrossRefGoogle Scholar
  62. 62.
    Hope HF, Bluett J, Barton A, Hyrich KL, Cordingley L, Verstappen SM (2016) Psychological factors predict adherence to methotrexate in rheumatoid arthritis; findings from a systematic review of rates, predictors and associations with patient-reported and clinical outcomes. RMD Open 2(1):e000171. CrossRefPubMedPubMedCentralGoogle Scholar
  63. 63.
    Fisher A, Bassett K, Goel G, Stanely D, Brookhart MA, Freeman HR, Wright JM, Dormuth CR (2016) Heterogeneity in comparisons of discontinuation of tumor necrosis factor antagonists in rheumatoid arthritis—a meta-analysis. PloS one 11(12):e0168005. CrossRefPubMedPubMedCentralGoogle Scholar
  64. 64.
    Kobue B, Moch S, Watermeyer J (2017) “It’s so hard taking pills when you don’t know what they’re for”: a qualitative study of patients’ medicine taking behaviours and conceptualisation of medicines in the context of rheumatoid arthritis. BMC Health Serv Res 17(1):303. CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Voshaar M, Vriezekolk J, van Dulmen S, van den Bemt B, van de Laar M (2016) Barriers and facilitators to disease-modifying antirheumatic drug use in patients with inflammatory rheumatic diseases: a qualitative theory-based study. BMC Musculoskelet Disord 17(1):442. CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    Gobbo M, Redondo M, León L, Torres X, Solorzano A, Brat M, Romero S, Medrano M, Díaz F, Núñez Cornejo C, Alegre C (2013) Criterios de derivación desde reumatología a psicología. Reumatol Clin 9 (Espec Cong):54Google Scholar
  67. 67.
    Silva Luna K, Ortiz AM, Patino E, Aguilera C, Velasco T, Garcia de Vicuna R, Gonzalez-Alvaro I (2012) Influence of the structure of mood in the assessment of rheumatoid arthritis through the visual analog scale for pain, HAQ and DAS28. Reumatol Clin 8(6):328–333. CrossRefPubMedGoogle Scholar
  68. 68.
    Marin-Jimenez I, Gobbo Montoya M, Panadero A, Canas M, Modino Y, Romero de Santos C, Guardiola J, Carmona L, Barreiro-de Acosta M (2017) Management of the psychological impact of inflammatory bowel disease: perspective of doctors and patients-The ENMENTE Project. Inflamm Bowel Dis 23(9):1492–1498. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Rheumatology Unit, IDISSCSan Carlos Clinical HospitalMadridSpain
  2. 2.Faculty of Heath SciencesCamilo José Cela UniversityMadridSpain
  3. 3.Rheumatology Clinical Management Unit, Biomedical Research Institute in Malaga (IBIMA), Regional University Hospital in MalagaUniversity of MalagaMalagaSpain
  4. 4.Pfizer Medical DepartmentAlcobendasSpain
  5. 5.Musculoskeletal Health InstituteMadridSpain
  6. 6.Rheumatology Service, Hospital Universitario de la PrincesaIIS-IPMadridSpain
  7. 7.Rheumatology Service12 de Octubre University HospitalMadridSpain

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