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Navarro-Fernández G, Bravo-Aparicio J, Del Castillo JL, Beltran-Alacreu H, Gil-Martínez A. Pre-Surgical Factors Influencing Post-Surgical Outcomes in Orthognathic Surgery Patients: A Longitudinal Study. J Clin Med 2024; 13:4445. [PMID: 39124712 PMCID: PMC11312505 DOI: 10.3390/jcm13154445] [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: 06/27/2024] [Revised: 07/23/2024] [Accepted: 07/23/2024] [Indexed: 08/12/2024] Open
Abstract
Background/Objectives: This study aims to assess the relationship between physical and psychosocial pre-surgical factors and post-surgical evolution in patients undergoing orthognathic surgery. Methods: A cohort study with 3 months of follow-up after maxillofacial surgery was conducted. Participants were recruited from the Maxillofacial Surgery Unit of Hospital Universitario La Paz in Madrid, Spain. Primary variables included the range of motion of mouth opening, protrusion tongue force, anxiety, depression and kinesiophobia. Assessments were realised on-site or via video call. Statistical analysis was conducted using mixed-effects models. Results: The initial recruitment yielded 22 patients, with 19 ultimately eligible for analysis. The study found significant impacts of pre-surgical factors on post-surgical evolution. Both ranges of motion and anxiety showed influences from baseline measures, with the range of motion affected by a pre-surgical range of motion (estimate: 3.89) and positive expectations (estimate: 4.83). Anxiety was influenced by both pre-surgical (estimate: 0.48) and baseline anxiety levels (estimate: 0.64). Kinesiophobia demonstrated a trend toward significance, with baseline levels affecting post-surgical evolution (estimate: 0.77). Conclusions: Our results highlight the relationship between pre-surgical factors and post-surgical outcomes in orthognathic surgery patients. Pre-surgical range of motion and positive expectations were found to influence post-surgical range of motion, while pre-surgical anxiety levels impacted post-surgical anxiety evolution. Pre-surgical kinesiophobia also showed potential as a post-surgical kinesiophobia predictor, but further investigation is needed to confirm this relationship.
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Affiliation(s)
- Gonzalo Navarro-Fernández
- Escuela Internacional de Doctorado, Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28922 Alcorcón, Spain
- CranioSpain Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28043 Madrid, Spain
| | - Javier Bravo-Aparicio
- Toledo Physiotherapy Research Group (GIFTO), Faculty of Physical Therapy and Nursing, Universidad de Castilla-La Mancha, 45071 Toledo, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Castilla-La Mancha, Spain
| | - Jose Luis Del Castillo
- Department of Oral and Maxillofacial Surgery, University Hospital La Paz, 28046 Madrid, Spain
| | - Hector Beltran-Alacreu
- Toledo Physiotherapy Research Group (GIFTO), Faculty of Physical Therapy and Nursing, Universidad de Castilla-La Mancha, 45071 Toledo, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Castilla-La Mancha, Spain
| | - Alfonso Gil-Martínez
- CranioSpain Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28043 Madrid, Spain
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28043 Madrid, Spain
- Unit of Physiotherapy, Hospital La Paz-Carlos III, Institute for Health Research IdiPAZ, 28046 Madrid, Spain
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Bourne G, Kinard B. Current Orthognathic Surgery Practice Patterns Among Academic OMS. Cleft Palate Craniofac J 2024; 61:986-996. [PMID: 36692966 DOI: 10.1177/10556656231151722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Currently there is variation in perioperative care of orthognathic surgery patients and limited clinical practice guidelines. The current orthognathic surgery practice patterns among US academic OMFS training centers have not been described. The purpose of this study is to describe the practice patterns among US academic OMFS training centers. DESIGN The study design is cross-sectional. Data was collected through a survey of the sample. SETTING OMFS programs in the US. PARTICIPANTS Academic OMFS. 573 surgeons were contacted and 85 responses were received. MAIN OUTCOME MEASURE Descriptive and bivariate statistics were reported. RESULTS Respondents were 87% male and worked in full-time academic (80%), part-time academic (19%), or military settings (1%). Thirty-one percent have practiced for 30 years or more and then 29% with 11-20 years, 18% with 21-30 years, 12% with 6-10 years and 11% with 1-5 years. Twenty-six percent of respondents perform 20-40 orthognathic surgeries a year, 22% perform less than 20 surgeries a year, 21% perform 40-60 surgeries per year, and 19% perform more than 100 surgeries per year. Intraoperatively, 48% of surgeons request a mean arterial pressure of 60-64 mmHg, 25% utilize tranexamic acid (TXA), 85% report a blood loss of less than 400 milliliters, and 93% report a blood transfusion rate of <1%. CONCLUSION There are variations in orthognathic surgery practice patterns with limited clinical practice guidelines. Only 13 of the 32 survey questions had a single response holding a simple majority. This study demonstrates the need for further research and evidence-based protocols and decision making.
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Affiliation(s)
- Graham Bourne
- University of Alabama at Birmingham School of Dentistry, Birmingham, Alabama, USA
| | - Brian Kinard
- Department of Oral and Maxillofacial Surgery, Department of Orthodontics University of Alabama at Birmingham School of Dentistry, Birmingham, Alabama, USA
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Millett DT, Benson PE, Cunningham SJ, McIntyre GT, Tsichlaki A, Naini FB, Laide C, Fleming PS. "Over-reviewing" of research? An analysis of orthodontic reviews. Am J Orthod Dentofacial Orthop 2024; 165:385-398.e5. [PMID: 38149957 DOI: 10.1016/j.ajodo.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 10/01/2023] [Accepted: 10/01/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION Research overviews may be undertaken to identify gaps in the literature, evaluate existing systematic reviews (SRs), and summarize evidence. This paper aims to profile overviews that have been conducted in orthodontics and related interventions since 2012 and to evaluate the degree of overlap among these overviews. METHODS Overviews published between January 1, 2012 and June 20, 2023 were identified using an electronic search involving Google Scholar and PubMed. A descriptive summary was produced, and citation matrices were used to evaluate the percentage of overlap between overviews using corrected covered area and covered area. This was classified as slight, moderate, high, or very high. RESULTS A total of 35 overviews were identified across a wide range of topics. Eight overviews included <10 SRs; 21 had 10-20 SRs; and 6 included >20 SRs (median no. of SRs per overview, 15; range, 3-62). Meta-analysis was conducted in only 5 overviews. Overlap between overviews on the same topic ranged from slight (2.7%) to very high (53.8%). CONCLUSIONS Almost all overview topics address treatments and their effects, with a wide variation in the number and quality of SRs included. There is considerable overlap in some orthodontic overviews, suggesting unnecessary duplication and research waste. Researchers should be encouraged to focus on primary data collection to add more high-quality data to SRs, which will ultimately enhance the yield from secondary and tertiary orthodontic research.
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Affiliation(s)
- Declan T Millett
- Cork University Dental School and Hospital, University College Cork, Cork, Ireland.
| | - Philip E Benson
- Academic Unit of Oral Health, Dentistry and Society, School of Clinical Dentistry, University of Sheffield, Sheffield, United Kingdom
| | - Susan J Cunningham
- Department of Orthodontics, University College London Eastman Dental Institute, London, United Kingdom
| | - Grant T McIntyre
- Dundee Dental Hospital, School of Denistry, University of Dundee, Dundee, United Kingdom
| | - Aliki Tsichlaki
- Department of Orthodontics, Barts and the London School of Medicine and Dentistry, Barts Health NHS Trust, London, United Kingdom
| | - Farhad B Naini
- St. George's University Hospitals NHS Foundation Trust, Kingston Hospital NHS Foundation Trust, London, United Kingdom
| | - Claire Laide
- Cork University Dental School and Hospital, University College Cork, Cork, Ireland
| | - Padhraig S Fleming
- Division of Public and Child Dental Health, Dublin Dental University Hospital, Trinity College Dublin, Dublin, Ireland
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Grillo R, Borba AM, Brozoski MA, da Silva YS, Samieirad S, Naclério-Homem MDG. Postoperative nausea and vomiting in orthognathic surgery: systematic review and meta-analysis. Oral Maxillofac Surg 2024:10.1007/s10006-024-01235-0. [PMID: 38509315 DOI: 10.1007/s10006-024-01235-0] [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: 06/23/2023] [Accepted: 03/11/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE Postoperative nausea and vomiting (PONV) is a frequently reported adverse event following orthognathic surgery. The aim of this work is to conduct a systematic review of the literature on the subject, and to discuss the role of maxillofacial surgeons and the steps that can be taken to prevent or control PONV in orthognathic surgery. METHODS A systematic review was conducted according to the PRISMA guidelines, using the search strategy: (orthognathic AND (nausea OR vomiting)). The authors searched PubMed, Embase, Dimensions, Web of Science and Google Scholar databases, without any language restrictions. RevMan 5.4 was used to create a risk of bias graph and a forest plot. RESULTS The included articles were classified as having a low risk of bias, despite the limited literature on the subject. Various measures have been reported to be beneficial in preventing or managing PONV, such as the use of dexamethasone, antiemetic drugs, gastric aspiration, and anesthetic blocks. Effective bleeding control and faster surgeries can also be helpful. CONCLUSIONS Throat packs have not been found to be effective in preventing PONV. Although no definitive protocol has been established in the literature, the Enhanced Recovery After Surgery (ERAS) protocol could be a useful approach. Overall, a multimodal approach may be taken to prevent PONV, and further research is needed to establish definitive protocols.
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Affiliation(s)
- Ricardo Grillo
- Department of Oral & Maxillofacial Surgery, Traumatology and Prosthesis, Faculty of Dentistry, University of São Paulo, São Paulo, SP, Brazil.
- Department of Oral & Maxillofacial Surgery, Faculdade Patos de Minas, Brasília, DF, Brazil.
- Faculdade de Odontologia, University of São Paulo, Av. Prof. Lineu Prestes, 2227. Cidade Universitária, São Paulo, 05508-000, SP, Brazil.
| | | | - Mariana Aparecida Brozoski
- Department of Oral & Maxillofacial Surgery, Traumatology and Prosthesis, Faculty of Dentistry, University of São Paulo, São Paulo, SP, Brazil
| | | | - Sahand Samieirad
- Department of Oral & Maxillofacial surgery, Mashhad dental school, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maria da Graça Naclério-Homem
- Department of Oral & Maxillofacial Surgery, Traumatology and Prosthesis, Faculty of Dentistry, University of São Paulo, São Paulo, SP, Brazil
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Grillo R, Reis BAQ, Brozoski MA, Traina AA, Melhem-Elias F. Optimizing drug regimens and supplementation in orthognathic surgery: A comprehensive and practical guide. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024; 125:101639. [PMID: 37729964 DOI: 10.1016/j.jormas.2023.101639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/17/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE This study aimed to comprehensively review the literature and provide a practical guide for optimizing drug regimens and supplementation related to orthognathic surgery. METHODS The authors conducted a thorough review of the existing literature, following the PRISMA-ScR guidelines. Various types of studies except case reports and reviews were included. The study applied specific inclusion criteria, focusing on perioperative and/or postoperative drugs, medications, or supplementation related to orthognathic surgery. RESULTS This guide included 78 studies on various medications in orthognathic surgery. It encompasses clinical trials, cohort studies, cross-sectional studies, prospective and retrospective studies. The topics covered include antibiotics, analgesics, corticosteroids, antiemetics, hemostatic agents, local anesthetics, herbal medicine, and botulinum toxin. Pain and edema control involved specific medications, while local anesthesia utilized ropivacaine and bupivacaine. The guide also discusses mineral and vitamin supplementation. The effectiveness of hemostatic agents and antiemetics was highlighted. CONCLUSION Pain management, reduced swelling, enhanced wound healing, and faster recovery are among the advantages. In addition to the standard drugs and medications, the inclusion of vitamin and mineral supplements, tranexamic acid, postoperative anesthetic blocks, and preemptive antiemetics is anticipated to offer various benefits in orthognathic surgery, despite the limited available evidence.
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Affiliation(s)
- Ricardo Grillo
- Department of Oral and Maxillofacial Surgery, Traumatology and Prosthesis - Faculty of Dentistry of the University of São Paulo, São Paulo-SP, Brazil; Department of Oral and Maxillofacial Surgery, Faculdade Patos de Minas, Brasília-DF, Brazil.
| | | | - Mariana Aparecida Brozoski
- Department of Oral and Maxillofacial Surgery, Traumatology and Prosthesis - Faculty of Dentistry of the University of São Paulo, São Paulo-SP, Brazil
| | - Andreia Aparecida Traina
- Department of Oral and Maxillofacial Surgery, Traumatology and Prosthesis - Faculty of Dentistry of the University of São Paulo, São Paulo-SP, Brazil
| | - Fernando Melhem-Elias
- Department of Oral and Maxillofacial Surgery, Traumatology and Prosthesis - Faculty of Dentistry of the University of São Paulo, São Paulo-SP, Brazil; Private Practice in São Paulo-SP, Brazil
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Sakane K, Hasegawa S, Nakao H, Sasaki J, Miyachi H, Nagao T. Factors affecting progressive facial swelling immediately after orthognathic surgery: A retrospective cohort study. J Craniomaxillofac Surg 2023; 51:692-695. [PMID: 37816659 DOI: 10.1016/j.jcms.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 08/27/2023] [Accepted: 09/30/2023] [Indexed: 10/12/2023] Open
Abstract
The aim of this study was to identify clinical factors associated with progressive facial swelling after orthognathic surgery. Patients diagnosed with jaw deformities and undergoing orthognathic surgery were retrospectively evaluated, and those with surgical site infection, Le Fort I osteotomy, or genioplasty only were excluded. Facial swelling volume was calculated by comparing facial volume preoperatively and three days postoperatively using 3D images and image analysis software (VECTRA H2). FXIII was measured within three days after surgery in only patients with unexplained postoperative bleeding or hematoma. The correlation between facial swelling volume and clinical factors was statistically analyzed. Facial swelling volume was examined in 78 patients. Univariate analysis showed a significant difference between facial swelling volume (mean = 41.6 cm3) and operation time (mean = 209.3 min, r = 0.283, p = 0.012), ΔHb level (mean = 1.18 g/dL, r = 0.235, p = 0.039), as well as decreased factor XIII activity (mean = 75.3%, p = 0.012). Multivariate analysis showed a significant difference between facial swelling volume and FXIII deficiency (standard error = 6.44, p = 0.031).Progressive facial swelling immediately after orthognathic surgery may be due to factor XIII deficiency.
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Affiliation(s)
- Kaori Sakane
- Department of Maxillofacial Surgery, School of Dentistry, Aichi-Gakuin University, 2-11 Suemori-Dori, Chikusa, Nagoya, Aichi, 464-8651, Japan
| | - Shogo Hasegawa
- Department of Maxillofacial Surgery, School of Dentistry, Aichi-Gakuin University, 2-11 Suemori-Dori, Chikusa, Nagoya, Aichi, 464-8651, Japan.
| | - Hiroaki Nakao
- Department of Maxillofacial Surgery, School of Dentistry, Aichi-Gakuin University, 2-11 Suemori-Dori, Chikusa, Nagoya, Aichi, 464-8651, Japan
| | - Jun Sasaki
- Department of Maxillofacial Surgery, School of Dentistry, Aichi-Gakuin University, 2-11 Suemori-Dori, Chikusa, Nagoya, Aichi, 464-8651, Japan
| | - Hitoshi Miyachi
- Department of Maxillofacial Surgery, School of Dentistry, Aichi-Gakuin University, 2-11 Suemori-Dori, Chikusa, Nagoya, Aichi, 464-8651, Japan
| | - Toru Nagao
- Department of Maxillofacial Surgery, School of Dentistry, Aichi-Gakuin University, 2-11 Suemori-Dori, Chikusa, Nagoya, Aichi, 464-8651, Japan
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Hattori Y, Uda H, Niu A, Yoshimura K, Sugawara Y. Ambulatory sagittal split ramus osteotomy: strategy for enhanced recovery after surgery. Int J Oral Maxillofac Surg 2023; 52:476-480. [PMID: 36100528 DOI: 10.1016/j.ijom.2022.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 08/02/2022] [Accepted: 08/16/2022] [Indexed: 11/19/2022]
Abstract
The sagittal split ramus osteotomy (SSRO) has been performed mainly on an inpatient basis because of the duration of anaesthesia and the potential risk of postoperative complications, such as bleeding, pain, nausea, and vomiting. However, advances in both surgical and anaesthetic management have enabled the reduction of these risks and shortened the length of hospital stay. Thus, the SSRO may be feasible even in the ambulatory setting in elective cases. The clinical records of all patients who underwent an outpatient SSRO between August 2011 and September 2020 at Lilla Craniofacial Clinic were reviewed retrospectively. Data on age, sex, duration of surgery, operative procedures, intraoperative bleeding, and admission status were investigated. In total, 143 patients underwent a bilateral SSRO. The SSRO was performed as an isolated procedure in 73 patients and concomitantly with other surgical procedures in the remaining 70 patients. Overall, 142 of the 143 patients were discharged on the day of surgery (99.3%); only one (0.7%) required an overnight stay because of a submental haemorrhage after genioplasty. No emergency hospitalizations or readmissions occurred after discharge. Multimodal perioperative management, both surgical and anaesthetic, facilitated enhanced patient recovery after surgery, and SSRO was performed successfully and safely as an ambulatory procedure.
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Affiliation(s)
- Y Hattori
- Department of Plastic Surgery, Kanto Central Hospital of the Mutual Aid Association of Public School Teachers, Setagaya-ku, Tokyo, Japan
| | - H Uda
- Department of Plastic Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan; Lilla Craniofacial Clinic Tokyo, Chuo-ku, Tokyo, Japan.
| | - A Niu
- Department of Plastic Surgery, Kanto Central Hospital of the Mutual Aid Association of Public School Teachers, Setagaya-ku, Tokyo, Japan
| | - K Yoshimura
- Department of Plastic Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Y Sugawara
- Department of Plastic Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan; Lilla Craniofacial Clinic Tokyo, Chuo-ku, Tokyo, Japan
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Navarro-Fernández G, Gil-Martínez A, Diaz-Saez MC, Elizagaray-Garcia I, Pili-Mayayo PQ, Ocampo-Vargas JE, Beltran-Alacreu H. Effectiveness of Physical Therapy in Orthognathic Surgery Patients: A Systematic Review of Randomized Controlled Trials. J Funct Morphol Kinesiol 2023; 8:jfmk8010017. [PMID: 36810501 PMCID: PMC9944893 DOI: 10.3390/jfmk8010017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
Orthognathic surgery (OS) can present many complications that affect patients' rehabilitation. However, there have been no systematic reviews that assessed the effectiveness of physiotherapy interventions in the postsurgical rehabilitation of OS patients. The aim of this systematic review was to analyze the effectiveness of physiotherapy after OS. The inclusion criteria were randomized clinical trials (RCTs) of patients who underwent OS and who received therapeutic interventions that included any physiotherapy modality. Temporomandibular joint disorders were excluded. After the filtering process, five RCTs were selected from the 1152 initially obtained (two had acceptable methodological quality; three had insufficient methodological quality). The results obtained showed that the effects of the physiotherapy interventions studied in this systematic review on the variables of range of motion, pain, edema and masticatory muscle strength were limited. Only laser therapy and LED showed a moderate level of evidence in the postoperative neurosensory rehabilitation of the inferior alveolar nerve compared with a placebo LED intervention.
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Affiliation(s)
- Gonzalo Navarro-Fernández
- Escuela Internacional de Doctorado, Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28922 Alcorcón, Spain
- CranioSPain Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28049 Madrid, Spain
| | - Alfonso Gil-Martínez
- CranioSPain Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28049 Madrid, Spain
- Department of Physiotherapy, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28023 Madrid, Spain
- Unit of Physiotherapy, Hospital La Paz-Carlos III, Institute for Health Research IdiPAZ, 28046 Madrid, Spain
- Correspondence: ; Tel.: +34-917401980 (ext. 291)
| | - Marta Carlota Diaz-Saez
- CranioSPain Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28049 Madrid, Spain
- Department of Physiotherapy, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28023 Madrid, Spain
| | - Ignacio Elizagaray-Garcia
- CranioSPain Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28049 Madrid, Spain
- Department of Physiotherapy, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28023 Madrid, Spain
- Motion in Brains Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28023 Madrid, Spain
| | - Paloma Qinling Pili-Mayayo
- Department of Physiotherapy, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28023 Madrid, Spain
| | - Julian Esteban Ocampo-Vargas
- Department of Physiotherapy, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28023 Madrid, Spain
| | - Hector Beltran-Alacreu
- CranioSPain Research Group, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28049 Madrid, Spain
- Toledo Physiotherapy Research Group (GIFTO), Faculty of Physical Therapy and Nursing, Universidad de Castilla-La Mancha, 45004 Toledo, Spain
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