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Mingels S, Granitzer M, Luedtke K, Dankaerts W. What is the Status Quo of Patient-Centred Physiotherapy Management of People with Headache within a Biopsychosocial Model? - A Narrative Review. Curr Pain Headache Rep 2024:10.1007/s11916-024-01306-7. [PMID: 39141253 DOI: 10.1007/s11916-024-01306-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2024] [Indexed: 08/15/2024]
Abstract
PURPOSE OF REVIEW Patient-centred care (PCC) is deemed essential in the rehabilitation of musculoskeletal pain. Integrating such care within a biopsychosocial framework, enables to address all facets of the individual pain experience, and to manage the individual instead of the condition. This narrative review describes the status quo of PCC physiotherapy management of people with headache within a biopsychosocial model. PubMed, EMBASE, Web of Science, Scopus were searched (update 07.05.2024). The search-query comprised terminology relating to "headache", "patient-centred", "biopsychosocial", "physiotherapy". Additional eligibility criteria were reviews, trials, cohort, case report, case-control studies in English, Dutch, French. RECENT FINDINGS Gaps are exposed in patient-centred physiotherapy management of migraine, tension-type headache, and cervicogenic headache. While a biopsychosocial approach is advised to manage migraine and tension-type headache, its use in clinical practice is not reflected by the literature. A biopsychosocial approach is not advised in cervicogenic headache. Psychosocial-lifestyle interventions are mainly delivered by health-care providers other than physiotherapists. Additionally, psychologically-informed practice is barely introduced in physiotherapy headache management. Though, managing the social context within a biopsychosocial framework is advised, the implementation by physiotherapists is unclear. Comparable conclusions apply to PCC. PCC is recommended for the physiotherapy management of primary and secondary headache. Such recommendation remains however theoretical, not reaching clinical implementation. Yet, a shift from the traditional disease-centred model of care towards PCC is ongoing and should be continued in physiotherapy management. With this implementation, clinical and economical studies are needed to evaluate its effectiveness.
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Affiliation(s)
- Sarah Mingels
- Musculoskeletal Research Unit, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Leuven University, Leuven, Belgium.
- Faculty of Rehabilitation Sciences and Physiotherapy, REVAL Rehabilitation Research Centre, Hasselt University, Hasselt, Belgium.
| | - Marita Granitzer
- Faculty of Rehabilitation Sciences and Physiotherapy, REVAL Rehabilitation Research Centre, Hasselt University, Hasselt, Belgium
| | - Kerstin Luedtke
- Department of Physiotherapy, Pain and Exercise Research, Institute of Health Sciences, Universität Zu Lübeck, Zu Lübeck, Germany
| | - Wim Dankaerts
- Musculoskeletal Research Unit, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Leuven University, Leuven, Belgium
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Pozo-Rosich P, Carmo M, Muñiz A, Armada B, Moya-Alarcón C, Pascual J. Migraine treatment: quo vadis? Real-world data study (2015-2022) in Spain. BMC Neurol 2024; 24:107. [PMID: 38566063 PMCID: PMC10985889 DOI: 10.1186/s12883-024-03600-8] [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: 06/12/2023] [Accepted: 03/15/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Migraine is a leading cause of disability, estimated to affect one-in-ten people in Spain. This study aimed to describe the management of migraine in Spain and identify improvement areas. METHODS Non-interventional, retrospective, cross-sectional cohort study conducted using an electronic medical records database covering visits to public healthcare providers for 3% of the Spanish population. Patients with a migraine diagnosis (ICD-9 346) between 01/2015 and 04/2022 were included, as well as their demographic and clinical characteristics, prescribed migraine treatments and the specialty of the prescribing physicians. RESULTS The database included 61,204 patients diagnosed with migraine. A migraine treatment had been prescribed to 50.6% of patients over the last 24 months (only acute to 69.5%, both acute and preventive to 24.2%, and only preventive to 6.3%). The most frequently prescribed treatments were NSAIDs (56.3%), triptans (44.1%) and analgesics (28.9%). Antidepressants were the most common preventive treatment (prescribed to 17.9% of all treated patients and 58.7% of those treated with a preventive medication), and anti-CGRP monoclonal antibodies the least prescribed (1.7%; 5.7%). In 13.4% of cases, preventive medications were the first treatment: alone in 5.8% of cases and together with an acute medication in 7.6%. A fifth of patients who were initially prescribed with only acute treatment were later prescribed a preventive medication (20.7%). On average, it took 29.4 months for this change to occur. Two-thirds of patients started their preventive treatment in primary care (64.2%). The percentage of patients treated by a neurologist increased with the number of received preventive medications. However, 28.8% of patients who had already been prescribed five or more distinct preventive treatments were not treated by a neurologist. Migraine patients had between 1.2- and 2.2-times higher prevalence of comorbidities than the general population, age-gender adjusted. CONCLUSIONS Our study emphasizes the need for improved management of migraine in Spain to reduce the risk of chronification and improve patient outcomes. More training and coordination across healthcare professionals is necessary to recognize and address risk factors for migraine progression, including multiple associated comorbidities and several lines of treatment, and to provide personalized treatment plans that address the complex nature of the condition.
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Affiliation(s)
- Patricia Pozo-Rosich
- Neurology Department, Headache Unit, Hospital Universitari Vall d'Hebron, 119-129 Passeig de la Vall d'Hebron, Barcelona, 08035, Spain.
- Headache Research Group, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain.
| | | | | | | | | | - Julio Pascual
- Service of Neurology, University Hospital Marqués de Valdecilla, Universidad de Cantabria and Valdecilla Biomedical Research Institute (IDIVAL), Santander, Cantabria, Spain
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García-Azorín D, Moya-Alarcón C, Armada B, Sánchez Del Río M. Societal and economic burden of migraine in Spain: results from the 2020 National Health and Wellness Survey. J Headache Pain 2024; 25:38. [PMID: 38486155 PMCID: PMC10941425 DOI: 10.1186/s10194-024-01740-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 02/29/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND The burden of migraine goes beyond the pain and associated symptoms. We aimed to describe the impact of migraine in healthcare resource utilization (HCRU), work productivity, and mood disorders, as well as its economic cost. METHODS Case-control study nested in a cross-sectional analysis of patient-reported data collected between 30/12/2019 and 20/04/2020 as part of the National Health and Wellness Survey, from respondents located in Spain. Adults (≥ 18 years old) who reported a physician diagnosis of migraine and ≥ 1 monthly headache days (MHD) in the previous 30 days were included. HCRU, health-related quality-of-life, depression scores, work and activity impairment, and the associated direct and indirect costs were assessed for four cohorts of migraine patients, according to the frequency of headache (MHD: 1-3, 4-7, 8-14, ≥ 15) and compared to a no-migraine control, matched to migraine cases by a propensity score based on demographic and clinical variables. RESULTS The survey was completed by 595 people with active migraine, of whom 461 (77.4%) experienced < 8 MHDs and 134 (22.6%) ≥ 8 MHDs, and 1,190 non-migraine matched controls. Migraine patients presented worse mental and physical health functioning (SF-12 MCS: 41.9 vs. 44.7, p < 0.001; SF-12 PCS: 48.6 vs. 51.5, p < 0.001), worse self-reported health (EQ-5D VAS: 65.8 vs. 73.5, p < 0.001), more severe depression (PHQ-9: 8.9 vs. 6.1, p < 0.001), and higher overall work impairment (WPAI: 41.4 vs. 25.5, p < 0.001). People with migraine had higher HCRU, twice higher hospitalization rates (17.0% vs. 8.3%, p < 0.001) and 1.6 higher emergency room (ER) visit rates (51.4% vs. 31.2%, p < 0.001). Having migraine translated into higher annual costs with HCRU (€894 vs. €530) and productivity losses (€8,000 vs. €4,780) per person. Respondents with more MHDs presented worse outcomes and higher costs but suffering from 1-3 MHD also increased costs by 51.3%. CONCLUSIONS Having migraine not only causes a massive impact on patients' quality of life and ability to work, but it also generates considerable economic costs for society. In Spain, having migraine was associated to 1.7 higher costs per patient. The clinical and economic burden increases with the frequency of headaches but is higher than controls even in patients suffering from 1-3 MHD.
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Affiliation(s)
- David García-Azorín
- Headache Unit, Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid Health Research Institute (VALLHRI), Calle Rondilla Sta.Teresa, S/N, Valladolid, 47010, Spain.
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del Blanco Muñiz JÁ, Sánchez Sierra A, Ladriñán Maestro A, Ucero Lozano R, Sosa-Reina MD, Martín Vera D. Cervical impairments in subjects with migraine or tension type headache: an observational study. Front Neurol 2024; 15:1373912. [PMID: 38529031 PMCID: PMC10962388 DOI: 10.3389/fneur.2024.1373912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 02/21/2024] [Indexed: 03/27/2024] Open
Abstract
Objective The aim of this investigation was to compare the thickness of the deep local muscles in the neck region, as well as local and widespread sensitivity and functionality, between individuals with migraine, Tension-Type Headache (TTH), and healthy controls. To date, we know that the onset of migraine and TTH share similar pathophysiological pathways. Nevertheless, there may be some anatomical and functional differences which would explain why clinicians may obtain variable results when treating both pathological entities with similar or equal approaches. Methods An observational study was conducted in accordance with STROBE guidelines. The flexor longus colli and multifidus, two neck-stabilizing muscles, were measured using B-mode ultrasound imaging. The upper trapezius, masseter, temporalis, tibialis anterior, and median nerve all underwent bilateral pressure-pain threshold (PPT) assessments. Results Ninety participants were enrolled in the study. All subjects were equally divided into TTH, migraine and control groups. The PPT values exhibited lower thresholds in patients with TTH than both migraine and healthy participants. Specifically, in the temporal muscle on both sides, patients with TTH exhibited a significantly lower threshold (p < 0.001)than both migraine and healthy participants. Patients with TTH displayed significantly lower thresholds in both upper trapezius muscles (right: p < 0.001; left: p = 0.001). Similar results were obtained for the tibialis anterior PPTs from both sides (p = 0.001 in both). However, both clinical groups exhibited lower thresholds than the healthy subjects (p < 0.001). In multifidus muscle cross-sectional area (CSA), no statistically significant differences were found between migraine patients and healthy subjects, both in relaxation and contraction (right; p > 0.05 and p > 0.05; left: p > 0.05 and p > 0.05). However, patients with TTH exhibited a smaller CSA than both migraine patients and healthy controls in multifidus relaxed and contracted state (right: p < 0.001 in both relaxed and contracted multifidus; left: p = 0.001 and p < 0.001, respectively). Similar results were obtained for the left longus colli muscle in both relaxation and contraction for patients with TTH and migraine compared with healthy subjects (p = 0.001 and p < 0.001, respectively, for muscle relaxation and p < 0.001 for muscle contraction). However, no significant differences were observed between patients with TTH and migraine (p < 0.05 in both relaxation and contraction). In the right longus colli, TTH and migraine patients had a significantly smaller CSA during contraction than healthy subjects (p < 0.001 in both comparisons). In the craniocervical flexion test, both groups of patients with TTH and migraine showed significantly lower values than healthy subjects (p < 0.001 in both comparisons). However, no significant differences were found between patients with TTH and migraineurs (p > 0.05). Conclusion The findings provide a significant message for clinicians since anatomical and functional impairments were shown in patients with TTH and migraine. This study corroborates a lack of strength and smaller CSA in both clinical groups compared to controls. Therefore, strengthening programs may be addressed successfully for people with these pathological entities. To be more accurate, according to PPTs and CSA lower values in patients with TTH compared to migraine and controls, manual therapy approaches to desensitize craniocervical soft tissues and exercise therapy to increase endurance of deep cervical muscles may become meaningful especially in subjects with TTH. Nevertheless, in order to distinguish precisely between patients with TTH and migraine, different diagnostic strategies may be used in the future to describe these populations in further detail, which will assist health professionals in a more accurate treatment selection.
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Affiliation(s)
- Jose Ángel del Blanco Muñiz
- Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
- Research Group on Exercise Therapy and Functional Rehabilitation, Faculty of Health Sciences, Universidad Europea de Madrid, Madrid, Spain
| | - Alberto Sánchez Sierra
- Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
- Research Group on Exercise Therapy and Functional Rehabilitation, Faculty of Health Sciences, Universidad Europea de Madrid, Madrid, Spain
- Faculty of Physiotherapy and Nursing, University of Castilla La Mancha, Toledo, Spain
- Physiotherapy Research Group of Toledo (GIFTO), Faculty of Physiotherapy and Nursing, Universidad de Castilla-La Mancha, Toledo, Spain
| | - Arturo Ladriñán Maestro
- Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
- Research Group on Exercise Therapy and Functional Rehabilitation, Faculty of Health Sciences, Universidad Europea de Madrid, Madrid, Spain
- Faculty of Physiotherapy and Nursing, University of Castilla La Mancha, Toledo, Spain
| | - Roberto Ucero Lozano
- Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
| | - María Dolores Sosa-Reina
- Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
| | - Daniel Martín Vera
- Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
- Research Group on Exercise Therapy and Functional Rehabilitation, Faculty of Health Sciences, Universidad Europea de Madrid, Madrid, Spain
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Del Llano Señarís JE, Correia NN, Logusso LG, Errea Rodríguez M, Bringas Roldán C. [The indirect costs of tension type headache. A systematic literature review]. Aten Primaria 2022; 54:102238. [PMID: 35077913 PMCID: PMC8790615 DOI: 10.1016/j.aprim.2021.102238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/14/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The objective of this work was to systematically review the published literature in relation to the estimated indirect costs associated with TTH. DESIGN This systematic review followed the Preferred Reporting Items Statement for Systematic Reviews and Meta-analyzes (PRISMA). DATA SOURCES The review was performed in two main databases, PubMed and EconLit, and was completed with the gray literature search. STUDY SELECTION The basic criterion for the inclusion of studies was that they present at least one measure of indirect costs specific to TTH. DATA EXTRACTION 12 studies were finally selected for information extraction. Of all the selected articles, the characteristics of the study design, the types of costs included, as well as the measurement instrument, and the main results were synthesized. RESULTS The search yielded a total of 568 studies. Heterogeneity was found in the designs and samples/populations of the included studies. Only two studies estimated direct and indirect costs for TTH. Among the most notable results, we find an estimated moderate impact of disability due to TTH (between 0.037 and 0.15 per person, 0.06-0.09% for the population). Productivity and efficiency losses were observed and were very heterogeneous. The willingness to pay for effective treatment would range from $1.32 to $9.20 per month. Quality of life is low, between 28.2 and 28.4 points out of 100, and health-related quality of life seems to improve significantly with treatment. CONCLUSIONS Despite the high heterogeneity of the results, we can conclude that tension headache is characterized by a moderate impact on disability, on productivity and efficiency at work or school, and on the quality of life of those who suffer it.
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Prevalence of Migraine in General Spanish Population; Factors Related and Use of Health Resources. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111145. [PMID: 34769668 PMCID: PMC8583596 DOI: 10.3390/ijerph182111145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 11/17/2022]
Abstract
Migraine is a common neurological disorder considered the second most disabling condition worldwide. Its prevalence ranges from 2.6% to 21.7% in population studies. This study aimed to know the prevalence of diagnosed and undiagnosed migraine in the general Spanish adult population, their health care use, and factors related. A descriptive cross-sectional study was undertaken with 23,089 individuals >15 years from the 2017 Spanish National Health Survey. Three groups were defined: people diagnosed with migraine (DM), people reporting undiagnosed migraine (UM) and people without migraine. Sociodemographic, clinical and use of health resources data were collected. The scales Duke Social Support Index (DSSI) and General Health Questionnaire (GHQ-12) were used. Prevalence of DM and UM were determined with 95% confidence intervals. To determine the factors associated with DM and UM, a multinomial logistic regression model was used. The prevalence of DM was 8.6% (95%CI: 8.2–9), and UM, 0.9% (95%CI: 0.8–1). People with DM more frequently visited healthcare professionals (47.8%), required more supplementary tests (86.8), had a higher percentage of hospitalization (11.3%), and used emergency services (45.1%). Women had nearly three times the risk of DM and UM. Worse mental health was a risk factor for UM (OR = 1.20) and DM (OR = 1.18). The greater the work stress, the greater the risk of DM (OR = 1.12). An adequate monitoring and management of migraine in people with these characteristics could contribute to improving their quality of life and reducing costs in the system.
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Palacios-Ceña D, Albaladejo-Vicente R, Hernández-Barrera V, Lima-Florencio L, Fernández-de-Las-Peñas C, Jimenez-Garcia R, López-de-Andrés A, de Miguel-Diez J, Perez-Farinos N. Female Gender Is Associated with a Higher Prevalence of Chronic Neck Pain, Chronic Low Back Pain, and Migraine: Results of the Spanish National Health Survey, 2017. PAIN MEDICINE 2021; 22:382-395. [PMID: 33164071 DOI: 10.1093/pm/pnaa368] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To assess the prevalence of chronic neck pain (CNP), chronic low back pain (CLBP), and migraine headache (MH) in the Spanish population and to identify sociodemographic and health-related variables associated with CNP, CLBP, and MH. DESIGN Observational study. SETTING Spain. SUBJECTS A total of 22,511 persons 18 years of age or older (10,304 males and 12,207 females) who participated in the 2017 Spanish National Health Survey. METHODS Stratified three-stage sampling was applied. CNP, CLBP, and MH were the dependent variables. The analysis was conducted separately by gender. Sociodemographic features, self-perceived health status, lifestyle habits, comorbidities, and pain features were analyzed by using logistic regression models. RESULTS Females reported a higher prevalence of CNP, CLBP, and MH (P < 0.001) than males. For both sexes, anxiety and/or depression and poor self-rated health were associated with a significantly increased prevalence of CNP, CLBP, and MH. For CNP and CLBP, the identified associated factors were older age and limitations to usual activity. For CNP and MH, the most common associated factor was comorbid respiratory disease. CONCLUSIONS Our study identified several factors associated with CNP, CLBP, and MH in Spanish female and male adults, with potential implications for health care providers.
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Affiliation(s)
- Domingo Palacios-Ceña
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Research Group of Humanities and Qualitative Research in Health Science of Universidad Rey Juan Carlos (Hum&QRinHS), Universidad Rey Juan Carlos, Madrid, Spain
| | - Romana Albaladejo-Vicente
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Lidiane Lima-Florencio
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Research Group of Humanities and Qualitative Research in Health Science of Universidad Rey Juan Carlos (Hum&QRinHS), Universidad Rey Juan Carlos, Madrid, Spain
| | - Cesar Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Research Group of Humanities and Qualitative Research in Health Science of Universidad Rey Juan Carlos (Hum&QRinHS), Universidad Rey Juan Carlos, Madrid, Spain
| | - Rodrigo Jimenez-Garcia
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Ana López-de-Andrés
- Department of Medical Specialties and Public Health, Universidad Rey Juan Carlos, Madrid, Spain
| | - Javier de Miguel-Diez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Napoleon Perez-Farinos
- Department of Public Health and Psychiatry, Faculty of Medicine, Universidad de Málaga, Málaga, Spain
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De Andres J, Formicola GL, Rubio-Haro R, De Andres-Serrano C. Updated management of occipital nerve stimulator lead migration: case report of a technical challenge. Scand J Pain 2021; 21:415-420. [PMID: 34387963 DOI: 10.1515/sjpain-2020-0135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 12/01/2020] [Indexed: 11/15/2022]
Abstract
Electrode migration is a challenge, even with adequate anchoring techniques, due to the high mechanical stress on components of occipital nerve stimulation (ONS) for headache disorders. When a lead displacement of an ONS implant is diagnosed, there are currently different approaches described for its management. Nevertheless current neuromodulation devices are designed like a continuum of components without any intermediate connector, and if a lead displacement is diagnosed, the solution is the complete removal of the electrode from its placement, and its repositioning through an ex-novo procedure. The described technique can allow ONS leads to be revised while minimizing the need to reopen incisions over the IPG, thus improving patients' intraoperative and postoperative discomfort, shortening surgical time and medical costs, reasonably reducing the incidence of infective postoperative complications.
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Affiliation(s)
- Jose De Andres
- Anesthesia, Critical Care and Multidisciplinary Pain Management Department, Valencia University General Hospital, Avda. Tres Cruces, s/n 46014, Valencia, Spain.,Anesthesia Unit, Surgical Specialties Department, School of Medicine, University of Valencia, Valencia, Spain
| | - Giuseppe Luca Formicola
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Pain Management Department of Valencia University General Hospital, Milan, Italy
| | - Ruben Rubio-Haro
- Anesthesia Critical Care and Pain Management Department, Valencia University General Hospital, Valencia, Spain
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