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Rodrigues A, Carvalho GF, Florencio LL, Martins J, Pinheiro-Araújo CF, Rosa MDD, Dach F, Bevilaqua-Grossi D. Reliability and construct validity of the Craniocervical Flexion Test in patients with migraine. Braz J Phys Ther 2024; 28:101085. [PMID: 38936314 PMCID: PMC11260925 DOI: 10.1016/j.bjpt.2024.101085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 04/04/2024] [Accepted: 06/02/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Migraine may be accompanied by several cervical musculoskeletal dysfunctions, for example an altered performance on the Craniocervical Flexion Test (CCFT). However, CCFT measurement properties are still unclear in patients with migraine. OBJECTIVES To determine intra- and inter-examiner reliability, construct validity, standard measurement error (SEM), and minimal detectable change (MDC) of the CCFT in patients with migraine. METHODS Women diagnosed with migraine were considered eligible for this study. Participants were assessed by two examiners for the inter-examiner reliability, and with 7-10 days interval for the intra-examiner reliability. Construct validity was assessed considering headache and neck pain frequency and intensity, and self-reported questionnaires, including the Headache Impact Test - 6 items (HIT-6), the 12-item Allodynia Symptom Checklist/Brazil (ASC-12), and the Neck Disability Index (NDI). In addition, participants performed cervical endurance and maximal voluntary isometric contraction of the cervical flexors. RESULTS A total of 103 women with migraine were recruited. The intra-examiner reliability was rated as good (ICC= 0.81, 95% CI: 0.73, 0.87), while the inter-examiner reliability was rated as moderate (ICC= 0.55, 95% CI: 0.40, 0.67). The intra and inter-examiner SEM were 1.31 and 1.36 mmHg respectively, and MDC were 3.63 and 3.77 mmHg. The HIT-6 and the cervical endurance flexion test were associated with the CCFT in a multiple linear regression model (p = 0.004, R = 0.35). CONCLUSION The CCFT presents adequate intra- and inter-examiner reliability. Better performance on the CCFT test was associated with better HIT-6 scores and greater cervical endurance time, which was not influenced by the presence of neck pain.
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Affiliation(s)
- Amanda Rodrigues
- Department of Health Sciences, Ribeirão Preto Medical School, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Gabriela Ferreira Carvalho
- Department of Physical Therapy, Faculty of Health, Safety and Society, Furtwangen University, Furtwangen, Germany
| | - Lidiane Lima Florencio
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Rey Juan Carlos University, Madrid, Spain.
| | - Jaqueline Martins
- Department of Health Sciences, Ribeirão Preto Medical School, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | | | - Milena Dietrich Deitos Rosa
- Department of Health Sciences, Ribeirão Preto Medical School, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Fabíola Dach
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Débora Bevilaqua-Grossi
- Department of Health Sciences, Ribeirão Preto Medical School, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
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Di Antonio S, Arendt-Nielsen L, Ponzano M, Bovis F, Torelli P, Elisa P, Finocchi C, Castaldo M. Profiling migraine patients according to clinical and psychophysical characteristics: clinical validity of distinct migraine clusters. Neurol Sci 2024; 45:1185-1200. [PMID: 37833507 PMCID: PMC10858147 DOI: 10.1007/s10072-023-07118-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023]
Abstract
AIMS Investigate if different clinical and psychophysical bedside tools can differentiate between district migraine phenotypes in ictal/perictal (cohort 1) and interictal (cohort 2) phases. METHOD This observational study included two independent samples in which patients were subgrouped into distinct clusters using standardized bedside assessment tools (headache frequency, disability, cervical active range of motion, pressure pain threshold in different areas): (A) cohort 1-ictal/perictal migraine patients were subgrouped, based on previous studies, into two clusters, i.e., Cluster-1.1 No Psychophysical Impairments (NPI) and Cluster-1.2 Increased Pain Sensitivity and Cervical Musculoskeletal Dysfunction (IPS-CMD); (B) cohort 2-interictal migraine patients were subgrouped into three clusters, i.e., Cluster-2.1 NPI, Cluster-2.2 IPS, and Cluster-2.3 IPS-CMD. Clinical characteristics (multiple questionnaires), somatosensory function (comprehensive quantitative sensory testing (QST)), and cervical musculoskeletal impairments (cervical musculoskeletal assessment) were assessed and compared across headache clusters and a group of 56 healthy controls matched for sex and age. RESULTS Cohort 1: A total of 156 subjects were included. Cluster-1.2 (IPS-CMD) had higher headache intensity (p = 0.048), worse headache-related (p = 0.003) and neck-related disability (p = 0.005), worse quality of life (p = 0.003), and higher symptoms related to sensitization (p = 0.001) and psychological burden (p = 0.005) vs. Cluster-1.1(NPI). Furthermore, Cluster-1.2 (IPS-CMD) had (1) reduced cervical active and passive range of motion (p < 0.023), reduced functionality of deep cervical flexors (p < 0.001), and reduced values in all QST(p < 0.001) vs. controls, and (2) reduced active mobility in flexion, left/right lateral flexion (p < 0.045), and reduced values in QST (p < 0.001) vs. Cluster-1.1 (NPI). Cohort 2: A total of 154 subjects were included. Cluster-2.3 (IPS-CMD) had (1) longer disease duration (p = 0.006), higher headache frequency (p = 0.006), disability (p < 0.001), and psychological burden (p = 0.027) vs. Cluster-2.2 (IPS) and (2) higher headache-related disability (p = 0.010), neck-related disability (p = 0.009), and higher symptoms of sensitization (p = 0.018) vs. Cluster-2.1 (NPI). Cluster-2.3(IPS-CMD) had reduced cervical active and passive range of motion (p < 0.034), and reduced functionality of deep cervical flexors (p < 0.001), vs. controls, Custer-2.1 (NPI), and Cluster-2.2 (IPS). Cluster-2.2 (IPS) and 2.3 (IPS-CMD) had reduced QST values vs. controls (p < 0.001) and Cluster-2.1 (p < 0.039). CONCLUSION A battery of patient-related outcome measures (PROMs) and quantitative bedside tools can separate migraine clusters with different clinical characteristics, somatosensory functions, and cervical musculoskeletal impairments. This confirms the existence of distinct migraine phenotypes and emphasizes the importance of migraine phases of which the characteristics are assessed. This may have implications for responders and non-responders to anti-migraine medications.
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Affiliation(s)
- Stefano Di Antonio
- Department of Health Science and Technology, Center for Pain and Neuroplasticity (CNAP), School of Medicine, SMI, Aalborg University, Aalborg, Denmark
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal Child Health, Genoa, Italy
| | - Lars Arendt-Nielsen
- Department of Health Science and Technology, Center for Pain and Neuroplasticity (CNAP), School of Medicine, SMI, Aalborg University, Aalborg, Denmark
- Department of Gastroenterology & Hepatology, Mech-Sense, Clinical Institute, Aalborg University Hospital, 9000, Aalborg, Denmark
- Clinical Institute, Steno Diabetes Center North Denmark, Aalborg University Hospital, 9000, Aalborg, Denmark
| | - Marta Ponzano
- Department of Health Sciences (DISSAL), Section of Biostatistics, University of Genoa, Genoa, Italy
| | - Francesca Bovis
- Department of Health Sciences (DISSAL), Section of Biostatistics, University of Genoa, Genoa, Italy
| | - Paola Torelli
- Headache Centre, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Pelosin Elisa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal Child Health, Genoa, Italy
- IRCCS, Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Matteo Castaldo
- Department of Health Science and Technology, Center for Pain and Neuroplasticity (CNAP), School of Medicine, SMI, Aalborg University, Aalborg, Denmark.
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Bevilaqua-Grossi D, Pinheiro-Araujo CF, Carvalho GF, Florencio LL. Neck pain repercussions in migraine - The role of physiotherapy. Musculoskelet Sci Pract 2023; 66:102786. [PMID: 37291009 DOI: 10.1016/j.msksp.2023.102786] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 05/26/2023] [Accepted: 05/27/2023] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Migraine is a neurological and disabling disease whose peripheral manifestations can be addressed with physiotherapy. These manifestations can include pain and hypersensitivity to muscular and articular palpation in the neck and face region, a higher prevalence of myofascial trigger points, limitation in global cervical motion, especially in the upper segment (C1-C2), and forward head posture with worse muscular performance. Furthermore, patients with migraine can present cervical muscle weakness and greater co-activation of antagonists in maximum and submaximal tasks. In addition to musculoskeletal repercussions, these patients can also present balance impairment and a greater risk of falls, especially when chronicity of migraine frequency is present. The physiotherapist is a relevant player in the interdisciplinary team and can help these patients to control and manage their migraine attacks. PURPOSE This position paper discusses the most relevant musculoskeletal repercussions of migraine in the craniocervical area under the perspective of sensitization and disease chronification, besides addressing physiotherapy as an important strategy for evaluating and treating these patients. IMPLICATIONS Physiotherapy as a non-pharmacological treatment option in migraine treatment may potentially reduce musculoskeletal impairments related to neck pain in this population. Disseminating knowledge about the different types of headaches and the diagnostic criteria can support physiotherapists who compose a specialized interdisciplinary team. Furthermore, it is important to acquire competencies in neck pain assessment and treatment approaches according to the current evidence.
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Affiliation(s)
- Debora Bevilaqua-Grossi
- Health Sciences Department, Ribeirão Preto Medical School, University of São Paulo, Bandeirantes Avenue, Monte Alegre, Ribeirão Preto, SP, Brazil.
| | - Carina F Pinheiro-Araujo
- Health Sciences Department, Ribeirão Preto Medical School, University of São Paulo, Bandeirantes Avenue, Monte Alegre, Ribeirão Preto, SP, Brazil.
| | - Gabriela F Carvalho
- Institute of Health Sciences, Academic Physiotherapy, Pain and Exercise Research Luebeck (P.E.R.L.), University of Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany.
| | - Lidiane L Florencio
- Department of Physiotherapy, Occupational Therapy, Physical Medicine and Rehabilitation, King Juan Carlos University, Madrid, 28922, Alcorcón, Spain.
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Neck Active Movements Assessment in Women with Episodic and Chronic Migraine. J Clin Med 2021; 10:jcm10173805. [PMID: 34501252 PMCID: PMC8432227 DOI: 10.3390/jcm10173805] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 12/28/2022] Open
Abstract
We aimed to compare movement parameters and muscle activity during active cervical spine movements between women with episodic or chronic migraine and asymptomatic control. We also assessed the correlations between cervical movement measures with neck-related disability and kinesiophobia. Women with episodic (n = 27; EM) or chronic (n = 27; CM) migraine and headache-free controls (n = 27; CG) performed active cervical movements. Cervical range of motion, angular velocity, and percentage of muscular activation were calculated in a blinded fashion. Compared to CG, the EM and CM groups presented a reduced total range of motion (p < 0.05). Reduced mean angular velocity of cervical movement was also observed in both EM and CM compared to CG (p < 0.05). Total cervical range of motion and mean angular velocity showed weak correlations with disability (r = −0.25 and −0.30, respectively; p < 0.05) and weak-to-moderate correlations with kinesiophobia (r = −0.30 and −0.40, respectively; p < 0.05). No significant correlation was observed between headache features and total cervical range of motion or mean angular velocity (p > 0.05). No differences in the percentage of activation of both flexors and extensors cervical muscles during active neck movements were seen (p > 0.05). In conclusion, episodic and chronic migraines were associated with less mobility and less velocity of neck movements, without differences within muscle activity. Neck disability and kinesiophobia are negative and weakly associated with cervical movement.
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Rodrigues A, Florencio LL, Martins J, Bragatto MM, Fernández-de-Las-Penãs C, Dach F, Bevilaqua-Grossi D. Craniocervical flexion test in patients with migraine: Discriminative validity and accuracy. Int J Clin Pract 2021; 75:e14248. [PMID: 33884715 DOI: 10.1111/ijcp.14248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/16/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To evaluate the discriminative validity and provide a clinical cut-off of the craniocervical flexion test (CCFT) in migraineurs stratified by the report of neck pain, headache-related disability and neck disability. METHODS Fifty women without headache and 102 women with migraine were recruited by convenience from a local tertiary care setting. Migraine diagnosis followed the International Classification of Headache Disorders. All volunteers underwent the CCFT. Patients with migraine answered the Migraine Disability Assessment (MIDAS) and Neck Disability Index (NDI) questionnaires. Discriminative validity was verified by group comparison, and the clinical cut-off was obtained and classified according to the diagnostic accuracy of the CCFT. RESULTS The CCFT presented discriminative validity for comparing control (median = 28, IQR = 6) with migraine (median = 26, IQR = 4, P = .01) and migraine with neck pain (median = 26, IQR = 4, P = .01), but not among the migraine subtypes with disability by migraine or neck pain-related disability on the MIDAS and NDI. The diagnostic accuracies were classified between poor and not discriminating with the area under the receiver operating characteristic curve ranging from 57% to 69% and non-acceptable values of sensitivity, specificity and positive and negative likelihood ratios. CONCLUSION The CCFT can discriminate asymptomatic controls from migraine patients with and without neck pain. However, it cannot discriminate patients with migraine according to their pain-related disability. Also, the CCFT does not offer an optimal cut-off value in migraine patients adequate to clinical practice.
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Affiliation(s)
- Amanda Rodrigues
- Department of Health Sciences-Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Lidiane Lima Florencio
- Department of Physiotherapy, Occupational Therapy, Rehabilitation and Physical Medicine, King Juan Carlos University, Madrid, Spain
| | - Jaqueline Martins
- Department of Health Sciences-Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Marcela Mendes Bragatto
- Department of Health Sciences-Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - César Fernández-de-Las-Penãs
- Department of Physiotherapy, Occupational Therapy, Rehabilitation and Physical Medicine, King Juan Carlos University, Madrid, Spain
| | - Fabiola Dach
- Department of Neurosciences and Behavioral Sciences-Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Débora Bevilaqua-Grossi
- Department of Health Sciences-Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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Xavier NDS, Benatto MT, Florencio LL, Fernández-de-Las-Peñas C, Dach F, Bevilaqua-Grossi D. Are there gender differences in neck pain and musculoskeletal disorders of the cervical spine associated with migraine? PAIN MEDICINE 2021; 22:3021-3029. [PMID: 33739397 DOI: 10.1093/pm/pnab106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To evaluate gender differences in clinical characteristics of migraine by examining presence and severity of cutaneous allodynia, migraine-related disability, neck pain and its associated disability, passive mobility of the upper cervical spine, and performance of the deep neck flexor muscles. DESIGN cross-sectional study. SUBJECTS 30 men and 30 women with migraine. METHODS Participants responded to the questionnaires Migraine Disability Assessment questionnaire, 12-item Allodynia Symptom Checklist and Neck Disability Index. The mobility of the upper cervical spine was assessed by using the Flexion-Rotation Test. Performance of the deep neck flexor muscles was evaluated by applying the Craniocervical Flexion Test. Comparison of the groups was carried out by using the Student's t-test or the chi-square test. The prevalence ratio was also calculated. RESULTS Women showed a higher prevalence of cutaneous allodynia (p = 0.001) and a 4 times greater risk of having severe cutaneous allodynia than to men (p = 0.007). No gender differences were observed in migraine-related disability (p = 0.08). Women showed higher prevalence of self-reported neck pain (p = 0.03) and increased risk of having this symptom in comparison to men (Prevalence Ratio=1.69; p = 0.025). However, there were no gender differences in neck pain-related disability (p = 0.25), mobility of the upper cervical spine (p = 0.92), or performance of the deep neck flexor muscles (p = 0.52). CONCLUSION Women with migraine had a higher frequency of self-reported neck pain and higher prevalence and severity of cutaneous allodynia when compared to men. However, the two groups did not differ regarding neck pain-related disability and performance in the physical tests.
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Affiliation(s)
- Nathan da Silva Xavier
- Department of Health Sciences - Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto-SP, Brazil
| | - Mariana Tedeschi Benatto
- Department of Health Sciences - Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto-SP, Brazil
| | - Lidiane Lima Florencio
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine - Universidad Rey Juan Carlos, Alcorcón, Spain
| | - César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine - Universidad Rey Juan Carlos, Alcorcón, Spain
| | - Fabiola Dach
- Department of Neurosciences and Behavioral Sciences - Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto-SP, Brazil
| | - Débora Bevilaqua-Grossi
- Department of Health Sciences - Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto-SP, Brazil
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Mapping Assessments Instruments for Headache Disorders against the ICF Biopsychosocial Model of Health and Disability. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 18:ijerph18010246. [PMID: 33396262 PMCID: PMC7795912 DOI: 10.3390/ijerph18010246] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 12/12/2022]
Abstract
Headache disorders have a strong impact on sufferers’ lives. However, the “content” of assessment instruments addressing concepts, such as disability and quality of life (QoL), has not comprehensively been addressed. We searched SCOPUS for research papers in which outcome measures were used in adult populations of patients with migraine, tension-type headache (TTH), and cluster headache (CH). The content of single instruments was then mapped against the International Classification of Functioning, Disability, and Health. A total of 150 papers and 26 instruments were included: 15 addressed disability or impact, two addressed work-related difficulties, and nine addressed QoL. Few instruments were commonly used across the conditions and covered domains of functioning were impact on daily life activities, homework, school, and work-related tasks, leisure time, informal and family relations, pain, emotional difficulties, energy level, and impulse control. Most of the research is based on instruments that were developed for migraine, which is critical for CH, and the impact of headache disorders on work-related activities is poorly acknowledged. Further research is needed to expand the scope of headaches impact on daily life activities, and on environmental factors relevant to headache disorders to raise knowledge on the less represented areas, e.g., TTH impact.
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Bragatto MM, Bevilaqua-Grossi D, Benatto MT, Lodovichi SS, Pinheiro CF, Carvalho GF, Dach F, Fernández-de-las-Peñas C, Florencio LL. Is the presence of neck pain associated with more severe clinical presentation in patients with migraine? A cross-sectional study. Cephalalgia 2019; 39:1500-1508. [DOI: 10.1177/0333102419854061] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective To investigate the association between the presence of self-reported neck pain in patients with migraine and clinical features, upper cervical mobility, and neck muscle performance. Methods A total of 142 patients with migraine were recruited and stratified by the presence (n = 99) or absence of self-reported neck pain (n = 43). The clinical examination included the Migraine Disability Assessment, the 12-item Allodynia Symptom Checklist, a flexion rotation test, and the Craniocervical Flexion Test. Results Migraine-related disability was reported by more than 80% in both groups ( p = 0.82). However, there was a greater prevalence and severity of cutaneous allodynia observed in the group with neck pain ( p < 0.001). Reduced upper cervical mobility was verified in 67% of the patients with neck pain and in 41% of those without neck pain ( p = 0.005). In addition, 67% of the patients with neck pain and 40% without neck pain were not able to maintain the third stage of the Craniocervical Flexion Test without compensation ( p = 0.003). Conclusions The presence of self-reported neck pain in patients with migraine was associated with a poor clinical presentation regarding cutaneous allodynia, neck mobility, and muscle function. However, there were no differences in migraine-related disability.
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Affiliation(s)
- Marcela Mendes Bragatto
- Department of Health of Science, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Sao Paulo, Brazil
| | - Débora Bevilaqua-Grossi
- Department of Health of Science, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Sao Paulo, Brazil
| | - Mariana Tedeschi Benatto
- Department of Health of Science, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Sao Paulo, Brazil
| | - Samuel Straceri Lodovichi
- Department of Health of Science, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Sao Paulo, Brazil
| | - Carina Ferreira Pinheiro
- Department of Health of Science, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Sao Paulo, Brazil
| | - Gabriela Ferreira Carvalho
- Department of Health of Science, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Sao Paulo, Brazil
| | - Fabiola Dach
- Department of Neurosciences and Behavioral Sciences – Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Sao Paulo, Brazil
| | - César Fernández-de-las-Peñas
- Department of Physiotherapy, Occupational Therapy, Physiscal Medicine and Rehabilitation, King Juan Carlos University, Madrid, Spain
| | - Lidiane Lima Florencio
- Department of Physiotherapy, Occupational Therapy, Physiscal Medicine and Rehabilitation, King Juan Carlos University, Madrid, Spain
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