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Ortega-Martínez AR, Grande-Gascón ML, Calero-García MJ. Influence of socio-affective factors on quality of life in women diagnosed with fibromyalgia. Front Psychol 2023; 14:1229076. [PMID: 38023047 PMCID: PMC10664247 DOI: 10.3389/fpsyg.2023.1229076] [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: 05/25/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Fibromyalgia is a disease that involves chronic pain, with high prevalence in the female population and great impact on the bio-psycho-social sphere of people affected by it. However, few studies have analyzed the possible influence of socio-affective factors on the quality of life of people who suffer from this disease. Objective The aim of this study was to determine the relationships between the impact of this disease on the lives of people with fibromyalgia and these variables. Specifically, we analyzed the quality of partner relationship, perceived loneliness, life satisfaction, and perceived socio-family situation. Method A descriptive-correlational cross-sectional design was used. The sample consisted of 69 women diagnosed with fibromyalgia. The participants completed different questionnaires that measured their happiness, satisfaction with life, perceived loneliness, quality of partner relationship, socio-family valuation, and the impact of fibromyalgia. Results The quality of partner relationship, perceived loneliness and socio-family valuation seem to be good predictors of subjective happiness, life satisfaction, and the impact that fibromyalgia has on people's lives, in the sense that the more positive the valuation of the couple relationship and of the socio-family situation, and the lower the perceived loneliness, people feel happier, more satisfied with their lives and the lower the impact that fibromyalgia has on their lives. Conclusion The 50% of satisfaction with life can be explained from the scores obtained in perceived loneliness and the quality of partner relationship. In this sense, perceived loneliness was a good predictor of the impact of fibromyalgia on the lives of these patients.
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Calandre EP, García-Leiva JM, Ordoñez-Carrasco JL. Psychosocial Variables and Healthcare Resources in Patients with Fibromyalgia, Migraine and Comorbid Fibromyalgia and Migraine: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19158964. [PMID: 35897335 PMCID: PMC9331095 DOI: 10.3390/ijerph19158964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023]
Abstract
Fibromyalgia and migraine frequently coexist. We aimed to compare the burden caused by fibromyalgia (FM), migraine (M) and comorbid fibromyalgia and migraine (FM + M) by assessing psychosocial variables and the use of healthcare resources. A survey was posted to the websites of different patients’ associations. It included sociodemographic data, the Patient Health Questionnaire-9, the Insomnia Severity Index, the EuroQOL-5D-5L and a questionnaire evaluating the use of healthcare resources during the past six months. In total, 139 FM patients, 169 M patients and 148 FM + M patients participated in the survey. Mean depression and insomnia scores were clinically relevant in every group and significantly higher in FM + M (16.3 ± 5.4 for depression, 18.5 ± 5.6 for insomnia) than in FM (14.3 ± 5.7 for depression, 16.8 ± 5.5 for insomnia) or M (11.7 ± 5.4 for depression, 13.1 ± 5.9 for depression), where p < 0.001 in both cases. Suicidal ideation was frequent in every group, but significantly more frequent in FM + M (63% vs. 45% in FM and 35% in M; p < 0.001). EQ-5D-5L (0.656 ± 0.1 in FM + M, 0.674 ± 0.1 in FM, 0.827 ± 0.1 in M, p < 0.001) and EQ-5D-5L VAS scores (38.2 ± 21.9 in FM + M, 45.6 ± 21.8 in FM, 63.5 ± 23.7 in M, p < 0.00) were lower than the reported mean population values and the lowest in FM + M. FM and FM + M used more healthcare resources than M. It is concluded that the psychosocial burden was high in the three samples. FM and FM + M had a more relevant impact on patients’ wellbeing and required more medical attention than M. The burden caused by FM + M was higher than in both individual diseases.
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Affiliation(s)
- Elena P. Calandre
- Instituto de Neurociencias “F. Oloriz”, University of Granada, 18100 Granada, Spain;
- Correspondence:
| | - Juan M. García-Leiva
- Instituto de Neurociencias “F. Oloriz”, University of Granada, 18100 Granada, Spain;
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Younis A, Qasem Y, Ali Neamat Sulaiman Alallaf. The Frequency of Fibromyalgia in Migraine Patients. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Fibromyalgia (FM) is a prevailing debilitating ailment that has been described in patients with migraines in several investigations.
AIM: The study aimed to investigate the frequency of FM in migraine patients and to study the characteristics of migraine patients with comorbid FM.
METHODS: This case–control study was piloted in the Neurology Unit, Department of Medicine in Ibn Sina Teaching Hospital in Mosul, Iraq, between March and November 2020. One hundred consecutive patients with migraine and 100 healthy controls were included in this study. The sociodemographic and headache characteristics of the patients were recorded.
RESULTS: The frequency of FM was statistically higher among participants with migraines (27%) when compared to the controls (5%). Migraine patients with FM had a substantially older mean age and a higher ratio of female gender than migraine patients without FM. FM was found to be more common in patients without versus with aura. Patients with comorbid FM had greater headache frequency (p = 0.0002), headache intensity (p = 0.007), and higher scores on the “Headache Impact Test (HIT-6)” (p = 0.0001).
CONCLUSIONS: There is a high frequency of FM in patients with migraines. Patients with coexistent “FM” and “migraine” tended to have more depressive symptoms, greater headache intensity, headache frequency, and when compared to healthy people, they are more likely to have a significant headache-related disability.
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Radunović G, Veličković Z, Rašić M, Janjić S, Marković V, Radovanović S. Assessment of gait in patients with fibromyalgia during motor and cognitive dual task walking: a cross-sectional study. Adv Rheumatol 2021; 61:53. [PMID: 34446109 DOI: 10.1186/s42358-021-00212-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of the study was to assess gait pattern of patients diagnosed with fibromyalgia (FM) while performing demanding motor and/or cognitive dual tasks while walking. Further, idea was to explore possible correlations of dual task gait pattern alterations to patients' functional status and presence or absence of clinical symptoms associated with FM. METHODS Twenty-four female FM patients and 24 healthy female subjects performed a basic walking task, a dual motor, a dual mental (cognitive) and a combined, dual motor and cognitive task simultaneously. Quantitative spatial (stride length) and temporal (cycle time, swing time and double support time) gait parameters were measured using GAITRite walkway system and their variability was assessed. Patients underwent clinical examination including assessment of functional status, pain and fatigue level, psychiatric and cognitive manifestations. RESULTS The motor, cognitive and combined dual tasks affect gait performance in FM patients. Difference in tasks between FM and healthy subjects was found as double support time prolongation. Comparison of tasks showing that cycle time in FM was longer than controls and stride length was shorter in patients for all conditions, while no changes were found in any of the gait parameters variability. Further, mental/cognitive dual tasks had a larger effect than motor tasks. Correlations were also found between depression and functional status of the patients and the gait parameters. CONCLUSIONS Gait is affected in FM patients while dual task walking. No changes in stride-to-stride variability point that patients preserve stability in complex walking situations. Analysis of gait may provide additional information for the FM identification based on presence of clinical features and cognitive status. Correlation of dual task gait alterations with occurrence of clinical symptoms and influence of cognitive changes on gait pattern could additionally define FM subgroups.
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Affiliation(s)
- Goran Radunović
- Institute of Rheumatology, Faculty of Medicine, University of Belgrade, Resavska 69, Belgrade, Serbia
| | - Zoran Veličković
- Institute of Rheumatology, Faculty of Medicine, University of Belgrade, Resavska 69, Belgrade, Serbia
| | - Melanija Rašić
- Institute of Rheumatology, Faculty of Medicine, University of Belgrade, Resavska 69, Belgrade, Serbia
| | - Saša Janjić
- Institute of Rheumatology, Faculty of Medicine, University of Belgrade, Resavska 69, Belgrade, Serbia
| | - Vladana Marković
- Neurology Clinic, Faculty of Medicine, University of Belgrade, Dr Subotića 6, Belgrade, Serbia
| | - Saša Radovanović
- Institute for Medical Research, University of Belgrade, Dr Subotića 4, 11129, Belgrade, Serbia.
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Caponnetto V, Deodato M, Robotti M, Koutsokera M, Pozzilli V, Galati C, Nocera G, De Matteis E, De Vanna G, Fellini E, Halili G, Martinelli D, Nalli G, Serratore S, Tramacere I, Martelletti P, Raggi A. Comorbidities of primary headache disorders: a literature review with meta-analysis. J Headache Pain 2021; 22:71. [PMID: 34261435 PMCID: PMC8278743 DOI: 10.1186/s10194-021-01281-z] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/22/2021] [Indexed: 12/27/2022] Open
Abstract
Background Primary headache disorders are common and burdensome conditions. They are associated to several comorbidities, such as cardiovascular or psychiatric ones, which, in turn, contribute to the global burden of headache. The aim of this study is to provide a comprehensive description of the pooled prevalence of comorbidities of primary headache disorders using a meta-analytical approach based on studies published between 2000 and 2020. Methods Scopus was searched for primary research (clinical and population studies) in which medical comorbidities were described in adults with primary headache disorders. Comorbidities were extracted using a taxonomy derived from the Global Burden of Disease (GBD) study. We compared prevalence of comorbidities among headache sufferers against general population using GBD-2019 estimates, and compared comorbidities’ proportions in clinical vs. population studies, and by age and gender. Results A total of 139 studies reporting information on 4.19 million subjects with primary headaches were included: in total 2.75 million comorbidities were reported (median per subject 0.64, interquartile range 0.32–1.07). The most frequently addressed comorbidities were: depressive disorders, addressed in 51 studies (pooled proportion 23 %, 95 % CI 20–26 %); hypertension, addressed in 48 studies (pooled proportion 24 %, 95 % CI 22–26 %); anxiety disorders addressed in 40 studies (pooled proportion 25 %, 95 % CI 22–28 %). For conditions such as anxiety, depression and back pain, prevalence among headache sufferers was higher than in GBD-2109 estimates. Associations with average age and female prevalence within studies showed that hypertension was more frequent in studies with higher age and less females, whereas fibromyalgia, restless leg syndrome, and depressive disorders were more frequent in studies with younger age and more female. Conclusions Some of the most relevant comorbidities of primary headache disorders – back pain, anxiety and depression, diabetes, ischemic heart disease and stroke – are among the most burdensome conditions, together with headache themselves, according to the GBD study. A joint treatment of headaches and of these comorbidities may positively impact on headache sufferers’ health status and contribute to reduce the impact of a group of highly burdensome diseases. Supplementary Information The online version contains supplementary material available at 10.1186/s10194-021-01281-z.
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Affiliation(s)
| | - Manuela Deodato
- Department of Life Sciences, University of Trieste, Trieste, Italy. .,Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.
| | - Micaela Robotti
- Centro di Diagnosi e Cura delle Cefalee, Palazzo della Salute, Gruppo San Donato, Milano, Italy.,PainClinicMilano, Centro Medico Visconti di Modrone, Milano, Italy
| | | | - Valeria Pozzilli
- Internal Medicine Unit, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Cristina Galati
- UO Neuropsichiatria Infantile, Policlinico Universitario Paolo Giaccone, Università degli Studi di Palermo, Palermo, Italy
| | - Giovanna Nocera
- UO Neuropsichiatria Infantile, Policlinico Universitario Paolo Giaccone, Università degli Studi di Palermo, Palermo, Italy
| | - Eleonora De Matteis
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Gioacchino De Vanna
- Clinica Neurologica, Dipartimento di Medicina, Università degli Studi di Perugia, Perugia, Italy
| | - Emanuela Fellini
- Internal Medicine Unit, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Gleni Halili
- Department of Neurology, University Hospital Center 'Mother Teresa', Tirana, Albania
| | - Daniele Martinelli
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Gabriele Nalli
- Internal Medicine Unit, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Serena Serratore
- Internal Medicine Unit, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Irene Tramacere
- Dipartimento di Ricerca e Sviluppo Clinico, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Roma, Italy.,Regional Referral Headache Center, Sant'Andrea University Hospital, Roma, Italy
| | - Alberto Raggi
- UOC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
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Tu CH, Lin CL, Yang ST, Shen WC, Chen YH. Hormonal Contraceptive Treatment May Reduce the Risk of Fibromyalgia in Women with Dysmenorrhea: A Cohort Study. J Pers Med 2020; 10:jpm10040280. [PMID: 33327434 PMCID: PMC7768424 DOI: 10.3390/jpm10040280] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 12/15/2022] Open
Abstract
Dysmenorrhea is the most common gynecological disorder for women in the reproductive age. Study has indicated that dysmenorrhea might be a general risk factor of chronic pelvic pain and even chronic non-pelvic pain, such as fibromyalgia. We used the Longitudinal Health Insurance Database 2000 from the Taiwan National Health Research Institutes Database to investigate whether women with dysmenorrhea have a higher risk of fibromyalgia and whether treatment of dysmenorrhea reduced the risk of fibromyalgia. The dysmenorrhea cohort was matched with a non-dysmenorrhea cohort at a 1:1 ratio based on gender, age, and the year of entry study by frequency matching. Multivariable Cox proportional hazard regression models were used to assess the risk of fibromyalgia, with controlling for potential confounding variables such as age, comorbidities, and medication use. After controlling confounding variables, results revealed that women with dysmenorrhea have a significantly higher risk of fibromyalgia than women without dysmenorrhea. However, only treatment of dysmenorrhea with hormonal contraceptives reduce the risk of fibromyalgia. These results indicated that dysmenorrhea may be a risk factor of fibromyalgia, whereas personalized medicine for treatment of dysmenorrhea may be the key to reduce the risk of fibromyalgia. Future studies are needed to identify the causes and prevention strategies in detail.
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Affiliation(s)
- Cheng-Hao Tu
- Graduate Institute of Acupuncture Science, China Medical University, Taichung 404333, Taiwan
- Correspondence: (C.-H.T.); (Y.-H.C.); Tel.: +886-4-22053366 (C.-H.T.) (ext. 3336)
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung 404332, Taiwan;
| | - Su-Tso Yang
- Department of Medical Imaging, China Medical University Hospital, Taichung 404332, Taiwan;
- School of Chinese Medicine, China Medical University, Taichung 404333, Taiwan
| | - Wei-Chih Shen
- Center of Augmented Intelligence in Healthcare, China Medical University Hospital, Taichung 404332, Taiwan;
- Department of Computer Science and Information Engineering, Asia University, Taichung 413305, Taiwan
| | - Yi-Hung Chen
- Graduate Institute of Acupuncture Science, China Medical University, Taichung 404333, Taiwan
- Traditional Chinese Medicine Research Center, China Medical University, Taichung 404333, Taiwan
- Department of Photonics and Communication Engineering, Asia University, Taichung 41354, Taiwan
- Correspondence: (C.-H.T.); (Y.-H.C.); Tel.: +886-4-22053366 (C.-H.T.) (ext. 3336)
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Sastre Real M, Díaz de Terán J. OnabotulinumtoxinA Is an Effective Treatment for Chronic Migraine in Patients With Comorbid Fibromyalgia. Front Neurol 2020; 11:575130. [PMID: 33178117 PMCID: PMC7593548 DOI: 10.3389/fneur.2020.575130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/26/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction: Fibromyalgia (FM) is a frequent comorbidity in patients with chronic migraine (CM). PREEMPT trials, which demonstrated the efficacy of OnabotulinumtoxinA (OnabotA) on CM, excluded patients with FM. Our aim was to evaluate the effectiveness of OnabotA in a series of patients with CM and FM. Methods: We analyzed patients with a previous diagnosis of CM and FM who had received sessions of OnabotA quarterly between January 2014 and January 2020 in a specialized Headache Clinic. Primary endpoint was the reduction in moderate to severe headache days at 3, 6, 9, and 12 months. Results: Data were collected from 31 patients with CM and FM that received OnabotA (100% females). Mean age at first procedure was 50.2 ± 11.3 years. Depression (93.5%), other central sensitization syndromes (irritable bowel syndrome, interstitial cystitis, multiple chemical sensitivity, endometriosis, and chronic fatigue syndrome) (48.4%), and medication overuse headache (90.3%) were frequent comorbidities. 48.4% of patients had failed ≥3 preventives previously. The percentage of patients who achieved ≥30 and ≥50% moderate-severe headache reduction on the third month was 65.4 and 48.2%, respectively. Twenty-three patients completed four cycles of treatment, with 13.4 fewer headache days per month than at baseline (p < 0.001). By 1 year, 69.5% had ≥50% reduction of headache frequency and 39.1% had a ≥75% reduction. In 4 cases (21%), OnabotA was interrupted due to a lack of response. Only mild adverse effects were recorded. Conclusion: OnabotA is an effective treatment for CM in patients with FM.
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Affiliation(s)
- María Sastre Real
- Department of Neurology, La Paz University Hospital, Madrid, Spain.,La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Javier Díaz de Terán
- Department of Neurology, La Paz University Hospital, Madrid, Spain.,La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.,CranioSPain Research Group, La Salle Higher Center for University Studies, Physiotherapy Department, Autonomous University of Madrid, Madrid, Spain
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Correa-Rodríguez M, Mansouri-Yachou JE, Casas-Barragán A, Molina F, Rueda-Medina B, Aguilar-Ferrandiz ME. The Association of Body Mass Index and Body Composition with Pain, Disease Activity, Fatigue, Sleep and Anxiety in Women with Fibromyalgia. Nutrients 2019; 11:E1193. [PMID: 31137906 PMCID: PMC6566359 DOI: 10.3390/nu11051193] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/14/2019] [Accepted: 05/22/2019] [Indexed: 12/26/2022] Open
Abstract
The link between fibromyalgia syndrome (FMS) and obesity has not been thoroughly investigated. The purpose of this study was to examine the relationships among body mass index (BMI) and body composition parameters, including fat mass, fat mass percentage, and visceral fat, as well as FMS features, such as tender point count (TPC), pain, disease activity, fatigue, sleep quality, and anxiety, in a population of FMS women and healthy controls. A total of seventy-three women with FMS and seventy-three healthy controls, matched on weight, were included in this cross-sectional study. We used a body composition analyzer to measure fat mass, fat mass percentage, and visceral fat. Tender point count (TPC) was measured by algometry pressure. The disease severity was measured with the Fibromyalgia Impact Questionnaire (FIQ-R) and self-reported global pain was evaluated with the visual analog scale (VAS). To measure the quality of sleep, fatigue, and anxiety we used the Pittsburgh Sleep Quality Questionnaire (PSQI), the Spanish version of the multidimensional fatigue inventory (MFI), and the Beck Anxiety Inventory (BAI), respectively. Of the women in this study, 38.4% and 31.5% were overweight and obese, respectively. Significant differences in FIQ-R.1 (16.82 ± 6.86 vs. 20.66 ± 4.71, p = 0.030), FIQ-R.3 (35.20 ± 89.02 vs. 40.33 ± 5.60, p = 0.033), and FIQ-R total score (63.87 ± 19.12 vs. 75.94 ± 12.25, p = 0.017) among normal-weight and overweight FMS were observed. Linear analysis regression revealed significant associations between FIQ-R.2 (β(95% CI)= 0.336, (0.027, 0.645), p = 0.034), FIQ-R.3 (β(95% CI)= 0.235, (0.017, 0.453), p = 0.035), and FIQ-R total score (β(95% CI)= 0.110, (0.010, 0.209), p = 0.032) and BMI in FMS women after adjusting for age and menopause status. Associations between sleep latency and fat mass percentage in FMS women (β(95% CI)= 1.910, (0.078, 3.742), p = 0.041) and sleep quality and visceral fat in healthy women (β(95% CI)= 2.614, (2.192, 3.036), p = 0.008) adjusted for covariates were also reported. The higher BMI values are associated with poor FIQ-R scores and overweight and obese women with FMS have higher symptom severity. The promotion of an optimal BMI might contribute to ameliorate some of the FMS symptoms.
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Affiliation(s)
- María Correa-Rodríguez
- Department of Nursing, Faculty of Health Sciences, University of Granada (UGR), Instituto de Investigación Biosanitaria Granada (IBS Granada), 18016 Granada, Spain.
| | - Jamal El Mansouri-Yachou
- Department of Physical Therapy, Faculty of Health Science, PhD student of the Biomedicine program of the University of Granada (UGR), 18016 Granada, Spain.
| | - Antonio Casas-Barragán
- Department of Physical Therapy, Faculty of Health Science, PhD student of the Biomedicine program of the University of Granada (UGR), 18016 Granada, Spain.
| | - Francisco Molina
- Department of Health Science, University of Jaén, Paraje Las Lagunillas s/n, 23071 Jaén, Spain.
| | - Blanca Rueda-Medina
- Department of Nursing, Faculty of Health Sciences, University of Granada (UGR), Instituto de Investigación Biosanitaria Granada (IBS Granada), 18016 Granada, Spain.
| | - María Encarnación Aguilar-Ferrandiz
- Department of Physical Therapy, Faculty of Health Science, University of Granada (UGR), Instituto de Investigación Biosanitaria Granada (IBS. Granada), 18016 Granada, Spain.
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