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Chapter 7
Advances in Comprehensive Pulmonary Rehabilitation
for COPD Patients
R. Martín-Valero, M.C. Rodríguez-Martínez,
R. Cantero-Tellez, E. Villanueva-Calvero and
F. Fernández-Martín
Additional information is available at the end of the chapter
http://dx.doi.org/10.5772/57563
1. Introduction
Physical inactivity (lack of exertional pursuits) is the fourth leading risk factor for mortality
worldwide and contributes to 6% of all deaths. Only hypertension, smoking, and diabetes are
associated with greater mortality [1]. In addition, nearly 5% of worldwide mortality is caused
by excessive weight [2]. Numerous prospective, observational studies suggest that the least
active and unfit people are at the greatest risk for developing a variety of chronic diseases [3].
Physical inactivity has been identified as an independent risk factor for cardiovascular disease,
diabetes, hypertension, obesity, osteoporosis, colon, breast and other cancers, depression,
anxiety and other illnesses [4].
Chronic Obstructive Pulmonary disease (COPD) is the most common chronic lung disease and
is the fourth leading cause of death in the world. COPD has a high impact on patients´
wellbeing, health care utilization, and mortality [5] and causes a substantial and increasing
economic and social burden [6, 7].
As COPD worsens and individuals experience increasing respiratory symptoms, a vicious
cycle develops whereby activity declines, walking speed is reduced, fitness levels decline, and
activities of daily living become too difficult to carry out, eventually causing disability and
dependence [8]. Physical activity is reduced in severe COPD [9] but the level of activity in
individuals with moderate COPD is less well studied. Hence, inactivity may not only be a
manifestation of disease severity in COPD but may also contribute to disease progression [10].
In a recent study of the patterns of physical activity including the frequency, duration and
intensity of episodes of physical activity, patients with COPD wore the SenseWear® armband
© 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
acelerometer for eight consecutive days [11]. With increasing COPD severity, time in physical
activity, proportion of time performing activities, and frequency of activity decreased. These
objective outcomes provide the best measures of physical activity [12].
COPD is characterized by inexorably progressive, non-normalizing airflow limitation and the
severity of obstruction correlates with its morbidity and mortality [5, 13]. Based upon the
presence of oxidative stress, increased levels of circulating cytokines, and multiple nonpul‐
monary manifestations, COPD is increasingly being recognized as a systemic disorder [5].
Furthermore, COPD does not manifest in a homogeneous manner and many different
subgroups or phenotypes are being recognized. The polysystemic manifestations and hetero‐
geneity of clinical and inflammatory profile presentations of COPD have led to an expanded
classification in the most recent GOLD guidelines that incorporate clinical manifestations
including effects on physical activity and healthcare utilization or risk in addition to physio‐
logic impairment [5]. This multifactorial classification is used to stage COPD severity and to
guide and monitor treatment [5]. In addition, the clinical course of patients with COPD is
marked by repetitive exacerbations and abnormal inflammatory response which further
contribute to a downward spiral of physical activity [5, 14].
Decreased caloric intake leading to nutritional depletion occurs in about 20-35% of outpatients
with COPD and up to 70% of patients with acute respiratory failure or waiting for lung
transplantation [15]. Cachexia, defined as weight loss with disproportional fat-free mass
wasting, occurs in about one-third of patients with COPD eligible for pulmonary rehabilitation
and represents a cause of increased mortality independent of ventilatory limitation [16].
2. Biochemical changes
Many of the major pathophysiologic derangements in advanced COPD have been attributed
to systemic inflammation [17]. Previous studies show that systematic inflammation is induced
by inflammatory cytokines, such as tumor necrosis factor (TNF-α), interleukin (IL-6) and IL-8
[18, 19]. Fat-free mass (FFM) depletion marks the imbalance between tissue protein synthesis
and breakdown that occurs in COPD [20]. These inflammatory cytokines and endocrine
hormones contribute to the reduction in exercise tolerance and poor quality of life caused by
skeletal myopathy in COPD patients [21]. Skeletal muscle dysfunction plays an important role
in the symptoms and impairments in strength, endurance, and maximal exercise capacity
experienced by patients [22].
Bronchiectasis, permanent damage and widening of one or more of the large connecting
bronchi (airways), may occur in nearly one third of individuals with COPD [22]. Individuals
with bronchiectasis have elevated levels of proinflammatory cytokines that are associated with
decreased fat-free mass, increased proteolysis and worse respiratory function [22-24]. This
chronic inflammation increases the levels of oxidative stress [25, 26]. Circulating (plasma) and
intracellular biomarkers of oxidative stress are increased in patients with bronchiectasis
compared with control subjects [25].
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180
Decline in nutritional status is directly related to lung function outcomes and has been
proposed as a predictor of morbidity and even mortality in patients with chronic respiratory
diseases independent of the ventilatory limitation [15]. Furthermore, malnutrition is accom‐
panied by a loss of diaphragmatic and structural skeletal muscle mass, as well as humoral and
cellular dysfunction [15]. Anabolic stimulation through a combination of nutritional support
and exercise appears to be the best approach to improving functional status [27]. A multicenter
study of stable COPD patients with a body mass index of 22 kg/m2 and a fat-free mass index
of 16 showed that the consumption of oral nutritional supplements, rich in proteins (with 50%
of whey protein) produced a significant improvement in quality of life [28]. A subsequent
Cochrane Database meta-analysis showed that undernourished patients with COPD improved
with nutritional supplementation [29]. Malnourished patients who received supplementation
had significantly better maximum inspiratory pressures and maximum expiratory pressures
[29].
Thus, impaired skeletal muscle function is a potentially remediable systemic manifestation of
COPD [30]. These findings have implications for identification of drug targets aimed at
improving muscle function in COPD [30]. Except for markers of myogenesis, molecular
responses to resistance training are not tightly coupled to lean mass gains [30].
3. Management of comprehensive pulmonary rehabilitation
Pulmonary Rehabilitation (PR) has become a cornerstone in the management of patients with
stable COPD in recent years [31]. Systematic reviews show large and important clinical effects
of PR in these patients [32]. PR improves anxiety and depression in patients with COPD [33].
PR also reduces the number and duration of hospitalizations [34, 35]. In addition, physical
training and chest physiotherapy in respiratory disease have long-term, durable benefits
[36-38]. The components of PR vary widely but a comprehensive program includes smoking
cessation, education, nutrition counseling, and exercise training [5].
3.1. Educational and nutritional management
All patients enrolled in PR should receive educational and nutritional interventions as part of
an integrated care plan that seeks to achieve a normal nutritional status, either through natural
diet or supplements [15, 39]. Nutrition depletion occurs by multiple mechanisms including
energy imbalance, disuse atrophy of the muscles, hypoxemia, systemic inflammation and
oxidative stress [15]. Each of these mechanisms may represent targets for nutritional inter‐
vention.
Patients with COPD are best managed through multimodal therapies delivered through an
integrated healthcare system [40]. Dietary supplementation with whey may potentiate the
effects of exercise training on exercise tolerance and quality of life in patients with COPD [41].
Use of a nutritional supplement containing anti-inflammatory whey peptide with exercise
therapy in stable elderly COPD patients increased body weight, reduced markers of systemic
inflammation, and improved exercise levels and respiratory health [17].
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There is a clear need for adequately powered and controlled intervention and maintenance
trials to establish the role of nutritional supplementation in the enhancement of exercise
performance and training and wider management of the systemic features of COPD [40].
Hence, combination therapy, nutritional, pharmacologic, and physical training, may produce
weight gain, increases in lean mass, respiratory muscle strength, exercise capacity, lung
function, and respiratory health while reducing morbidity and mortality. Physiotherapy,
occupational therapy, and medical treatment are individually adjusted to each patient’s needs
and requirements with the goal of improving current quality of life and these targets should
be re-adjusted when patients opt for palliative care [42].
Although prior reviews did not provide evidence for the usefulness of nutritional supple‐
mentation therapy, more recent analyses concluded that nutritional supplemental therapy
increased weight, fat free mass, exercise tolerance, and hand grip strength in undernourished
patients with COPD [29, 43, 44]. High calorie nutrition therapy and L-carnitine supplementa‐
tion may be beneficial whereas no effect is observed with additional creatine [45]. The duration
and type of exercise may also affect PR results. Although both low and high intensity exercise
training are beneficial for patients with COPD, higher intensity lower extremity exercise yields
better physiologic improvement than lower intensity exercise [46]. PR programs that are 12
weeks or longer produce enhanced and more durable results than shorter programs [43, 46].
The benefits of PR tend to wane gradually over 12 to 18 months [43, 46].
3.2. Importance of exercise training
There are two different types of Physical Exercise Training for COPD patients: endurance
and interval type training [47]. Endurance or continuous programmes include constant load
and incremental load training. However, patients with symptoms of severe dysnea during
exercises were incapable of performing high-intensity (70 to 80 % of the peak work rate)
continuous type training. Interval training is recommended as an alternative to continuous
training in patients with severe symptoms of dyspnoea during exercise due to an inability
to sustain continuous training at the recommended intensities. During interval training short
exercise bouts (30-180 seconds) are performed at high intensity (at least 70-80% of peak work
rate). Recommended frequency of training is the same as with continuous training [47].
Finally, there is evidence that regular physical activity contributes to the primary and
secondary prevention of several chronic diseases and is associated with a reduced risk of
premature death [48].
Physical activity is defined as any bodily movement produced by the contraction of skeletal
muscle that increases energy expenditure above a basal level [49]. Exercise therapy is defined
as a subcategory of physical activity in which planned, structured, and repetitive bodily
movements are performed to maintain or improve one or more attributes of physical fitness
[49]. Physical fitness refers to the ability to carry out daily tasks with vigor and alertness
without undue fatigue and with ample energy to enjoy leisure time pursuits and to meet
unforeseen emergencies [49].
Physical activity is the strongest predictor of all-cause mortality in patients with COPD [50].
Nowadays, lack of physical activity is associated with the burden of chronic disease [51]. The
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low levels of Physical Activity (PA) generally observed in people with COPD may be due in
part to the difficulties they experience as they attempt to perform daily activities that they need
and want to perform [14]. Importantly, physical inactivity is potentially reversible [52].
There is strong evidence that community physiotherapy benefits health by promoting physical
activity [8, 53]. Exercise prescribed by a physiotherapist can target directly any impairments
contributing to activity limitations and requires the active participation of subjects in an
individualized physical exercise program [53]. Exercise training can produce significant
improvement in health related quality of life, exercise capacity, respiratory muscle strength,
and exertional dyspnea in patients with COPD who have normal exercise capacity [54]. Hence,
enrollment in a comprehensive Pulmonary Rehabilitation Program (PRP) that includes
exercise training and dietary supplementation may benefit patients with COPD. PRP may be
supported by motivational counseling [55]. Furthermore, physical activity is an attractive
outcome measure for interventional studies in patients with COPD.
Both physical activity and daily exercise improve the health of COPD patients [10]. It is
necessary to avoid a sedentary lifestyle and encourage them to perform physical activity and
exercises [10]. The performance of regular physical activity by patients with COPD reduces
the risk of both hospital admissions and all-cause and respiratory mortality [10]. It appears
that patients with COPD have a significantly reduced duration, intensity, and number of daily
physical activities when compared with healthy control subjects [56]. Hence, the recommen‐
dation that COPD patients be encouraged to maintain or increase their levels of regular
physical activity should be considered in future research [10]. A Spanish research group
developed a novel alternative to formal PRP that includes a walking training circuit in the city
of Catalonia [57] that has been replicated in other cities such as Navarre [58] (Figure 1).
Figure 1. Walking circuits from “Walking Guide for COPD patients” [58]
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3.3. Oxygen therapy
Oxygen theray is one of the therapies currently available to reduce COPD mortality [59]. Long-
term oxygen therapy (LTOT) reduces pulmonary hypertension and improves survival in
patients with COPD and resting hypoxemia (arterial partial pressure of oxygen ≤55 mmHg)
[60].
The use of oxygen supplementation during exercise training for individuals with COPD is
unclear [61]. Supplemental oxygen during exercise training improves functional outcomes
such as symptoms, health-related quality of life, and ambulation [61]. However, there are no
significant differences in maximal exercise outcomes, functional exercise outcomes (six-minute
walk test), shuttle walk distance, health-related quality of life, or oxygenation status [61, 62].
COPD patients with low fat-free mass (FFM) have lower levels of oxidative stress with
supplemental oxygen [63]. Patients with COPD are able to achieve a higher work rate during
exercise training, which positively affects training results after several weeks [64]. It is
generally recommended that COPD patients who are already hypoxaemic at rest should use
oxygen during exercise, aiming at a rather arbitrary oxygen saturation of > 90% [64]. A review
of the effect of oxygen in COPD patients with or without desaturation during exercise training
concluded that hyperoxia has no clear effect on the results of exercise training in COPD patients
with or without documented desaturation during exercise [64]. Only one study demonstrated
a significant, and clinically relevant, improvement in higher work load during rehabilitation
[65]. In conclusion, more studies are needed to define the role of supplemental oxygen in PR;
for instance, on the oxygen concentration, intensity of exercise programmes, and its effects in
different COPD phenotypes.
4. Measuring and improving the physical activity level in COPD patients?
Exercise tolerance is a well accepted clinical marker in COPD and provides information about
disease stage, prognosis, functional capacity, and the effects of treatment [66]. The assessment
of physical activity in healthy populations and in those with chronic diseases is challenging.
Furthermore, physical activity is most accurately measured using objective tools such as
accelerometer-based activity monitors [67]. In addition, other outcomes must be included, such
as quadriceps and grip strength [68].
Physical activity monitors are frequently used to estimate levels of daily physical activity [69].
These devices use piezoelectric accelerometers, which measure the body´s acceleration, in one,
two or three axes (uniaxial, biaxial or triaxial activity monitors). The signal can then be
transformed into an estimate of energy expenditure using one of a variety of algorithms, or
summarized as activity counts or vector magnitude units (reflecting acceleration) [69]. With
the information obtained in the vertical plane or through pattern recognition, steps or walking
time can also be derived from some monitors [69].
A systematic review identifies the available activity monitors that have been appropriately
validated for use in assessing physical activity in these groups [70]. Forty monitors were tested
COPD Clinical Perspectives
184
in validation studies; 12 uniaxial, 3 biaxial, 16 triaxial accelerometers and 9 multisensor devices
[70]. Furthermore, a recent study evaluated the validity and usability of six activity monitors
in COPD patients against the double labelled water indirect calorimetry method [71]. The
Actigraph GT3X and DynaPort MoveMonitor best explained the majority of the total energy
expenditure variance not explained by total body water and showed the most significant
correlations with activity energy expenditure [71].
Moreover, the Dynaport MiniMod and Actigraph GT3X discriminate best between different
walking speeds [69]. Overall, these findings should guide the choice of valid activity monitors
for research or for clinical use in patients with chronic diseases such as COPD. In a recent
comparison, two types of accelerometer: the DynaPort and the Actiwatch were used in order
to assess the level of physical activity [12] and compared with a multisensory armband device
(SenseWear, BodyMedia; Pittsburgh, PA) [9]. The main finding of this pilot-study was the
significant reduction in physical activity observed with each patient. The study provides
evidence for a gradual reduction in daily physical activity levels with increasing GOLD stage,
although the correlation between physical activity and lung function is weak [9].
5. Does the choice for inspiratory or expiratory muscle strength or
endurance training matter?
COPD alters muscle structure and/or functional. Strength and endurance are the two main
functional properties of both respiratory and peripheral muscles and reduction in either
strength or endurance leads to muscle dysfunction. Strength mainly depends on muscle mass,
and endurance is related to muscle fiber aerobic properties [72]. Muscle weakness is a relatively
stable condition related to the loss of muscle strength which requires long-term therapeutic
measures (training and/or nutritional interventions). In contrast, muscle fatigue is a temporary
dysfunction related to endurance [73]. Many COPD patients experience muscle dysfunction
and reduced muscle mass, primarily as a result of chronic immobilization [74]. Over the last
decade, the potential use of resistance training for COPD has gained increasing attention.
A Cochrane Database Systematic Review showed that breathing exercises over four to 15
weeks improve functional exercise capacity in people with COPD compared to no interven‐
tion; however, there were no consistent and clear effects on dysnoea or health-related quality
of life [75].
Muscle strength can be measured by the maximal inspiratory pressure (MIP) and maximal
expiratory pressure (MEP) [76]. Inspiratory muscle training (IMT) provides breathing training
together with resistance loading produced by a valve and is regarded as a mixture of strength
and endurance training. IMT may improve inspiratory muscle strength, endurance, functional
exercise capacity, dyspnoea, and quality of life. A question to be taken into account in the
planning of a respiratory muscles training protocol in COPD patients would be to determine
which is more important, inspiratory muscle strength training or endurance training. A meta-
analysis showed that inspiratory muscle endurance training was less effective than respiratory
muscle strength training [76]. Both types of training (strength and endurance) significantly
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improve the endurance of the muscles, but only strength training was able to significantly
improve the MIP, the MEP and functional exercise capacity [76].
Although many resistance devices are available, the Threshold-IMT® is frequently used and
produces loads of 7-41 cm H2O. The devices produce a range of resistance levels, with lower
resistance levels offered by the Threshold Inspiratory Muscle Trainer (Phillips Respironics,
Murrysville, PA) and higher resistance levels offered by the POWERBreathe® (HaB Interna‐
tional Ltd, Southam, Warwickshire, UK) and the PowerLung® (PowerLung, Houston, TX).
The POWERBreathe® is only for inspiratory muscle training and has three models. The Light
POWERbreathe® produces loads of 17-98 cm H2O, the medium device delivers loads of 23-186
cm H2O, and the heavy device achieves loads of 29-274 cm H2O. The PowerLung® is for
inspiratory and expiratory muscles training and has four models that produce varying levels
of resistance [72].
The Orygen-Dual Valve® was designed and patented by researchers of Barcelona and allows
both simultaneous and sequential dual training work (expiratory and inspiratory muscles)
(Figure 2) [72]. The Orygen-Dual Valve® is a relatively cheap, portable, and easy to use piece
of equipment that provides workloads up to 70 cm H2O at a rate of 15-20 breaths/min [72].
Figure 2. Martín-Valero, R. makes the rehabilitation programme with Orygen-Dual Valve®
High-intensity inspiratory muscle training improved inspiratory muscle function in subjects
with moderate-to-severe COPD, producing significant reductions in dyspnoea and fatigue
[77]. In addition, a 4-week supervised high-intensity respiratory training program in patients
with COPD demonstrated functional improvements [78, 79]. The Orygen-Dual Valve® makes
COPD Clinical Perspectives
186
the rehabilitation programme more efficient than usual training as it requires fewer resources
in terms of time and staff, and allows patients to acquire skills for further training outside the
Hospital [68]. Furthermore, the hi-IMT achieves this result in a shorter time, which is an
advantage for improving the efficiency of rehabilitation programmes within the public health
system [72]. The training must be supervised by a therapist once a week during the first month.
The addition of high-intensity IMT to aerobic exercise produced incremental benefits in muscle
weakness, cardiopulmonary function, and health-related quality of life in a randomized study
of patients with chronic heart failure [80]. A multicenter randomized controlled trial is
currently underway to determine whether the addition of IMT to a general exercise training
program improves the distance walked in six minutes, health related quality of life, daily
physical activity, and inspiratory muscle function in individuals with COPD and reduced
inspiratory muscle strength [81].
6. What are the views and perceptions of people with COPD regarding a
pumonary rehabilitacion?
Individuals with COPD people who complete a course of PR believe that ongoing structured
exercise with professional and peer support assists them with continued regular exercise [82].
However, patients with COPD often encounter potential barriers to PR attendance including
difficulties with travel to exercise venues, fluctuating health status with respiratory symptoms
that impede physical activity, and psychological emotional effects including feelings of
embarrassment [82, 83].
Many qualitative studies of PR in patients with COPD have been performed over the past
decade to determine the impressions and opinions of PR participants. There are two main
theories that have been used to analyse qualitative research [88, 89]. The first one is known as
the grounded theory approach [90] and the second theory is the interpretative phenomeno‐
logical analysis framework [88, 89, 91]. Qualitative research uses data collected from focus
groups [82, 92], semi-structured interviews [87, 93, 94] or a combination of both methods [92,
95]. Some studies use triangulation research (96) or embed a qualitative study in a randomized
controlled trial in order to explore patients’ views on self-management [97]. The main areas of
research were: the effect of people´s health status on exercise adherence [82], pain (85), and
social relationships, such as social integration and social support [86].
It is necessary to increase strategies for self motivation among individuals with COPD [87].
Encouraging health behaviours is a key feature relating to PR participation including physical
activity and smoking reduction or cessation [55]. Telephone delivery of health-mentoring is
feasible and acceptable to individuals with COPD in primary care and may improve PR
participation [55]. Telemonitoring of individuals with COPD enhanced self-management by
improving patients’ knowledge about their disease [97].
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7. Occupational therapy in COPD
Patients with COPD may benefit from occupational therapy as well as physical therapy.
However, there are few studies evaluating occupational therapy for individuals with COPD.
A qualitative study suggested that occupational therapy may reduce breathlessness, improve
mental outlook, and increase the confidence of individuals with COPD [84].
In the future, occupational therapists may be able to assess and provide rehabilitation inter‐
ventions for patients with COPD [98]. Incorporation of occupational therapy in PR may
increase patients’ knowledge of COPD, elevate their sense of control, promote re-engagement
in activities, reduce anxiety, and improve social engagement [98].
Theoretical and clinical occupational therapy supports a rehabilitation model based on
continued participation in activities that are considered essential in the life of the person [99].
The respiratory symptoms of patients with COPD have an impact on activities of daily living.
Occupational therapy interventions in patients with COPD aim to develop specific strategies
to perform basic activities of daily living, and leisure activities, so that they involve the least
possible waste of energy [100]. Through energy saving techniques, Occupational Therapy aims
to reduce the patient's subjective respiratory distress. In activities of daily living training,
patients learn to work efficiency and also learn economies of movement, minimizing the
energy cost of dressing, personal hygiene, home care, leisure activities, shopping, and other
activities related to the patients´ work [100]. Although simple, energy saving techniques
require a learning process that is difficult to achieve outside of a multidisciplinary rehabilita‐
tion program [100].
Research into COPD’s psychological effects on patients’ ability to perform daily activities
provides a wholistic approach to COPD and its consequences. The Occupational Therapy
framework provides a basis for the design of a comprehensive PR intervention that addresses
all aspects of a patient’s life. Recent research shows that optimization of occupational per‐
formance improves the welfare of individuals with COPD [101]. Members of the patient’s
social network should not be excluded from these plans and interventions. Application of a
family psychoeducational program based in training and information about COPD pathology
including risk factors, habits that facilitate disease progression, specific strategies for handling
the problems of daily life, and how to face the difficulties in occupational performance for each
stage of the disease may empower the patient’s friends and family to assist with rehabilitation
[102]. An initial interview with the patient, family, and friends is the initial step to developing
a comprehensive PR program that includes all members of the patients’ social network [103].
8. Conclusion
In conclusion, a multidimensional therapeutic approach is recommended for developing a
comprehensive pulmonary rehabilitation program for patients with COPD. Critical elements
of PR include optimization of pharmacologic and nonpharmacologic management, exercise,
COPD Clinical Perspectives
188
physical activity, ventilatory support, nutritional, and occupational therapy interventions. In
addition, there is a need for new models for pulmonary rehabilitation which allow all program
components to be delivered at home, with proven clinical outcomes and low costs [104]. It is
possible that undertaking pulmonary rehabilitation within the home environment may
promote more effective integration of exercise routines into daily life over the longer term with
greater adherence to exercise [104]. In fact, home-based exercise programs achieve equivalent
clinical outcomes and are cost effective compared with hospital-based programs. The decen‐
tralization of pulmonary rehabilitation increases the options for its provision and may assist
in overcoming the most frequently identified barriers to pulmonary rehabilitation [104].
Author details
R. Martín-Valero, M.C. Rodríguez-Martínez, R. Cantero-Tellez, E. Villanueva-Calvero and
F. Fernández-Martín
Faculty Health Sciences, Department Psychiatry and Physiotherapy, Málaga University,
Spain
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