Direct healthcare costs of spinal disorders in Brazil

  • Rodrigo Luiz Carregaro
  • Everton Nunes da Silva
  • Maurits van Tulder
Open Access
Original Article
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Abstract

Objectives

To investigate the direct healthcare costs of spinal disorders in Brazil, over 2016.

Methods

Prevalence-based cost-of-illness study, top-down approach and public healthcare system’s perspective. International Classification of Diseases codes related to spinal disorders were included. The following costs were obtained: (1) hospitalization; medical professional service costs; intensive care unit costs; companion daily stay; (2) outpatient (services/procedures). Data were analyzed descriptively and costs presented in US$.

Results

The healthcare system spent US$ 71.4 million and inpatient care represented 58%. The number of inpatient days was 250,426 and there were 36,654 hospital admissions (dorsalgia and disc disorders representing 70%). A total of 100,000 magnetic resonance and 80,000 computerized tomography scans was adopted. Men had more inpatient days (138,215) than women (112,211). Overall, the inpatient/outpatient cost ratio was twice as high for men.

Conclusions

We demonstrated that the direct costs of spinal disorders in Brazil in 2016 were high. We also found a substantial amount of financial resources spent on diagnostic imaging. This is relevant, as the routine use of diagnostic imaging for back pain is discouraged in international guidelines.

Keywords

Cost of illness Back pain Costs and cost analysis Hospital costs Ambulatory care 

Introduction

The functional and social impacts of spinal disorders on daily life and occupational activities have long been recognized (Gore et al. 2012). Chronic spinal disorders are one of the leading worldwide health problems, sustaining the highest rates of years lived with disability (GBD 2017) and prevalence ranging from 13 to 40% (Dean et al. 2014; Hoy et al. 2012). Moreover, spinal disorders can affect both men and women, within different age groups (Longworth et al. 2014; Muraki et al. 2014). The consequences of these conditions can also affect activities of daily living, work ability and quality of life (Weigl et al. 2008). Hence, poorer health conditions due to spinal disorders remain a concern for all members of society, such as workers and their families, employers and government (de Vroome et al. 2015). In this context, it is important to emphasize the increasing need of clinical decision-making based on scientific evidence, which supports the allocation of financial resources based on rational criteria (Ferraz 2015).

Cost-of-illness studies are useful and might help to determine the costs of the diagnosis and treatment of specific illness and to broaden the understanding of public health problems (Larg and Moss 2011). Evidence regarding the costs and economic burden of spinal disorders has been established in several countries since the 1990s (Asklof et al. 2014; Lambeek et al. 2011; Maniadakis and Gray 2000; van Tulder et al. 1995; Wenig et al. 2009). In Brazil, economic evaluations focusing on spinal disorders are still in its early stages, and there is scarce evidence on the use of financial resources directed to these diseases (Teles et al. 2016).

One study showed that the costs of ankylosing spondylitis in Brazil are considerable, though this was based on a cost analysis of a single outpatient clinic in 2005 (Torres et al. 2010). The Brazilian Social Security granted more than 1 million disability benefits to private sector workers in 2008, mostly due to spinal disorders (Vieira et al. 2011). Likewise, pension benefits due to spinal disorders covered approximately 12 million work days lost in 2007 (Meziat and Silva 2011). Moreover, it was estimated that costs of spinal surgeries had increased by 540%, in Brazil, in the past 20 years (Teles et al. 2016). It is well known that the Brazilian society is affected by the high prevalence of spinal disorders (Nascimento and Costa 2015; Zanuto et al. 2015). These findings were also corroborated by the Global Burden of Diseases Study, with recent data demonstrating that spinal disorders were one of the major components of worldwide disability, including Brazil (GBD 2017).

Nonetheless, gaps remain in our understanding of the major cost components of spinal disorders within the public healthcare system, which warrants further cost-of-illness studies with representative data. Therefore, the aim of the present study is to estimate the direct healthcare costs of spinal disorders in Brazil, over the year of 2016.

Methods

Study design

This is a prevalence-based cost-of-illness study with a top-down approach. We adopted the perspective of the public healthcare system. The study was approved by the Institutional Research Ethics Committee (Protocol n. 1.969.372; 16/03/2017).

We used the following International Classification of Diseases 10th revision (ICD-10) codes related to spinal disorders: M40 (kyphosis and lordosis); M41 (scoliosis); M42 (spinal osteochondrosis); M43 (other deforming dorsopathies); M45 (ankylosing spondylitis); M46 (other inflammatory spondylopathies); M47 (spondylosis); M48 (other spondylopathies); M49 (spondylopathies in diseases classified elsewhere); M50 (cervical disc disorders); M51 (other intervertebral disc disorders); M53 (other dorsopathies); M54 (dorsalgia); M96 (postprocedural musculoskeletal disorders, not elsewhere classified); M99 (biomechanical lesions, not elsewhere classified).

Data sources

Costs related to hospital inpatient and outpatient care were obtained (in Brazilian Reais—R$) from the Brazilian Health Ministry’s Hospital Information System (SIH) and Outpatient Information System (SIA), respectively. The Hospital Information System contains all records of inpatient care which are processed and sent to the Ministry of Health and included in a National Database. The Outpatient Information System includes all outpatient care by public and private providers contracted by the Brazilian Public Health System (SUS). For that purpose, the Brazilian Healthcare System adopts a reference registered in the Table Management System of Procedures, Medical Drugs, Orthotics, Prosthetics and Special Materials of the Brazilian Health System (SIGTAP). Both systems are intended for the registration, control and processing of all healthcare provided, with an accounting and payment purpose (BRASIL 2017).

These systems present all procedures performed in the Brazilian Public Health System (SUS), which is financed by the Ministry of Health and covers approximately 75% of hospital and outpatient care in Brazil (Sussenbach et al. 2014). The systems use the ICD-10, which allows epidemiological analysis. The total number of hospital admissions in 2016 was 11,522,919 within a network of approximately 6712 registered hospitals. In 2010, the Brazilian census (IBGE 2017) estimated 193,976,530 inhabitants, with a perspective of 206,081,432 inhabitants in 2016.

Inpatient costs

The following direct medical costs were obtained: hospitalization (i.e., daily rate; room fees; food; personal hygiene; bed support; hospital supplies; allied healthcare professional service costs; medications and diagnostic and therapeutic auxiliary services); medical professional service costs; intensive care unit (ICU) costs (including the use of all equipment for intensive care, technical teams and 24-h patient monitoring); companion daily stay (for each patient only one companion is allowed, and the amount includes adequate accommodation and provision of the main meals).

Outpatient costs

The Brazilian Outpatient Information System (SIA) accounts for all ambulatory services and procedures, such as medical and allied healthcare consultations, examinations, diagnostic imaging, clinical and surgical procedures, physiotherapy, acupuncture, rehabilitation and other procedures registered in the SIGTAP.

Data analysis

The inpatient and outpatient costs and procedures data are presented descriptively with tables and figures. The TABWIN software version 1.4.1 was used for extracting and processing data from the public health system. The outpatient costs were discriminated and reported separately for each category (clinical, surgical, diagnosis and, orthosis and prosthetics). For the inpatient care, as all costs are consolidated within the hospital system, the discrimination was not possible, and only the resource use (quantity) was presented for each category.

Age groups were classified as follows: < 1, 1–4, 5–11, 12–18, 19–28, 29–38, 39–48, 49–58, 59–68, 69–78 years and more than 79 years.

The population of each age group was based on the available information of the Brazilian population census of 2010. These data were used for the calculation of the ratio between the male population divided by the female population (ratio M/F). Additionally, the inpatient to outpatient costs ratio (I/O ratio) and the average cost per hospital admission (in US$; Currency—Dec 07, 2017: US$ 1 = R$ 3.2348) was calculated for each age group.

The total cost ratio (TCR) considered the total direct costs (in US$) spent per 1000 people, according to the following equation:
$${\text{TCR:}}\,\frac{{{\text{Inpatient}} + {\text{Outpatient costs }}({\text{US}}\$ )}}{{{\text{Population }}({\text{age groups}})}} \times 10^{3} .$$

Results

In 2016, the Brazilian public healthcare system spent approximately US$ 714 million on spinal disorders and the inpatient costs represented 58% of the total direct costs (Table 1). The geographic distribution of these costs in Brazilian states is given in Online Resource Figure 1. Both inpatient and outpatient costs were more concentrated in the southeast and south regions.
Table 1

Direct healthcare costs of inpatient (hospital) and outpatient (ambulatory) care for spinal disorders in 2016

 

Inpatient

Outpatient costs

Admissions

Hc

Pc

ICUc

CSc

Inpatient costs

Kyphosis and lordosis

52

120,226

15,574

17,551

511.93

153,864

231,400

Scoliosis

842

3,381,910

293,811

196,923

7636

3,880,281

821,996

Spinal osteochondrosis

51

30,822

7366

1970

405

40,565

19,566

Other deforming dorsopathies

539

1,048,272

127,881

46,230

3507

1,225,891

232,274

Ankylosing spondylitis

294

134,998

17,845

8651

1311

162,804

140,730

Other inflammatory spondylopathies

766

871,141

146,084

84,697

9210

1,111,132

100,336

Spondylosis

1060

605,648

108,023

49,137

10,666

773,475

444,366

Other spondylopathies

527

672,858

113,070

62,543

3455

851,926

188,984

Spondylopathies classified elsewhere

97

100,726

15,233

2775

1395

120,129

511,099

Cervical disc disorders

2202

2,624,601

439,776

279,981

12,348

3,356,705

928,829

Other intervertebral disc disorders

12,201

19,205,532

3,208,300

796,688

63,111

23,273,631

4,149,866

Other dorsopathies

156

191,246

32,275

28,581

952

253,053

329,571

Dorsalgia

13,143

1,771,210

276,105

57,943

50,380

2,155,637

18,472,097

Postprocedural musculoskeletal disorders

4075

2,662,950

391,280

219,632

32,383

3,306,245

1,160,103

Biomechanical lesions

649

504,441

96,921

24,835

2720

628,917

2,388,433

Total

36,654

33,926,584

5,289,547

1,878,138

199,993

41,294,262

30,119,656

Total direct costs in 2016 (US$)

71,413,918

Values are presented in US dollars. Currency: US$ 1 = R$ 3.2348

Hc hospital costs, Pc professional costs, ICUc intensive care unit costs, CSc companion stay costs

The total number of inpatient days due to spinal disorders in 2016 was 250,426 and the number of hospital admissions was 36,654. Dorsalgia and intervertebral disc disorders represented approximately 70% of all hospital admissions in 2016 (Table 1).

Arthrodesis surgeries and treatment of complications were most frequently reported as the main reason for hospital admission (115,148 and 97,042 procedures, respectively—additional data are given in Online Resource Table 1). Approximately, US$ 10 million was spent on diagnostic imaging (additional data are given in Online Resource Table 2), mostly due to magnetic resonance (MRI), computed tomography (CT) and ultrasonography (US). Specifically, around 36,000 MRI scans were used for low back pain with or without sciatica and 30,000 CT scans for low back pain only. Additionally, physiotherapy interventions were predominantly reported in the outpatient context, which represented approximately US$ 10 million (14% of the direct costs—Table 2).
Table 2

Most common procedures and services adopted during outpatient care in 2016

Nature of procedure

Quantity

Most used

Quantity

Costs (US$)

Diagnostic

270,418

Magnetic resonance imaging: lumbosacral spine

82,494

6,897,010

Computed tomography: lumbosacral spine

68,328

2,138,933

Magnetic resonance imaging: cervical spine

23,177

1,935,270

Computed tomography: cervical spine

21,728

583,3012

Evaluation of respiratory function

7212

22,295

Total diagnostic

202,939

11,554,515

Clinical

10,087,558

Physiotherapy: motor changes

8,687,766

12,619,325

Physiotherapy: pre- and post-surgery in musculoskeletal dysfunctions

1,047,136

2,061,215

Multiprofessional/multidisciplinary team: rehabilitation of physical dysfunctions

191,308

1,162,537

Physiotherapy: neuromusculoskeletal disorders without complications

45,066

65,061

Clinical consultation of health professionals

21,568

42,005

Total clinical

9,992,844

15,950,143

Surgery

2296

Curative (with or without debridement)

734

7352

Joint manipulation (osteomuscular surgery)

665

5842

Wound suture

321

2298

Local anesthesia

320

2203

Sedation

235

1101

Total surgery

2275

18,796

Orthoses, prostheses and special materials

3854

Brace: Putti (high)

1159

57,183

Brace: Putti (low)

986

59,438

Brace: Milwaukee

573

161,194

Brace: Boston

311

57,541

Brace: Philadelphia (immobilization of the cervical spine)

207

5106

Total orthoses, prostheses and special materials

3236

340,463

Total amount (in 2016)

12,892,406

Total

10,179,726

27,886,212

The number of hospital admissions in 2016 due to spinal disorders between men and women was similar, except between the ages of 29–38 years, in which a slightly higher percentage (less than 2%) of admissions was found for men (Fig. 1). Additionally, men’s admissions to hospitals accounted for a higher cost between the ages of 19–48 years, compared to women. Contrarily, the costs of outpatient care were higher for women, with a higher amount between the ages of 39–68 years compared to men (Fig. 2).
Fig. 1

Inpatient admissions among men and women, stratified by age groups (values are presented in % of the total number of admissions)

Fig. 2

Distribution of a inpatient (hospital) and b outpatient (ambulatory) direct costs among men and women, stratified by age groups (values are presented in % of the total cost)

Table 3 presents the inpatient days and costs ratios among men and women during inpatient and outpatient care. Overall, men had more days of hospitalization compared to women between the ages of 19–68 years. The ratio between inpatient and outpatient costs was twice as high for men compared to women between the ages of 19–68. Likewise, the average cost per hospital admission tended to be higher for men.
Table 3

Values of inpatient days and cost ratios among men and women, stratified by age groups

 

Age groups (years)

< 1

1–4

5–11

12–18

19–28

29–38

39–48

49–58

59–68

69–78

> 79

Ratio M / F

103

104

104

102

99

96

94

90

87

78

63

Inpatient days

           

Men

171

401

1196

4113

11,083

19,954

27,193

31,107

26,679

11,648

4670

Women

105

349

1418

5462

7078

13,169

20,056

23,491

19,667

13,204

8212

TCR

           

Men

35.4

14.1

29.4

111.9

116.2

286.9

540.8

888.3

1056.6

845.1

651.6

Women

52.7

16.1

45.3

236.1

90.3

238.5

548.1

997.0

1187.8

972.4

645.5

I / O ratio

           

Men

0.2

0.2

1.2

3.0

2.2

1.9

1.9

1.7

1.9

1.8

1.5

Women

0.2

0.3

1.7

4.3

1.4

0.9

0.9

0.8

0.9

0.9

1.0

C / A ratio

           

Men

503

211

842

2002

1001

890

1050

1198

1200

1105

780

Women

834

340

1515

2870

882

734

913

1117

1183

945

575

Ratio M/F ratio between the male population divided by the female population (values presented as quantity of men for 100 women), TCR (total cost ratio) total direct costs (inpatient + outpatient, in US$) per 1000 people, I/O ratio ratio between inpatient (I) and outpatient (O) costs, C/A ratio average cost per hospital admission (in US$)

Discussion

The aim of our study was to estimate the direct costs of spinal disorders in Brazil, from the perspective of the public healthcare system over 2016. This is the first study that investigated the costs related to spinal disorders using national data covering all of Brazil. We demonstrated that dorsalgia and intervertebral disc disorders accounted for the highest percentage of the direct costs. Moreover, approximately 14% of the direct costs were attributed to the routine use of diagnostic imaging. Men in the economically active age group (19–68 years of age) had slightly higher inpatient costs, while women had higher outpatient costs. Physiotherapy covered the largest part of outpatient care, accounting for around 14% of the direct costs.

We showed that in 2016, the Brazilian public healthcare system spent approximately US$ 72 million on spinal disorders, of which 58% were attributed to inpatient care. This finding is of utmost importance and might help to improve our understanding of the burden to the Brazilian society, considering that there is a high prevalence and well-known impacts of these conditions in different populational groups (Depintor et al. 2016; Nascimento and Costa 2015). Even though the comparison with international studies is difficult, we found similar costs components to those of other countries (Lambeek et al. 2011; Maniadakis and Gray 2000; Walker et al. 2003; Wenig et al. 2009). However, caution is suggested since the costs in Brazil were lower than in developed countries. For instance, similar cost-of-illness studies reported direct costs of approximately € 400 million in the Netherlands (Lambeek et al. 2011) and £ 1600 million in the United Kingdom (Maniadakis and Gray 2000). Likewise, Torres et al. (2010) demonstrated a lower cost for the treatment of ankylosing spondylitis in Brazil compared to other countries. The authors (Torres et al. 2010) highlighted methodological differences and a low per capita spending on healthcare in Brazil. Our findings could also be explained by healthcare systems operational differences (Ferraz 2015), discrepancies between perspectives and different cost components being included (Lambeek et al. 2011; Larg and Moss 2011).

Notwithstanding, some interesting comparisons are possible. We found an overall inpatient to outpatient cost ratio of 1.4, which could be interpreted as a relative equilibrium between inpatient and outpatient care and a fair amount of investment in outpatient facilities (Adam and Evans 2006). Data from previous studies are heterogeneous, with inpatient to outpatient ratios ranging from approximately 2 to 19 (Adam and Evans 2006; Lambeek et al. 2011; Maniadakis and Gray 2000), which could be attributable to differences in gross domestic product per capita, type of insurance (public or private), occupancy rate and hospital sizes within countries (Adam and Evans 2006). Nevertheless, it is recognized that outpatient care has advantages, such as to use hospital capacity for more complex patients and reduce costs, making it possible to treat more patients within the limited financial resources (Vitikainen et al. 2010). Outpatient services could help avoiding hospitalization-related costs, shorter operation times and lower complication rates of spine surgical procedures (Ahn et al. 2016). Therefore, the 2016s inpatient to outpatient cost ratio found in Brazil was interesting and warrants further investigations, to elucidate the trend pattern over a wider period of time. We would suggest that future studies investigate the impact of outpatient services on the efficiency and costs (Vitikainen et al. 2010) of inpatient spinal care in Brazil.

We found that dorsalgia and intervertebral disc disorders represented approximately 70% of all hospital admissions and 60% of the direct costs. This was expected, as previous Brazilian studies demonstrated a sustained and high prevalence of spinal disorders throughout the years (Depintor et al. 2016; Fernandes and Carvalho 2000; Zanuto et al. 2015). Additionally, our findings are similar to other countries and support the worldwide health burden due to spinal disorders (Asklof et al. 2014; Lambeek et al. 2011; Wenig et al. 2009). We also found that men aged between 19 and 68 years had slightly more inpatient days and more hospital admissions compared to women. There were fewer men than women in these age groups (ratio M/F), indicating that the relative cost for men was higher. This finding may be explained by epidemiological and socioeconomic aspects. For instance, the number of disability benefits claims and the number of days off work due to back pain are higher for men in Brazil (Meziat and Silva 2011; Vieira et al. 2011). Also, it is usually assumed that men seek health assistance later, and with a worsened clinical condition (Galdas et al. 2005). Thus, it might be speculated that men needed more complex and costly actions during inpatient care. It is worth noting that inpatient and outpatient costs were higher in the south and southeast regions, which are more developed, industrialized and densely populated. Therefore, as the most affected age group was in the economically active range, the impacts of inherent risk factors such as increased occupational physical demand (Bevan 2015) might also explain the present costs.

Procedures adopted to justify hospital admissions were mostly the treatment of complications after surgical or clinical procedures, surgery (such as arthrodesis/vertebral fusion and discectomy), and drug treatment for severe pain. The employment of more complex interventions such as vertebral fusion is increasing with associated increase in costs and surgical complications (Balagué et al. 2012). There is a current debate regarding the efficacy of operative procedures in back pain (Koes et al. 2006), and systematic reviews reached conclusions towards limited or insufficient evidence of spinal surgery on clinical outcomes for lumbar spinal stenosis (Zaina et al. 2016) and lumbar spondylosis (Gibson and Waddell 2005). Additionally, a recent systematic review did not identify any evidence comparing surgical to non-surgical interventions for scoliosis with severe curvature (Bettany-Saltikov et al. 2015). In the context of conservative treatments, physical therapy interventions were widely employed, but mainly in the outpatient setting, totaling approximately 10 million sessions in 2016. Physical therapy had a significant share of the direct costs (approximately 14%). Our findings are similar to a systematic review that demonstrated physical therapy as responsible for the highest percentage attributed to direct costs, with an average of 17% (Dagenais et al. 2008). This finding is interesting because physical therapy interventions focused on spinal disorders are widely recommended by international clinical guidelines (NICE 2016, 2017; Stochkendahl et al. 2018). Interventions such as exercise therapies are considered beneficial and were supported by low (Stochkendahl et al. 2018), moderate (NICE 2016) and strong (Delitto et al. 2012) evidence for the improvement of outcomes related to quality of life, pain and disability. Furthermore, though evidence-quality of structured exercise for spondyloarthritis was considered low, it was deemed to be useful for relevant outcomes such as fatigue, stiffness and joint mobility (NICE 2017). Nonetheless, future studies are warranted that evaluate whether conservative interventions are being implemented or whether implementation could be improved. It would also be important to analyze if conservative interventions are cost-saving and could reduce the number of spinal surgeries.

One interesting result was the high amount of routine diagnostic imaging adopted in 2016, which represented roughly 14% of the direct costs. It is worth mentioning that the costs are an underestimation of the real costs, as diagnostic imaging is also included in the costs of inpatient care. Nevertheless, our findings were higher compared to those reported by other studies, ranging from approximately 1 to 7% of the direct costs (Dagenais et al. 2008; Lambeek et al. 2011; Wieser et al. 2011). This is relevant and comprises decision-making implications, as international clinical guidelines rather discourage the frequent use of diagnostic imaging (NICE 2016). A considerable number of MRI and CT scans were used for low back pain or sciatica. It is important to note that the information included in our study does not allow inferences on the exact decision-making flow and patient context which determined the use of diagnostic imaging. Notwithstanding, the National Institute for Health and Care Excellence (NICE) guideline (NICE 2016) reported that there is no clear benefit for imaging all individuals with low back pain or sciatica. As a recommendation, the NICE guideline suggests alternative diagnoses, particularly in light of new or altered symptoms. Additionally, imaging should only be carried out in the presence of red flags and/or if the procedure will considerably change the management (for example, if epidural or spinal surgery is being considered), and not in response to a diagnostic uncertainty (Balagué et al. 2012; Koes et al. 2006; NICE 2016). Therefore, it is suggested that specific actions might be adopted to assess the decision-making process for using diagnostic imaging in back pain patients in Brazil, in light of up-to-date international guidelines.

We were not able to include the indirect costs in 2016, as the information was not available in the Brazilian Social Security System during the writing of this paper. However, we verified that in 2016, the Social Security System granted approximately 205,000 benefits due to spinal disorders, considering the same ICD-10 classifications adopted in this study. Including the costs of productivity losses would lead to much higher total costs and show a higher burden to the Brazilian society.

Our study has some limitations. First, we might have underestimated the direct costs related to spinal disorders, as the Brazilian’s Hospital and Outpatient System covers approximately 75% of all healthcare services, though this is a representative sample. Second, inherent limitations to cost-of-illness studies should also be considered. For instance, the poor reliability of specific diagnostics (ICD-10 categories) and problems related to the diagnosis during hospital admission due to the lack of information in the patient’s medical records (Bittencourt et al. 2006) might have influenced our findings. Third, as the private care and health insurances were not included in the present study, the direct costs of spinal disorders in Brazil would be higher.

Conclusion

Our study demonstrated that the direct healthcare costs of spinal disorders in the Brazilian public healthcare system in 2016 were very high. Dorsalgia and intervertebral disc disorders accounted for approximately 60% of these costs. A significant amount of financial resources was spent on diagnostic imaging, both during inpatient and outpatient care. This is an interesting finding, as international clinical guidelines recommend that the routine use of diagnostic imaging for back pain should be limited.

Notes

Acknowledgements

To CAPES (Brazilian Federal Agency for Support and Evaluation of Graduate Education) for the Postdoctoral Research Abroad scholarship, process n. 88881.120102/2016-01.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The Institutional Research Ethics Committee granted approval for the present study (Protocol n. 1.969.372; 16/03/2017). Informed consent was not needed, as public secondary data were used for the analysis.

Supplementary material

38_2018_1099_MOESM1_ESM.pdf (78 kb)
Supplementary material 1 (PDF 78 kb)

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  1. 1.School of Physical TherapyUniversidade de Brasília (UnB)BrasíliaBrazil
  2. 2.Department of Health Sciences, Faculty of ScienceVrije Universiteit AmsterdamAmsterdamThe Netherlands
  3. 3.School of Collective HealthUniversidade de Brasília (UnB)BrasíliaBrazil

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