Sandra Calvo - Academia.edu (original) (raw)
Papers by Sandra Calvo
Pain Research and Management
Many clinicians increasingly use dry needling in clinical practice. However, whether patients’ in... more Many clinicians increasingly use dry needling in clinical practice. However, whether patients’ intake of antithrombotic drugs should be considered as a contraindication for dry needling has not been investigated to date. As far as we know, there are no publications in analyzing the intake of antiplatelet or anticoagulant agents in the context of dry needling techniques. A thorough analysis of existing medications and how they may impact various needling approaches may contribute to improved evidence-informed clinical practice. The primary purpose of this paper is to review the current knowledge of antithrombotic therapy in the context of dry needling. In addition, reviewing guidelines of other needling approaches, such as electromyography, acupuncture, botulinum toxin infiltration, and neck ultrasound-guided fine-needle aspiration biopsy, may provide specific insights relevant for dry needling. Based on published data, taking antithrombotic medication should not be considered an abs...
Journal of Acupuncture and Meridian Studies, 2021
Acupuncture in Medicine
Introduction: Dry needling (DN) has been shown to be effective for the treatment of upper extremi... more Introduction: Dry needling (DN) has been shown to be effective for the treatment of upper extremity hypertonia in patients with stroke. Purpose: To evaluate the cost-effectiveness of DN in patients with stroke. Methods: A cost-effectiveness analysis was performed in a research study conducted at a Spanish public hospital where patients were classified into two groups with or without DN. Hypertonia was measured using the Modified Modified Ashworth Scale (MMAS), and quality of life (QOL) was assessed using the EuroQoL 5-dimension questionnaire. Data regarding the effects and costs of physiotherapy were presented by calculating the mean and 95% confidence interval. The health outcomes were evaluated considering the rate of responders to the treatment based on the MMAS. Spanish preference weights were used to estimate quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR) were calculated to determine the economic va...
RIDAS. Revista Iberoamericana de Aprendizaje-Servicio, 2020
espanolEl Trabajo Fin de Grado en Fisioterapia debe centrarse en el contenido clave de la teoria ... more espanolEl Trabajo Fin de Grado en Fisioterapia debe centrarse en el contenido clave de la teoria y la practica de la fisioterapia y tambien tiene que demostrar competencias en investigacion, desarrollo y habilidades de comunicacion profesional. Para lograr esto, los estudiantes pueden desarrollar su proyecto llevando a cabo un programa de aprendizaje-servicio en colaboracion con asociaciones de pacientes. Debido a la pandemia de COVID-19, el contacto entre las personas se vio interrumpido durante varios meses, impidiendo la ejecucion normal de estos proyectos y se planteo realizar campanas educativas de concienciacion a traves de recursos digitales. Para analizar la experiencia vivida por parte de los estudiantes y usuarios de las asociaciones se utilizo un enfoque cualitativo de fenomenologia descriptiva. Tras el analisis de los resultados, se concluyo que la realizacion de proyectos aprendizaje-servicio de forma online permitio a los estudiantes realizar un servicio a la comunidad...
Clinical Gerontologist
Objective: The objective of this study was to analyze the long-term effects of a personalized cog... more Objective: The objective of this study was to analyze the long-term effects of a personalized cognitive stimulation (PCS) program on the global cognition, cognitive aspects, activities of daily living (ADLs), anxiety, and depression in older adults with possible mild cognitive impairment (MCI).Methods: A 12-month follow-up analysis was carried out in a single-blind, randomized clinical trial to research the long-term effects of a 10-week PCS program evaluating the cognitive level, depression, and anxiety of older adults with possible MCI.Results: Fifty older adults were assessed 12 months after the CS program, 23 in the intervention group and 27 in the control group. There were significant differences between the groups at 12 months in the global cognition (p = .002), in global orientation (p < .001), and in spatial orientation (p = .004) in favor of the intervention group, measured with the Spanish version of the Mini-Mental Status Examination (MEC-35).Conclusions: A PCS program could be effective in improving global cognition and global and spatial orientation.Clinical implications: A PCS program based on cognitive levels in older adults with possible MCI achieves improvements in global cognition and global and spatial orientation. PCS programs can be applied successfully by trained occupational therapists.
International Journal of Environmental Research and Public Health
The objective of this work is to compare the homogeneity of instrumental and manual compression d... more The objective of this work is to compare the homogeneity of instrumental and manual compression during the simulation of a pressure release technique, measured with a dynamometer, as well as to evaluate the comparative degree of comfort by physiotherapists and physiotherapy students when performing this technique. Methods: A comparative cross-sectional study was carried out with physiotherapists (lecturers with clinical experience) and 4th year students of the Physiotherapy Degree at Universidad San Jorge. The amount of pressure performed and how it was maintained during 80 s with both techniques was analysed using a digital dynamometer. The degree of comfort was evaluated using a modified numeric rating scale, with higher values representing a higher degree of discomfort. Results: A total of 30 subjects participated. Significant differences were found between the techniques in terms of maintaining a constant pressure level for 80 s (p = 0.043). A statistically significant differenc...
Acupuncture in Medicine
Background: Alterations in gait and muscular rigidity are common and disabling in persons with Pa... more Background: Alterations in gait and muscular rigidity are common and disabling in persons with Parkinson’s disease (PD). Objective: The aim of this study was to determine whether a single dry needling (DN) session can promote changes in gait and muscle tone in the lower extremities as well as in the evolution of the disease in persons with PD. Methods: A randomized double-blind clinical trial was designed. Participants were randomly assigned to an intervention group (IG) that received a session of DN over the semitendinosus, medial gastrocnemius, soleus and rectus femoris muscles, or to a control group (CG) that received a session of sham DN in the same muscles. The effects of DN were assessed using the timed up and go test (TUG), 10 meter walk test (10MWT), 6 minute walk test (6MWT) and myotonometry before, immediately after, and 7 days after the intervention. Results: Thirty-three participants were analyzed aged 69.9 ± 7.2 years (mean ± SD; 39% female). There were no significant d...
International Journal of Environmental Research and Public Health
Plantar heel pain is a common cause of foot pain that affects patients’ quality of life and repre... more Plantar heel pain is a common cause of foot pain that affects patients’ quality of life and represents a significant cost for the healthcare system. Dry needling and percutaneous needle electrolysis are two minimally invasive treatments that were shown to be effective for the management of plantar heel pain. The aim of our study was to compare these two treatments in terms of health and economic consequences based on the results of a published randomized controlled trial. For this, we evaluated the costs from the point of view of the hospital and we carried out a cost-effectiveness study using quality of life as the main variable according to the Eq-5D-5L questionnaire. The cost of the complete treatment with dry needling (DN) was €178.86, while the percutaneous needle electrolysis (PNE) was €200.90. The quality of life of patients improved and was translated into +0.615 quality-adjusted life years (QALYs) for DN and +0.669 for PNE. PNE presented an average incremental cost-effectiv...
Acupuncture in Medicine
Background: Stroke is the fourth leading cause of death in Europe, represents one of the most com... more Background: Stroke is the fourth leading cause of death in Europe, represents one of the most common causes of disability in adult patients, and involves considerable short- and long-term social and healthcare costs. The effectiveness of deep dry needling (DDN) on affected arm functionality was assessed throughout 8 weeks of treatment in patients with stroke in the subacute phase. Methods: Eighty patients were included in this two-group non-randomised study after a propensity score analysis was carried out. Both groups received standard physiotherapy treatment on the affected arm. The needling group also received six sessions of DDN during the 8-week period. Patients were evaluated before and after each session using the Fugl-Meyer upper extremity (FM UE) scale, the modified modified Ashworth scale (MMAS), the resistance to passive movement scale (REPAS) and a 10-point numeric pain rating scale (NPRS 10). The Brunnstrom recovery stage was recorded at the beginning and at the end of ...
Revista Fisioterapia Invasiva / Journal of Invasive Techniques in Physical Therapy
Introduction Percutaneous needle electrolysis is a technique of invasive physical therapy which h... more Introduction Percutaneous needle electrolysis is a technique of invasive physical therapy which has been applied successfully in tendinopathies over the last decade. This study sought to explore the opinion and criteria employed by physical therapists who apply this technique in tendinopathies. Material and Methods A cross-sectional study based on a survey of 15 questions to gather the sociodemographic characteristics of attendees and to examine four dimensions associated with the application of percutaneous needle electrolysis (indications, dosage, ultrasound-guidance, supporting therapies). The participants voted on the survey simultaneously after installing the “Votephone” App on their mobile phones or smartphones. Results The study participants included 212 people who attended the CIFI 2018 conference and four experts. Of those who responded, 74.5% were men, who were mainly dedicated to clinical work (91.8%), and were aged between 25 and 45 years (97.6%). Electrolysis was used b...
Revista Fisioterapia Invasiva / Journal of Invasive Techniques in Physical Therapy
Presently, there is no clear consensus on the essential and confirmatory criteria which should go... more Presently, there is no clear consensus on the essential and confirmatory criteria which should govern the application of dry needling (DN) in the treatment of myofascial trigger points. The aim of this study was to generate a consensus on these criteria, via a panel discussion with DN experts which took place at the International Conference of Invasive Physical Therapy held in 2018, including the opinion of the attendees who participated in a live survey on the subject at the conference via an app. The results obtained reveal discrepancies regarding confirmatory criteria such as the elicitation of referred pain; nonetheless, consensus exists on the suitability of the application of individualized and personalized DN treatment and the combination of treatment with other intervention approaches in physical therapy, with the use of ultrasound when required to support a safer clinical practice.
Topics in stroke rehabilitation, Jan 23, 2018
Objectives The objective of this study was to assess the short-term effects of dry needling on sp... more Objectives The objective of this study was to assess the short-term effects of dry needling on spasticity, gait, and muscle architecture of patients with chronic stroke. Methods A case series study was designed; and six chronic stroke patients with ankle spasticity and gait impairment received a single session of dry needling for gastrocnemius medialis, lateralis, and soleus muscles. The main outcome measures were the Modified Modified Ashworth Scale (MMAS), and Timed Up and Go test (TUG). In addition, ultrasonography measurements (e.g. thickness, pennation angle, and fascicle length) were performed for gastrocnemius medialis at baseline (T0), immediately after intervention (T1) and 30 min after intervention (T2), while the MMAS and TUG Test were only measured at T0 and T2. Results Based on the TUG test, there was a significant improvement in gait function (p = 0.023). Furthermore, the MMAS results (p = 0.014) showed a decrease in resistance to passive movements from plantar flexor ...
International Journal of Rehabilitation Research, 2016
Dry needling for hypertonia and spasticity (DNHS) is a technique used for decreasing hypertonia a... more Dry needling for hypertonia and spasticity (DNHS) is a technique used for decreasing hypertonia and spasticity and for the improvement of function in patients with damage to the central nervous system. There is limited evidence supporting the effectiveness of this technique on the basis of objective assessments. The aim of the present case report was to quantify the effects of dry needling (DNHS technique) on the contractile properties of spastic muscles in an individual with stroke. The DNHS technique was applied to a 50-year-old male 2.5 years after stroke who had a complaint of spasticity. The treated muscles were biceps brachii, triceps brachii, rectus femoris, semitendinosus, biceps femoris, medial gastrocnemius, and lateral gastrocnemius. Tensiomyography was used to assess maximal displacement (Dm) of treated muscles. We performed a preintervention and postintervention measurement and a follow-up measurement 3 weeks after intervention. After the application of the DNHS technique, a decrease in the level of local muscle stiffness was observed for all muscles after intervention and at the 3-week follow-up, quantified by an increase in Dm. The usefulness of tensiomyography for detecting changes in patients with spasticity correlated with clinical measures in this field requires further research to establish the reliability of the different parameters provided by the equipment.
BMJ Open
IntroductionWork-related musculoskeletal (MSK) pain is a highly prevalent condition and one of th... more IntroductionWork-related musculoskeletal (MSK) pain is a highly prevalent condition and one of the main contributors to disability and loss of work capacity. Current approaches to the management and prevention of work-related MSK pain do not consistently integrate current evidence-based knowledge and seem to be outdated. The Prevent4Work (P4W) Project aims to collect and spread evidence-based information to improve the management and prevention of work-related MSK pain. P4W will longitudinally investigate (1) risk factors associated with the prevalence of work-related MSK pain, (2) predictive factors for new events of work-related MSK pain in the short term and (3) the modification of pain beliefs after participating in evidence-based e-learning courses.Methods and analysisThis project employs a mixed-methods design with international cohorts of workers from Spain, Italy and Denmark. All participants will be assessed using self-reported variables at baseline (ie, cross-sectional des...
Pain Research and Management
Many clinicians increasingly use dry needling in clinical practice. However, whether patients’ in... more Many clinicians increasingly use dry needling in clinical practice. However, whether patients’ intake of antithrombotic drugs should be considered as a contraindication for dry needling has not been investigated to date. As far as we know, there are no publications in analyzing the intake of antiplatelet or anticoagulant agents in the context of dry needling techniques. A thorough analysis of existing medications and how they may impact various needling approaches may contribute to improved evidence-informed clinical practice. The primary purpose of this paper is to review the current knowledge of antithrombotic therapy in the context of dry needling. In addition, reviewing guidelines of other needling approaches, such as electromyography, acupuncture, botulinum toxin infiltration, and neck ultrasound-guided fine-needle aspiration biopsy, may provide specific insights relevant for dry needling. Based on published data, taking antithrombotic medication should not be considered an abs...
Journal of Acupuncture and Meridian Studies, 2021
Acupuncture in Medicine
Introduction: Dry needling (DN) has been shown to be effective for the treatment of upper extremi... more Introduction: Dry needling (DN) has been shown to be effective for the treatment of upper extremity hypertonia in patients with stroke. Purpose: To evaluate the cost-effectiveness of DN in patients with stroke. Methods: A cost-effectiveness analysis was performed in a research study conducted at a Spanish public hospital where patients were classified into two groups with or without DN. Hypertonia was measured using the Modified Modified Ashworth Scale (MMAS), and quality of life (QOL) was assessed using the EuroQoL 5-dimension questionnaire. Data regarding the effects and costs of physiotherapy were presented by calculating the mean and 95% confidence interval. The health outcomes were evaluated considering the rate of responders to the treatment based on the MMAS. Spanish preference weights were used to estimate quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR) were calculated to determine the economic va...
RIDAS. Revista Iberoamericana de Aprendizaje-Servicio, 2020
espanolEl Trabajo Fin de Grado en Fisioterapia debe centrarse en el contenido clave de la teoria ... more espanolEl Trabajo Fin de Grado en Fisioterapia debe centrarse en el contenido clave de la teoria y la practica de la fisioterapia y tambien tiene que demostrar competencias en investigacion, desarrollo y habilidades de comunicacion profesional. Para lograr esto, los estudiantes pueden desarrollar su proyecto llevando a cabo un programa de aprendizaje-servicio en colaboracion con asociaciones de pacientes. Debido a la pandemia de COVID-19, el contacto entre las personas se vio interrumpido durante varios meses, impidiendo la ejecucion normal de estos proyectos y se planteo realizar campanas educativas de concienciacion a traves de recursos digitales. Para analizar la experiencia vivida por parte de los estudiantes y usuarios de las asociaciones se utilizo un enfoque cualitativo de fenomenologia descriptiva. Tras el analisis de los resultados, se concluyo que la realizacion de proyectos aprendizaje-servicio de forma online permitio a los estudiantes realizar un servicio a la comunidad...
Clinical Gerontologist
Objective: The objective of this study was to analyze the long-term effects of a personalized cog... more Objective: The objective of this study was to analyze the long-term effects of a personalized cognitive stimulation (PCS) program on the global cognition, cognitive aspects, activities of daily living (ADLs), anxiety, and depression in older adults with possible mild cognitive impairment (MCI).Methods: A 12-month follow-up analysis was carried out in a single-blind, randomized clinical trial to research the long-term effects of a 10-week PCS program evaluating the cognitive level, depression, and anxiety of older adults with possible MCI.Results: Fifty older adults were assessed 12 months after the CS program, 23 in the intervention group and 27 in the control group. There were significant differences between the groups at 12 months in the global cognition (p = .002), in global orientation (p < .001), and in spatial orientation (p = .004) in favor of the intervention group, measured with the Spanish version of the Mini-Mental Status Examination (MEC-35).Conclusions: A PCS program could be effective in improving global cognition and global and spatial orientation.Clinical implications: A PCS program based on cognitive levels in older adults with possible MCI achieves improvements in global cognition and global and spatial orientation. PCS programs can be applied successfully by trained occupational therapists.
International Journal of Environmental Research and Public Health
The objective of this work is to compare the homogeneity of instrumental and manual compression d... more The objective of this work is to compare the homogeneity of instrumental and manual compression during the simulation of a pressure release technique, measured with a dynamometer, as well as to evaluate the comparative degree of comfort by physiotherapists and physiotherapy students when performing this technique. Methods: A comparative cross-sectional study was carried out with physiotherapists (lecturers with clinical experience) and 4th year students of the Physiotherapy Degree at Universidad San Jorge. The amount of pressure performed and how it was maintained during 80 s with both techniques was analysed using a digital dynamometer. The degree of comfort was evaluated using a modified numeric rating scale, with higher values representing a higher degree of discomfort. Results: A total of 30 subjects participated. Significant differences were found between the techniques in terms of maintaining a constant pressure level for 80 s (p = 0.043). A statistically significant differenc...
Acupuncture in Medicine
Background: Alterations in gait and muscular rigidity are common and disabling in persons with Pa... more Background: Alterations in gait and muscular rigidity are common and disabling in persons with Parkinson’s disease (PD). Objective: The aim of this study was to determine whether a single dry needling (DN) session can promote changes in gait and muscle tone in the lower extremities as well as in the evolution of the disease in persons with PD. Methods: A randomized double-blind clinical trial was designed. Participants were randomly assigned to an intervention group (IG) that received a session of DN over the semitendinosus, medial gastrocnemius, soleus and rectus femoris muscles, or to a control group (CG) that received a session of sham DN in the same muscles. The effects of DN were assessed using the timed up and go test (TUG), 10 meter walk test (10MWT), 6 minute walk test (6MWT) and myotonometry before, immediately after, and 7 days after the intervention. Results: Thirty-three participants were analyzed aged 69.9 ± 7.2 years (mean ± SD; 39% female). There were no significant d...
International Journal of Environmental Research and Public Health
Plantar heel pain is a common cause of foot pain that affects patients’ quality of life and repre... more Plantar heel pain is a common cause of foot pain that affects patients’ quality of life and represents a significant cost for the healthcare system. Dry needling and percutaneous needle electrolysis are two minimally invasive treatments that were shown to be effective for the management of plantar heel pain. The aim of our study was to compare these two treatments in terms of health and economic consequences based on the results of a published randomized controlled trial. For this, we evaluated the costs from the point of view of the hospital and we carried out a cost-effectiveness study using quality of life as the main variable according to the Eq-5D-5L questionnaire. The cost of the complete treatment with dry needling (DN) was €178.86, while the percutaneous needle electrolysis (PNE) was €200.90. The quality of life of patients improved and was translated into +0.615 quality-adjusted life years (QALYs) for DN and +0.669 for PNE. PNE presented an average incremental cost-effectiv...
Acupuncture in Medicine
Background: Stroke is the fourth leading cause of death in Europe, represents one of the most com... more Background: Stroke is the fourth leading cause of death in Europe, represents one of the most common causes of disability in adult patients, and involves considerable short- and long-term social and healthcare costs. The effectiveness of deep dry needling (DDN) on affected arm functionality was assessed throughout 8 weeks of treatment in patients with stroke in the subacute phase. Methods: Eighty patients were included in this two-group non-randomised study after a propensity score analysis was carried out. Both groups received standard physiotherapy treatment on the affected arm. The needling group also received six sessions of DDN during the 8-week period. Patients were evaluated before and after each session using the Fugl-Meyer upper extremity (FM UE) scale, the modified modified Ashworth scale (MMAS), the resistance to passive movement scale (REPAS) and a 10-point numeric pain rating scale (NPRS 10). The Brunnstrom recovery stage was recorded at the beginning and at the end of ...
Revista Fisioterapia Invasiva / Journal of Invasive Techniques in Physical Therapy
Introduction Percutaneous needle electrolysis is a technique of invasive physical therapy which h... more Introduction Percutaneous needle electrolysis is a technique of invasive physical therapy which has been applied successfully in tendinopathies over the last decade. This study sought to explore the opinion and criteria employed by physical therapists who apply this technique in tendinopathies. Material and Methods A cross-sectional study based on a survey of 15 questions to gather the sociodemographic characteristics of attendees and to examine four dimensions associated with the application of percutaneous needle electrolysis (indications, dosage, ultrasound-guidance, supporting therapies). The participants voted on the survey simultaneously after installing the “Votephone” App on their mobile phones or smartphones. Results The study participants included 212 people who attended the CIFI 2018 conference and four experts. Of those who responded, 74.5% were men, who were mainly dedicated to clinical work (91.8%), and were aged between 25 and 45 years (97.6%). Electrolysis was used b...
Revista Fisioterapia Invasiva / Journal of Invasive Techniques in Physical Therapy
Presently, there is no clear consensus on the essential and confirmatory criteria which should go... more Presently, there is no clear consensus on the essential and confirmatory criteria which should govern the application of dry needling (DN) in the treatment of myofascial trigger points. The aim of this study was to generate a consensus on these criteria, via a panel discussion with DN experts which took place at the International Conference of Invasive Physical Therapy held in 2018, including the opinion of the attendees who participated in a live survey on the subject at the conference via an app. The results obtained reveal discrepancies regarding confirmatory criteria such as the elicitation of referred pain; nonetheless, consensus exists on the suitability of the application of individualized and personalized DN treatment and the combination of treatment with other intervention approaches in physical therapy, with the use of ultrasound when required to support a safer clinical practice.
Topics in stroke rehabilitation, Jan 23, 2018
Objectives The objective of this study was to assess the short-term effects of dry needling on sp... more Objectives The objective of this study was to assess the short-term effects of dry needling on spasticity, gait, and muscle architecture of patients with chronic stroke. Methods A case series study was designed; and six chronic stroke patients with ankle spasticity and gait impairment received a single session of dry needling for gastrocnemius medialis, lateralis, and soleus muscles. The main outcome measures were the Modified Modified Ashworth Scale (MMAS), and Timed Up and Go test (TUG). In addition, ultrasonography measurements (e.g. thickness, pennation angle, and fascicle length) were performed for gastrocnemius medialis at baseline (T0), immediately after intervention (T1) and 30 min after intervention (T2), while the MMAS and TUG Test were only measured at T0 and T2. Results Based on the TUG test, there was a significant improvement in gait function (p = 0.023). Furthermore, the MMAS results (p = 0.014) showed a decrease in resistance to passive movements from plantar flexor ...
International Journal of Rehabilitation Research, 2016
Dry needling for hypertonia and spasticity (DNHS) is a technique used for decreasing hypertonia a... more Dry needling for hypertonia and spasticity (DNHS) is a technique used for decreasing hypertonia and spasticity and for the improvement of function in patients with damage to the central nervous system. There is limited evidence supporting the effectiveness of this technique on the basis of objective assessments. The aim of the present case report was to quantify the effects of dry needling (DNHS technique) on the contractile properties of spastic muscles in an individual with stroke. The DNHS technique was applied to a 50-year-old male 2.5 years after stroke who had a complaint of spasticity. The treated muscles were biceps brachii, triceps brachii, rectus femoris, semitendinosus, biceps femoris, medial gastrocnemius, and lateral gastrocnemius. Tensiomyography was used to assess maximal displacement (Dm) of treated muscles. We performed a preintervention and postintervention measurement and a follow-up measurement 3 weeks after intervention. After the application of the DNHS technique, a decrease in the level of local muscle stiffness was observed for all muscles after intervention and at the 3-week follow-up, quantified by an increase in Dm. The usefulness of tensiomyography for detecting changes in patients with spasticity correlated with clinical measures in this field requires further research to establish the reliability of the different parameters provided by the equipment.
BMJ Open
IntroductionWork-related musculoskeletal (MSK) pain is a highly prevalent condition and one of th... more IntroductionWork-related musculoskeletal (MSK) pain is a highly prevalent condition and one of the main contributors to disability and loss of work capacity. Current approaches to the management and prevention of work-related MSK pain do not consistently integrate current evidence-based knowledge and seem to be outdated. The Prevent4Work (P4W) Project aims to collect and spread evidence-based information to improve the management and prevention of work-related MSK pain. P4W will longitudinally investigate (1) risk factors associated with the prevalence of work-related MSK pain, (2) predictive factors for new events of work-related MSK pain in the short term and (3) the modification of pain beliefs after participating in evidence-based e-learning courses.Methods and analysisThis project employs a mixed-methods design with international cohorts of workers from Spain, Italy and Denmark. All participants will be assessed using self-reported variables at baseline (ie, cross-sectional des...