Headache Medicine 2021, 12(4):309-316 p-ISSN 2178-7468, e-ISSN 2763-6178
309
ASAA
DOI: 10.48208/HeadacheMed.2021.51
Headache Medicine
© Copyright 2021
Original
Headache-related cognitive distortions questionnaire
Rebeca Veras De Andrade Vieira
1,2
, B. Lee Peterlin
3
, Fernando Kowacs
4,5
, Renata Gomes Londero
4,6
Liselotte Menke Barea
5,7
, Vanise Grassi
7
, William Barbosa Gomes
2
, Gustavo Gauer
2
1
Universidade do Vale do Rio dos Sinos, São Leopoldo, Rio Grande do Sul, Brazil.
2
Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
3
Pennsylvania Headache Center, Camp Hill, Pennsylvania, USA
4
Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil.
5
Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil.
6
Hospital de Clínicas de Porto Alegre, Serviço de Neurologia, Porto Alegre, Rio Grande do Sul, Brazil.
7
Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil.
Abstract
Background
Cognitive distortions are systematic errors in thinking and can be observed in the rela-
tionship of headache patients with their own disease and treatment.
Objective
To construct and validate an instrument to evaluate headache-related cognitive distortions
in those with primary headache disorders; and to investigate the psychometric properties
of this new instrument.
Methods
One hundred thirty-six (136) migraine outpatients from three Brazilian specialized hea-
dache hospital services completed the Headache-related Cognitive Distortions Inventory
(HCDQ) and validated measures of psychological symptoms, pain catastrophizing, mood
disorders, quality of life and headache-related disability.
Results
All hypothesized study measures’ correlations were statistically signicant, supporting cons-
truct validity. HCDQ scores were positively correlated with headache frequency, headache
intensity, psychological symptoms, depression, anxiety, and pain catastrophizing; and
negatively correlated with 7 of 8 quality of life domains and time the patient was in treat-
ment. Cronbach’s alpha demonstrated excellent internal consistency for the 17-item total
scale (alpha=.92). Along with headache intensity and depression, HCDQ Pain subscale
accounted for 46% of variance in the prediction of headache-related disability.
Conclusions
HCDQ is a valid and reliable measure of migraine patients´ cognitive distortions about
their headaches and headache treatment.
Rebeca Veras de Andrade Vieira
rebecavieirapsico@gmail.com
Edited by:
Marcelo Moraes Valença
Keywords:
Cognitive distortions
Depression
Anxiety
Pain catastrophizing
Migraine
Received: January, 29 2022
Accepted: February, 16 2022
310
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Vieira RVA, Peterlin BL, Kowacs F, Londero RG, Barea LM, Grassi V, Gomes WB, Gauer G.
Headache-related cognitive distortions questionnaire
Introduction
T
here are some robust evidence showing the efcacy of
cognitive behavioral therapy (CBT) on the reduction of
headache days and headache-related disability.
1
More-
over, CBT is considered one of the behavioral treatments
with grade A evidence for the prevention of migraine.
2
The
identication and restructuring of cognitive distortions play
a central role in cognitive therapy.
3
Among the cognitive distortions, pain catastrophizing
has been postulated as a multidimensional phenomenon
composed by dimensions of rumination, magnication,
and helplessness. Thus, by catastrophizing, the individual
can magnify and ruminate about this experience with
repetitive thoughts and believes that there is nothing he
can do to deal with his pain.
4
In the context of headache, there is a concern about the
impact of coping strategies and the use of catastrophizing
in relation to pain. A study conducted by Lucas et al.
5
with 1534 patients with migraine showed that pain-
related catastrophizing represents one of the factors
most strongly associated with non-response to treatment.
It has been shown that symptoms of depression, anxiety,
and pain catastrophizing are strongly associated with
severe migraine-related disability.
6
In contrast, decreases
in catastrophizing have been associated with a larger
behavioral migraine management on headache-related
disability.
7
Pain-related catastrophizing is one of the chosen
psychological variables to evaluate effectiveness in
preventing drug abuse.
8
In addition, it has been associated
with chronicity
9
and impaired functioning and quality of life
regardless of the characteristics of migraine and psychiatric
comorbidities.
10
Along with pain-related catastrophizing,
some studies have pointed to the presence of unrealistic
beliefs about the disease and treatment in patients with
headache. For example, understanding the effectiveness
of treatment within a dichotomous criterion “works/ does
not work”, and the use of emotional reasoning to conceive
the emotions as reliable guides to assess treatment
effectiveness.
11
However, the literature lacks instruments to
investigate cognitive distortions in patients with migraine.
The aim of the present study was to develop and
validate a new instrument to evaluate primary headache
patients´cognitive distortions about their headaches
and headache treatment. Furthermore, the study aimed
to investigate the psychometric properties of the new
instrument.
Methods
Participants and Procedure. - This is a scale development
and validation study. The sample was composed of 136
patients with a migraine diagnosis made by experienced
neurologists according to the International Classication of
Headache Disorders 3
rd
Edition (beta version).
12
Exclusion
criteria were psychotic disorder, cognitive impairment,
or the patient lacking time to take part in the study. The
participants’ age ranged from 18 to 65 years old (M
=43.50; SD = 12.76) and were selected among the
outpatients registered at the Headache Centers of three
hospitals located in the city of Porto Alegre, state capital
of Rio Grande do Sul, Brazil: Hospital de Clínicas de Porto
Alegre (HCPA), Irmandade Santa Casa de Misericórdia de
Porto Alegre (ISCMPA), and Hospital Moinhos de Vento
(HMV). The instruments were applied on one occasion,
on the same day of patients’ routine doctor’s appointment.
All participants gave written informed consent. The study
received the approval by each Hospital's Institutional
Review Board.
Measures-. Structured interviews were held to characterize
the sample and to evaluate clinical headache parameters,
such as years of diagnosis, years under treatment, headache
frequency in the last three months (HF), headache intensity
(HI), and screening for medication overuse headache
diagnosis.
Headache Cognitive Distortions Questionnaire (HCDQ)
. The
instrument aims to investigate primary headache patients´
cognitive distortions about their headaches and headache
treatment. The process of constructing the instrument
followed theoretical, empirical, and analytical procedures.
Initially, 80 potential items were generated by headache
specialists during the rst author’s doctoral internship at
Johns Hopkins Headache Center. The rst author worked
both the construction and translation of the set of itens.
The itens were based on Burns' ten categories of cognitive
distortions.
13
The high number of items sought to generate
a global and ne-grained rst version of the instrument.
Once the items were completed, they were analyzed by ve
specialists in headache and cognitive distortion, with the
objective of analyzing each item according to two criteria:
1) relevance (belonging to the theoretical dimension); and
2) adequacy (clarity in the understanding of writing). Each
expert used a scale of 0-4 (0 = not at all, 1= a little, 2
= moderately, 3 = very, 4 = extremely) to evaluate both
criteria (relevance and adequacy). Items that obtained a
consensus score between specialists equal to or greater
than .80 were maintained. Thus, the instrument ended with
53 items to be applied in the clinical population (empirical
311
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Vieira RVA, Peterlin BL, Kowacs F, Londero RG, Barea LM, Grassi V, Gomes WB, Gauer G.
Headache-related cognitive distortions questionnaire
procedure). The response format for all items was a ve-
point Likert-type scale with the following values: 1= "strongly
disagree", 2= "disagree",3="neutral", 4= "agree" and 5=
"strongly agree". The analytical procedures corresponded
to the statistical analyzes to understand the psychometric
qualities of the new instrument. Sample size calculations
were performed according to international guidelines.
14
Self-Reporting Questionnaire (SRQ).
The SRQ is a validated
questionnaire for screening of psychiatric disorders at
the primary care level.
15
It is composed of 24 questions
subdivided in two subscales. The rst subscale is composed
by twenty questions and evaluate mood, anxiety, and
somatoform disorders utilizing the SCID-IV -TR (Structured
Clinical Interview for DSM-IV-TR).
16
The individual fullls
criteria for this subscale by scoring 7 or more points.
Given the well-known comorbidity of migraine with mood
and anxiety disorders, we utilized the mood, anxiety, and
somatoform subscale.
Short Form Health Questionnaire (SF-36)
. The instrument is
an indicator of overall health status and has eight scaled
scores: vitality (VT), physical functioning (PF), bodily
pain (BP), general health perceptions (GH), physical role
functioning (PR), emotional role functioning (ER), social role
functioning (SF), and mental health (MH).
17,18
Headache Impact Test (HIT-6)
. This 6-item questionnaire
19
measures the impact of headaches on usual daily activities
through questions regarding work, school, social activities,
pain intensity, fatigue and bedtime, frustration, and
concentration difculties.
Each item is answered on a 5-point Likert scale (6 = never, 8
= rarely, 10 = sometimes, 11 = very often, 13 = always). The
higher the score obtained, the greater the degree of impact.
Pain Catastrophizing Scale (PCS).
This instrument assesses
catastrophization as a style of negative cognitions related
to pain.
4
Catastrophization refers to a unique construct,
evaluated from three dimensions: magnication, rumination,
and helplessness.
Patient Health Questionnaire (PHQ-9) and Generalized
Anxiety Disorder 7 (GAD-7)
. PHQ-9 and GAD-7 are
instruments for the evaluation of depression and anxiety
according to the criteria of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV), respectively. PHQ-9
is composed of nine items, distributed on a 4-point Likert
scale: "0" (not at all) to "3" (nearly every day). The total
score varies from 0 to 27, being considered a positive
indicator of major depression the value greater or equal
to 10. GAD- 7 is composed of seven items, distributed on
a 4-point Likert scale: "0" (not at all) to "3"(nearly every
day). The sum of the scores ranges from 0 to 21. Values
greater than or equal to 10 are positive indicators for
anxiety disorders. In the headache eld, both PHQ-9 and
GAD-7 have been considered reliable and valid screening
instruments for major depressive disorders and generalized
anxiety disorders in patients with migraine.
20,21
Data Analysis
Descriptive statistics were performed for the participants'
demographic data, including mean, standard deviation,
and frequency of each study measure. The Kolmogorov
– Smirnov test was used to investigate patterns of data
distribution and the adequacy of using parametric tests.
Psychometric properties of HCDQ were analyzed using
exploratory factor analysis, Maximum Likelihood (ML)
estimation method, with Varimax rotation, using RStudio
software. Kaiser criterion based in eigenvalues >1 was used
to identify the number of selected factors. Internal stability
was analyzed using Cronbach’s α coefcient. Construct
validity was assessed by examining the correlations
between HCDQ, psychopathological symptoms, pain
catastrophizing, depression, anxiety, quality of life, and
headache-related disability. The literature supports the
convergent validity between these variables, given the
high comorbidity between cognitive distortions, mood, and
anxiety disorders.
22-24
To evaluate possible associations
between HCDQ scores and sociodemographic measures,
we run Pearson correlations for continuous variables (age)
and T test for independent samples or one-way between-
subjects ANOVA for categorical variables (income,
educational level, marital status and laboral status). A
linear multiple regression analysis (Stepwise method) was
conducted to investigate the HCDQ relative contribution
to the prediction of headache-related disability. Inferential
statistics were run using SPSS (Statistical Package for Social
Sciences) version 22, adopting a 5% signicance level
AND two-tailed testing.
Results
A total of 136 patients from the three tertiary headache
centers were included. The number of patients included in the
calculation varied from 106 to 136 in each measure due to
some missing values. The sample was mainly composed by
women (88.8%) with mean age of 43 years old and who were
diagnosed with episodic migraine (75.7%). Fifteen participants
(11%) met criteria for medication overuse headache. Table 1
shows demographic and clinical data of the sample.
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Headache-related cognitive distortions questionnaire
Table 1. Demographic data (n=136)
Variable Frequency (%) or Mean (SD)
Sex (%Female) 119 (88.8%)
Mean age (SD) 43.50(47)
Diagnosis (Episodic Migraine %) 103 (75.7%)
Employment (%Unemployed) 69 (50.7%)
Income (%<5.500 BRL) 117 (85%)
Education up to High School degree (%) 94 (69.1%)
Married or living with partner (%) 81 (59.6%)
Years of diagnosis 21.9 (14.7)
Years under treatment 9.9 (10.45)
HF/HI 28.4 (24.9) / 8.22 (2.0)
SD= standard deviation, HF= headache frequency in the last three months,
HI= headache intensity attributed by the participants to the pain in the last
three months in a scale ranging from 0-10
Descriptive statistics for study measures are presented
in Table 2. The items for each factor and their respective
factor loading are presented on Table 3. Cronbach’s alpha
demonstrated excellent internal consistency for the 17-item
total scale (alpha=.92). Corrected item-total correlations
ranged from .61 to .76. An exploratory factor analysis (EFA)
was run, and items were retained considering a) higher
loadings (above .60) and b) signicant correlations with
study measures. A two-factor solution accounted for 37%
of variance. Factor 1 was labeled “Pain” and included
items of catastrophizing (items 1,2,3,4,5,6,7) and emotional
reasoning (item 8). Factor 2 was labeled “Treatment” and
included items of labeling (item 9), discounting the positives
(items 10,11, 16, 17), mental lter (item 12), jumping to
conclusions (item 14), and overgeneralization (items 13,15).
The Kaiser-Meyer-Olkin (KMO) measure of sampling
adequacy was satisfactory (KMO=0.85), and the test of
sphericity was signicant (Bartllet=4959. 87; p<0.001).
Table 2. Descriptive Statistics of study Measures
Measure Mean (SD) Range
INDICCE (n=136) 49.38(14.72) 17-73
Pain Subscale 23(8.12) 8-40
Treatment Subscale 16.46(6.33) 9-37
PHQ-9 (n=133) 10.26(6.71) 0-27
GAD-7 (n=133) 10.19 (6.16) 0-21
PCS (n=133) 42.80 (12.12) 19-65
SRQ (n= 135) 10.11(4.96) 0-20
HIT-6 (n=136) 62.03 (7.93) 40 -78
PF (n=133) 63.05 (29.39) 0-100
PR (n=133) 39.85 (42.87) 0-100
BP (n=133) 39.47 (22.34) 0-90
VT (n=105) 12.31 (3.77) 4-22
SF (n=133) 57.24 (28.67) 0-100
ER (n=133) 37.59 (43.31) 0-100
MH (n=133) 55.01 (10.93) 12-80
GH (n=133) 6.80 (1.69) 2-10
Note. SD = standard deviation. PHQ-9 Patient Health Questionnaire
9, GAD-7 Generalized Anxiety Disorder, PCS Pain Catastrophization
Scale, SRQ Self-Report Questionnaire; HIT-6 Headache Impact Test; PF=
physical functioning, PR= physical role functioning, BP= bodily pain, GH=
general health perceptions, VT= vitality, SF= social role functioning, RE=
emotional role functioning role, MH= and mental health
Table 3. HCDQ items, factor loadings and internal reability
Item Factor Communality
Factor 1 - Pain (Cronbach’s a = 0.88) loading (h
2
)
1- I feel so helpless when I have a headache that I believe
nothing will bring me relief.
.62 .742
2- Once my headache starts, I know that my day is lost
.60 .726
3-I will not be able to bear my headaches anymore
.66 .692
4-When I have a headache, I fear the pain will be
devastating.
.70 .683
5- I will not know what to do when I have a headache.
.67 .773
6-I'm afraid my headache is a more serious health
problem.
.67 .709
7- I'm afraid to die because of my headaches
.68 .714
8- Headaches must be dangerous because I feel anxious
about them.
.61 .681
Factor 2 - Treatment (Cronbach’s α = 0.92)
9- My headache treatment is a failure
.77 .830
10- I usually think more about what has gone wrong in
my treatment
.75 .816
11- The negative aspects of my headache treatment call
me more attention than the positive ones
.73 .808
12- It seems that I am the only person who does not get
a good result in the headache treatment
.63 .798
13- If my headache treatment failed today, it will always
fail.
.75 .875
14- My treatment will never work
.67 .766
15-There are no medications that can help with my
headaches
.70 .778
16-I do not take into account any improvement in my
headaches
.67 .679
17- I do not consider what has worked in my treatment
for headaches
.77 . 749
Construct validity was assessed by examining correlations between
HCDQ scores and the other study measures. Study measures’ correlations
were statistically signicant, supporting construct validity. HCDQ scores
were positively correlated with psychological symptoms (r=.45; p<0.01),
depression (r=.49; p<0.01), anxiety (r=.52; p<0.01), pain catastrophizing
(r=.59; p<0.01); headache-related disability (r=.50; p<0.01), and
negatively correlated with 7 of 8 quality of life domains and time the
patient was in treatment. These correlations varied in magnitude from mild
(r=-.25; p<.05) to moderate (r=-.57; p<.01). Table 4 shows Correlation
Matrix.
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Headache-related cognitive distortions questionnaire
Table 4. Correlations between HCDQ subscales and other measures
Measures HCDQ Pain HCDQ Treatment HCDQ Total
Psychological symptoms (SRQ) .48** .25** .45**
Depression (PHQ-9) .48** .32** .49**
Anxiety (GAD-7) .49** .36** .52**
Pain Catastrophizing (PCS) .71** .22* .59**
Disability (HIT-6) .53** .27** .50**
PF -.25** -.16 -.25**
PR -.33** -.25** -.35**
BP -.34** -.23** -.35**
VT -.31** -.14 -.29**
SF -.39** -.32** -.43**
ER -.27** -.19* -.28**
MH -.28** -.18* -.28**
GH -.47** -.45** -.57**
Headache frequency .21* .44** .36**
Headache intensity .31** .19* .31**
Years of diagnosis -.11 -.15 -.15
Years under treatment -.20* -.12 -.20*
*p<.05; **p<.01; SRQ= Self-report Questionnaire; PHQ-9= Patient Health
Questionnaire 9; GAD-7= Generalized Anxiety Disorder, PCS= Pain Cat-
astrophizing Scale; HIT-6 = Headache Impact Test; PF= physical function-
ing, PR= physical role functioning, BP= bodily pain, GH= general health
perceptions, VT= vitality, SF= social role functioning, RE= emotional role
functioning role, MH= and mental health.
There was a lack of correlation between HCDQ TOTAL
or subscales and almost all sociodemographic variables
(education, laboral status, income, and marital status). Age
was only associated with total HCDQ (r=-.18; p<0.05). All
hypothesized study measures correlations were statistically
signicant (psychiatric comorbidity, headache-related
disability, headache frequency and intensity), supporting
construct validity.
Furthermore, HCDQ full scale showed strong and signicant
(p<0.01) correlations with HCDQ Pain Subscale (r=.88) and
HCDQ Treatment Subscale (r=.80). Pain Subscale accounted
for 19.8% and Treatment Subscale for 17.2% of variance.
Table 5 shows a multiple linear regression (stepwise
method) was conducted to investigate the HCDQ relative
contribution to the prediction of headache-related
disability. The newly developed scale was able to predict
a unique portion of the variance in headache-related
disability after accounting for well-known predictors, such
as depression and headache intensity. The multicollinearity
was inspected and VIF value was below 2 for all variables.
Along with depression and headache intensity, HCDQ Pain
subscale accounted for 46% of variance in the prediction
of headache-related disability (R2 = .46).
Table 5. Predictors variables for headache-related disability
Variables
B 95% IC b t p R
2
adj.
Step 1
.001
(Constant)
55.44 [53.310; 547.570] 51.50 .001 .29
Depression
.65 [.474; .821] .546 7.395 .001
Step 2
(Constant)
45.14 [40.629; 49.647] 19.807 .001 .40
Depression
.52 [.352; .686] .437 6.156 .001
Headache Frequency
1.42 [.859; 1.979] .357 5.017 .001
Step 3
(Constant)
[37.137; 46.361] 17.913 .001 .46
Depression
.37 [.200; .549] .315 4.240 .001
Headache Frequency
1.21 [.673; 1.756] .305 4.440 .001
HCDQ Pain
.29 [.141; .431] .290 3.896 .001
SD= standard deviation, HF= headache frequency in the last three months,
HI= headache intensity attributed by the participants to the pain in the last
three months in a scale ranging from 0-10
Discussion
The psychometric properties of HCDQ support its use as
a new measure to evaluate primary headache patients´
cognitive distortions about their headaches and headache
treatment. The new instrument showed excellent internal
consistency, with Cronbach’s α of 0.92 for the full scale
and .88 and .92 for Pain Subscale and Treatment Subscale,
respectively. Considering that cognitive distortions are
a contextualized construct, the solution of two factors
proved to be useful since it differentiated these distortions
in relation to the pain itself and the treatment. It is possible
to think that treatment beliefs might difcult treatment
adherence and satisfaction, whereas pain beliefs are
associated with headache-related disability, as observed
in the results of the present study.
Construct validity was supported since all hypothesized
study measures correlations were statistically signicant.
HCDQ scores showed mild, but signicant positive
correlations with headache frequency, headache intensity,
and moderate positive correlations with psychological
symptoms, depression, anxiety, depression, and pain
catastrophizing. These ndings are in line with prior
studies evaluating the relationship between migraine and
psychiatric comorbidity, specically regarding depression
and anxiety.
25,26
As noted previously, cognitive distortions
are negative biases in thinking that may represent
vulnerability factors for depression.
23
In addition, HCDQ
scores showed mild, but signicant, negative correlations
with 7 of 8 quality of life domains and time the patient was
in treatment, and a moderate negative correlation with
general health.
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Headache-related cognitive distortions questionnaire
These ndings support the idea that these unrealistic beliefs
may play an important role in patient functioning and quality
of life. Along with depression and headache intensity,
HCDQ Pain subscale accounted for 46% of variance in the
prediction of headache-related disability. The inclusion of
cognitive distortions as one of the predictors of headache-
related disability together with other variables already
expected (depression, headache intensity) reinforces the
relevance of restructuring these unrealistic beliefs in routine
treatment. As already pointed
27
, possible consequence
of using these distorted patterns of thought would be
the overestimation of the discomfort caused by painful
experience, the belief that pain will never cease, and that
it will ruin the lives of these individuals. In addition, these
individuals may victimize themselves, blame themselves for
not being able to satisfactorily conduct work and family
responsibilities and focus their thoughts on the problem of
pain by mentally reliving painful episodes through negative
ruminative thoughts.
Our ndings have clinical and research implications. In
clinical terms, cognitive restructuring of such distortions will
be able to provide more realistic beliefs about headache
management and treatment, reduce psychological distress,
and modify possible maladaptive behaviors. In addition,
sharing with the patients the evolutionary functions
present in cognitive distortions may be a useful strategy
to avoid a possible moralization of these unrealistic
reasoning patterns, which, in turn, could increase beliefs
of inadequacy and inferiority in these individuals. Thus,
individuals would no longer engage in the eradication
of such beliefs, but in learning more adaptive ways of
managing these natural tendencies of irrationality.
28
Moreover, researchers may take these cognitions as useful
indicators of a good response to the proposed treatments.
Future studies may clarify the associations between these
distortions and other cognitive variables such as self-
efcacy and locus of control and coping strategies.
The present study has limitations. First, our ndings are
specic to migraine and cannot be generalized to all
primary headache disorders. Second, all patients in
the present study were treated in tertiary health centers
and came from the Southern region of Brazil. Future
investigations with patients who are not in routine treatment,
and with inclusion of other primary headache diagnoses
such as tension-type headache, could add further evidence
of validity to HCDQ and decrease the selection bias of the
sample.
In our study, HCDQ was found to be a valid and reliable
measure of headache patients´ cognitive distortions about
their headaches and headache treatment. The instrument
shows excellent internal consistency and was signicantly
correlated with a variety of relevant clinical measures.
Along with headache intensity and depression, HCDQ
Pain subscale was considered one of the headache-related
disability predictors, pointing to the clinical and research
relevance of this new measure in patients with headache.
Conflict of interest: There is no conict of interest to declare.
Authors’ contributions: RVAV, BLP, WBG and GG:
conception and design. RVAV, FK, RGL, LMB and VG:
acquisition of data. RVAV, BLP, FK, RGL, LMB, VG, WBG
and GG: analysis and interpretation of data. RVAV:
drafting the manuscript. RVAV, BLP, FK, RGL, LMB, VG,
WBG and GG: revising it for intellectual content. RVAV,
BLP, FK, RGL, LMB, VG, WBG and GG: nal approval of
the completed manuscript.
Rebeca Veras De Andrade Vieira
https://orcid.org/0000-0003-2907-8699
B. Lee Peterlin
https://orcid.org/0000-0002-5298-5185
Fernando Kowacs
https://orcid.org/0000-0002-0407-407X
Renata Gomes Londero
https://orcid.org/0000-0002-9780-4739
Liselotte Menke Barea
https://orcid.org/0000-0002-9531-9115
Vanise Grassi
https://orcid.org/0000-0002-9859-9167
William Barbosa Gomes
https://orcid.org/0000-0002-6537-608X
Gustavo Gauer
https://orcid.org/0000-0002-8536-9493
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