WATSU COMO PROPOSTA DE TRATAMENTO PARA PACIENTES COM SÍNDROME DO PANICO DURANTE O PERÍODO DE CRISES

Andrea Hess Engström– physiotherapist, post graduated in Rehabilitation of Neurological Diseases in the Faculdades de Guarulhos, SP, Brazil
Andréia Mesquita Fonseca – graduated in physiotherapy in Faculdades de Guarulhos, SP, Brazil

Abstract

Introduction: Panic Disorder is characterized by a set of clinical manifestations and for recurrent crises that happen suddenly, related to stress factors or situations, anxiety or substances that accelerate the crises in liable individuals. The Watsu is a hydrotherapy technique able to promote relaxation by its movements based in the eastern medicine, which purposes is the stretching of the meridians of the body, where the patient is a passive receptor.
Objective: Purpose auxiliary treatment for panic disorder which, together with psychotherapy and remedy therapy, helps to decrease the symptoms until they can be controlled.
Material and methods: The study was done using a bibliographical revision, with references published between 1987 and 2002.
Conclusion: The technique can promote an improvement of the quality of life for patients suffering from panic disorder due to the relaxation potential. However there are not studies which prove this.

Key-words: Panic Disorder, Hydrotherapy, Watsu, Anxiety disorders, Physiotherapy

Introduction

According to Gentil et al (1997) (1), Panic Disorder is defined as a set of clinical manifestations included in the concept of panic disorder, characterized by recurrent crises; a spontaneous, unexpected, moral and physical indisposition and danger sensation, or feeling of eminent death, accompanied by autonomic hyperactivity. This leads to a desperate behaviour characterised by feelings of need to escape or seek aid, named panic.

The panic disorder has as a feature the abrupt beginning, while the other kinds of anxiety disorders are characterized by persistent symptoms and a gradual beginning (1). There is approximately one case of panic disorder in each thousand individuals (0,1%). There is, i.e., using this index, just in Sao Paulo County (Brazil) around 30.000 people, and in all Brazil 130.000 individuals with this syndrome (2). The number of incidences of panic disorder is more or less twice as big among females, more common in Caucasian individuals and among people with a higher educational level (3, 4).

The panic attacks can happen in any period of life, but most incidences occur between the age of 21 and 36, and are often related with inhibited emotional reactions that are set free. These tend to be subjective, indicating infantile dependence and significant need of support and assistance (5).

Epidemiological studies show that only 20 to 30 percent of the patients with panic disorder have the pure disease, not complicated or followed by other phobias. Another study shows that Panic Disorder often is associated with other psychiatric disorders, especially depression (4, 6).

The relation between the precipitating factors and the panic attacks is relevant since it occurs in two thirds of the cases. Emotional stress, physical stress (surgery, infections and childbirth), drugs (cannabis and amphetamines) or adrenaline during anaesthesia aggravates the picture. However, there is often a reduction of the crises during pregnancy (7).

Therefore, according Del Porto et al (2002) (8), it is possible to support the hypothesis that the feelings of panic are not just a specific reaction to the stressing factors, but something that is bases on a determined biological base, since pharmacological agents can block the crises. Some substances as carbon dioxide, iombine and sodium lactate can lead to a crisis in predisposed individuals. The main theories includes the hypothesis that adrenergic hyperactivity, serotoninergic dysfunction (based on the assumption that serotonin stimulants could induce the panic crises), hypersensitivity to CO2 receptors in the brain axis and abnormal function of the gaba-benzodiazepines receptors can play an important role in the occurrence of Panic Disorder.

The recurrent and unexpected attacks of anxiety is considered to be clinical manifestations, which reaches it’s peak in up until ten minutes, followed in most cases by cognitive and psychosomatic symptoms like pounding of the heart, perspiration, trembling, dyspnoea, suffocation sensations, asphyxia, dizziness, vertigo or fainting, nausea or abdominal discomfort, chills, heat waves, pain, discomfort in the chest, hemi lateral paraplegia, a fear of dying, going crazy or lose control. These symptoms are also followed by anticipated anxiety and phobias that are related to places or circumstances where the patients first experienced their symptoms (9).

Usually the first attack happens during a routine activity, such as working, driving a car, watching television or listening to music. Suddenly, they feel a huge anxiety and some autonomic sensations or a fear of eminent death (6).

For 30 to 50% of the patients the syndrome appears with moderate symptoms, and 50% of them show recovery in the long term. The psychiatric co morbidity impairs the prognosis, but the treatment right after the beginning of the symptoms improves it (3).

According to diagnostic studies of Panic Disorder, many of the severe panic attacks follow certain criterions: (a) Occurrence in circumstances where there is no objective danger. (b) That the circumstances of the situation are familiar.(c) That the patients are relatively free of anxious symptoms between two panic attacks, with exception of that the anticipated anxiety that can be present (10).

To diagnose someone as having a panic crisis it must be represented by four or more of the symptoms mentioned earlier (according with the criterions of the American Psychiatric Association). These symptoms start in an acute way, reaching the maximum intensity in ten minutes and disappear in a period of minutes or hours (8).

Panic disorder is a condition who causes a significant impairment in the occupational and psychosocial function of the patient. The disease also has economical consequences for society as a whole as well as those who suffer from it. Many of them are only working sporadically and most of those who work have experienced a fall in personal performance due their situation (1).

The biological theories around Panic Disorder shows an initial excess of noradrenalin, leading to low regulation of the receptors adrenergic pos synaptic, characterizing the hypersensitivity of the patients to the antagonists alpha 2 and hyposensitivity to the agonists alpha 2. There is an increase in the elimination of the catecholamine. Something that leads us to this conclusion is that the iombine and the caffeine can provoke the panic crises. High doses of aspartame could also lead to a crisis, as can a medicine for migraine named Sumatriptan. This is because they cause a decrease of the gamma aminobutyric acid (GABA) that can lead to an alteration in the specific cerebral receptor (11).

In these patients apparent alterations of the attached benzodiazepines endogenous occurs; this way the brain can produce less agonist and more inverses agonists, forming a cycle of anxiety and panic (11).

These, essentially biological, features of the panic attacks are suggested to explain the spontaneous stereotyped feature of the clinical manifestations (12).

The current studies and definitions regarding the physiology of Panic Disorder are mainly based on the results of the pharmacological treatments and the results of agents capable to precipitate the panic attacks. What makes the symptoms of a panic different from the other psychiatric pathologies is that attacks can be reproduced in laboratories through the agents as caffeine, CO2, noradrenalin and others (1). For example, metabolic studies with sodium lactate led to panic attacks in up to 75% of the cases of patients with a history of panic disorder. However, equivalent doses of sodium lactate only have lower anxiolytic effects or no effect on normal people. The mechanism in which the sodium lactate induces the panic attacks has not been so well established, but there is a hypotheses that the increase of the carbon dioxide (CO2) levels in the central nervous system, a final product of the metabolization of the lactate, induce to hyperventilating and respiratory alkalosis. This produces as a secondary factor called autonomic discharge which is characteristic of the panic (1).

The CO2 inhalation causes an increase of the blood flow in the brain, the same effect caused by the sodium lactate infusion what could be a stimulus to cause a panic reaction. The hyperventilation would be a response to this. Chronic hyperventilation would thus be an adaptation mechanism to compensate the low trigger limit for a panic reaction, which keeps the CO2 levels lower than the normal (12).

Amongst the neurochemical models, the noradrenergic is the main one involved in the physiopathology. The noradrenergic transmission (i.e. tricyclic antidepressants) demonstrates sedative action. However, the electric stimulation of the Loccus Ceruleus (brain axis region responsible for the discharge of the scare) produces an escape reply interpreted as similar to a panic attack. This results in the hypothesis that panic attacks can be caused by an increased stimulation of the Loccus Ceruleus (1).

The effect of the CO2 occurs by direct stimulation of the noradrenergic system. It is known that the CO2 causes a stimulation of the Loccus Ceruleus. This stimulation would then be responsible for the symptoms that induce panic (1).

The treatment duration for Panic Disorder is established and based more on clinical experiences than scientific facts. It depends on the presence or absence of another additional anxious disorder, the seriousness and intensity of the attacks, and the time the symptoms has existed. If the patient is rigorously evaluated he or she can be prescribed tricyclic antidepressants, selective inhibitors of serotonin and/or high-potency benzodiazepines. These remedies are initially used to control the crises in the first weeks. A medicine adaptation occurs after the first weeks. The psychotherapy and Cognitive Behaviour Therapy helps to decrease the anxiety and stabilize the patient’s mood. Panic disorder is a chronic disease with a relatively favourable prognosis (1).

The pharmacological treatment has shown good results in 30 to 50% of the treated cases. The medication can be discontinued after 6 and 18 months, leaving just a gentle symptomatology. For individuals born with a pre disposition to panic disorder a simple treatment will probably not cure the syndrome. The stressing circumstances of their life usually provoke returns. These episodes should be reduced with medical treatment which gives these patients a good chance of not having to suffer from these kinds of crises again (1).

Hydrotherapy

Hydrotherapy is a physiotherapeutic resource which uses water and its effects to reach its objectives. Examples of these objectives can be promotion of the functional independence, maintenance and improvement of movement amplitude and muscular strength, re-education of movements through the kinesitherapy and the reduction of pain and muscular cramps. Furthermore, the hydrotherapy also promotes improvement of the socialization, self confidence and quality of life of the patients (13).

The aquatic rehabilitation is based on exercises and movements determined by the specific needs of each individual. The water works as a hot conductor and, associated with other stimuli and the therapeutic exercises, acts on the body and the organism as a whole. The hydrotherapy reaches the organism metabolism, and the muscle-skeletal, as well as the cardio-respiratory and nerve system (14).

The relaxation is a psycho-physiologic method for reconditioning which, in the aquatic setting, works with the contact between the body and the water, and the well-being which that provides. The relaxation leads progressively to improved movement in all the body, tranquillity, socialization and the decrease of emotional stress and tensions (13).

The physiological effects are similar to the ones produced by any other kind of therapeutic heat, except that they are more general. The effects can vary according with the water temperature, water pressure, treatment duration and the exercises intensity. The therapeutic effects on the patient can be motor, sensory, and psychological as well as preventive (14).

The most used hydrotherapy techniques are named Hallywick, Bad Ragaz and Watsu. The Hallywick method was initially intended to teach swimming to handicap patients. The concepts and principles were then changed for adaptation in the water, balance restoration, inhibition of pathologic patterns, and posture and movements facilitation. The Bad Ragaz rings method is a set of therapeutic techniques in the water. It was developed in Switzerland and is still in evolution. Nowadays the Bad Ragaz is used improvement of muscular re-education, gain of strength, stretching of the spine, and relaxation and hypertonia regulation in the water. In this technique, the therapist acts as a fixed point during the whole activity to move the patient through the water (15).

Developed by Harold Dull, in Harbin Hot Springs, California, the Water Shiatsu, or Watsu, is a technique with the same principles as the Zen Shiatsu. The technique was created for well-being, without an original intention to be used in patients with for example neurological disorders (16).

The Watsu was based in the eastern medicine theory which works with the stretching of the meridians of the body (energy channels). The eastern medicine preaches that through the stretching the energy can be set free because of the proximity of the meridians to the body’s surface. The effects of the technique are accented by its rotational movements which liberate blocked energy of the joints. The patient experiences a deep relaxation and is as a receiver completely passive. The relaxation occurs through the patients floating in the water and the continuous and rhythmic movements as one position is softly changed for another. The therapist stabilizes or moves a segment of the body to perform the stretches, while the movement through the water, which results in a haul effect, stretches another segment (16).

The Watsu technique is based on the transition and sequence of movements specifically prescribed. The therapist can adapt the movements accordingly to the specific limitations found on the patients (15).

Many of the principles of Zen shiatsu have found a place in the Watsu technique. The most basic movement is the Water Breath Dance. This movement consists in the patient and the therapist submerging in each exhalation, letting the water bring them up during inhalation. This exercise is connected to all the other stretches and movements that come after (15).

The transitions, which are the ways to move from one position to another in Watsu, are as important as the positions and the specific movements done in each position. The transitions create a sense of continuity, a flow, which develops trust and helps the patient to relax. The Transition Flow which is the name of the first transition in Watsu consists in an opening, a set of basic movements, three sessions and one completion (15).

Objectives

This article purposes a treatment to relief signs and symptoms in patients with Panic Disorder during the crises period through the Watsu technique, performed in a therapeutic pool.

Material and Methods

The material used in this paper is a result of research in scientific literature publications, between 1987 and 2007, in the form of articles, books and theses, which have as their theme panic disorder, hydrotherapy, Watsu and related subjects.

The referred material was searched on databases and in the libraries of the Faculdades Integradas de Ciencias Humanas, Saúde e Educacao de Guarulhos, and in the Biblioteca Regional de Medicina, BIREME, Universidade Federal de Sao Paulo, UNIFESP. The material was chosen by scientific relevance for the boarded subject.

The SF-36 was the questionnaire used to evaluate quality of life. The material used for the treatment was a therapeutic pool, placed in the clinic of physiotherapy in the Faculdades Integradas de Ciencias Humanas, Saúde e Educacao de Guarulhos. The patient signed a term agreeing to participate of this research.

Discussion

According with Gentil (1997) (1) and Caetano (1987) (2), Panic Disorder is characterized as a set of spontaneous and recurrent crises, sudden and imprevisible, which leads to an autonomic hyperactivity and causes several symptoms. The symptoms of the crisis are panic, perspiration, escape behaviour, tremors, dyspnoea, fainting or vertigo, discomfort in the chest, fear of be dying, pounding of the heart, suffocation sensation and asphyxia, chills, heat waves, losing control sensation or going crazy, nauseas, hemi lateral paraplegia, and others, as irreality sensation and strangeness referred to himself (respectively, desrealization and despersonalization). According to Del Porto (2002) (8), to diagnose Panic Disorder four or more symptoms of the ones described here must be present. These symptoms must also occur in an acute and abrupt way. The maximum intensity of the crisis is reached in ten minutes and disappears in about two hours. The crises lead the patients to an intense worry.

Accordingly to Haggstram (1993) (6), the panic attacks are occurring where there is no objective danger and during routine activities, and it can not be identified immediately what really caused the crisis. However, according to Paprocki (1990) (7), precipitant factors such a separation anxiety picture during the childhood, physical or emotional stress or drugs can lead to a crisis. More consistent evidences are based in biological factors, such as a dysfunction that leads to an inadequate discharge of adrenaline, which modifies the autonomic system as a consequence. Del Porto (2002) (8), cites that the panic is not just a reaction to the stress, but something that has a biological base. Substances such as carbon dioxide can for example lead to crises, presumably caused by a hypersensitivity of the receptors of this substance in the brain axis. Other theories cite serotonin dysfunction and adrenergic hyperactivity.

Gentil (1997) (1), Haggstram (1993) (6), Del Porto (2002) (8), Bruce (2003) (4) and Bernik (1999) (11), cite that the currently most used treatment for panic disorder is the remedy therapy, which is responsible for 50% of the therapeutic results and which aims to interrupt the attacks. The psychotherapy helps the patients to reach a better comprehension of the factors that can lead to the syndrome as well as to emotional stabilization.

Gentil (1997) (1) and Caetano (1987) (2) claim that patients who suffers from Panic Disorder represents significant occupational and social expenses since the syndrome often leads to a substantial loss of working hours for the patient as well for the family who are involved in the care and treatment of the patient, which often leads to a decrease of the economic standard of these families.

Watsu can be an interesting choice of treatment for patients with Panic disorder, since the emotional stability is the most difficult part to achieve during the treatment, and since the Watsu has relaxation as its main objective. Thus, to add Watsu as a auxiliary treatment can help the patients to overcome the period of crises more quickly and can thus give them a possibility to go back to their routines and work activities before the patients who did not receive this kind of treatment. To be able to come back to their routine can avoid unnecessary suffering for the patient as well as a decrease in the economic standard of these patients and their respective families. Concomitantly, the auxiliary treatment could also help with the social expenses since it is the state that must provide the patients when they are unable to work.

According to previous studies from Haggstram (1993) (6) patients with panic disorder have a decrease of the quality of life due to the impediments that the crises causes in their lives. Del Porto (2002) cites that panic disorder usually leads to secondary phobias (in most cases agoraphobia), and can also be associated with depressive disorders.

One of the problems with having Watsu as an auxiliary treatment to patients with Panic Disorder is that these patients often suffer from associated phobias, which can impair the assiduity to the hydrotherapy. For example, patients with agoraphobia will probably need someone to accompany them from their houses to the clinic so they can feel safe. Thus, the assiduity of the patient will be directly related with the possibility of always being accompanied in the days and time of the hydrotherapy. Another issue to be discussed is about hydrophobia or fear of the pool and deep water. This fear can perturb the development of the therapy, since the patient will not feel safe and relaxed, which is the main goal of the Watsu treatment where the patient is meant to be a passive receptor. Depression is also an associated disorder which can add problems to the therapy. Despite of all the benefits that the hydrotherapy can provide to patients with Panic Disorder, it is necessary that the patients feel enough stimulated to come to their sessions. One solution for this issue would be a stronger cooperation between the physiotherapist and the psychologist. The psychotherapist could for example treat the phobia while the physiotherapist carefully introduces the patient to hydrotherapy over time before starting the real treatment with Watsu. The Hallywick technique has as one of the main objectives to adapt patients in the pool which would make it suitable for such an introduction. Thus, The Watsu technique would be used only after the patient feels adapted to the pool and safe. However, it is necessary to discuss if it benefits the patient to be introduced to a technique if it causes more fear and anxiety in patients who are already emotionally sensitive, and how much the technique can improve or impair the prognosis of a patient who is already undertaking medical and psychological treatment. A contact between the physiotherapist and the psychologist regarding the patients’ treatment is recommended during the entire treatment period.

One great advantage of the auxiliary treatment is the implementation of many of the symptoms experienced by patients with the syndrome. For example, the hydrotherapy can improve the proprioception, corporal perception and corporal image. If patients who suffer from Panic Disorder often feel despersonalization and desrealization, perhaps these symptoms could be relieved by Watsu. Other symptoms as depression, insecurity and anxiety might also be helped through Watsu, since the technique provides enough relaxation and self confidence to make the patients feel better emotionally. At the same time, the Watsu is a technique which uses breathing as a part of all its movements. The effect of this association seems similar to the breath exercises used by psychotherapists to relief anxiety.

The hypotheses presented here can be strengthened through the practical part of this paper. The practical test was done as an auxiliary treatment of a patient who had a Panic Disorder diagnosis, with agoraphobia and depression associated. The patient was 21 years old, female, and had concomitantly psychotherapeutic and medical treatment. The treatment length was purposed to be two months, with one session of one hour a week. The patient was evaluated before the beginning of the treatment through the evaluation protocol SF-36 (Short Form Health Survey).

SF-36 is a generic questionnaire which measure the quality of life. The evaluation consists in two parts; the first one evaluates the health state (with questions related to physical mobility, pain, sleep, social isolation, and emotional reactions). The second part evaluates the impact of the disease in the daily life of the patient (17).

The patient had shown depression, insomnia, difficulty with social relations, suicidal thoughts and fear. After the hydrotherapies, the patient reported relaxation and a sensation of wellbeing, which was reported to last all day after each therapy. However, due the agoraphobia and depression, the patient missed many sessions, due to not have anyone to accompany her, or a lack of initiative. It was therefore not possible to make any real conclusions regarding the practical part of the study, due to the absence of results from many sessions, which impeded the reliability of the evaluations, since the patient did not receive hydrotherapeutic treatment during the purposed time period. However, we believe it was possible to conclude that even though the influence of the agoraphobia and depression in patients with Panic Disorder can cause a problem for this kind of treatment, the effects in a shortest term where positive and that further tests could prove to be more successful.

We therefore purpose this treatment for patients during the crises period, since there is a deficiency of auxiliary treatments for patients with Panic Disorder. The aim with this treatment would be to relief the symptoms of Panic Disorder by decreasing the intensity of the attacks as well as increasing the length of time between them. With the help of the therapeutic pool and with the Watsu technique we believe that it can be possible to reach this objective, due to the potential of relaxation and the physiological and therapeutic effects of the technique.

According to Chirinea (1998) (13) and Degani (1998) (14), hydrotherapy has the ability to promote the improvement of the quality of life, through the improvement of the self-confidence and socialization, relaxation (physical and mental) and decrease of emotional stress and anxiety. Furthermore, hydrotherapy can also improve proprioception and corporal perception, and lead to better physical and mental self awareness.

Since hydrotherapy is a controlled situation, stable and safe, the feelings and sensations are not intense, making it possible for the patients to realize and understand their own physical reactions. The patient can experience in the hydrotherapy some physiological effects that can be beneficial during the crises period. Some physical reactions caused by the immersion and water temperature are possible to compare with the reactions felt during a crisis, such as an increase in perspiration and pulse, which are related to changes in blood pressure. Thus, these physical reactions can start to be associated with a feeling of control rather then the opposite. During the treatment the patients will notice the benefits of the activity. For example the increase of the serotonin by the physical activity will quickly improve the well being of the patient.

Conclusion

In our opinion, the hydrotherapy could benefit patients during the crises period since it can diminish anticipated anxiety, decrease the tensions and fears which are associated and can lead to a crisis, and as a consequence, to better control the syndrome as a whole. The conclusion is therefore that the Watsu technique can benefit patients with Panic Disorder, during the crises period, due the relaxation factors. The Watsu technique as an auxiliary treatment can reduce the suffering of patients with the syndrome and, at the same time, help them to better handle the symptoms in a crisis.

However, it is necessary to study this closer in order to prove the efficiency of the technique in this respect, and to correlate the benefits of the hydrotherapy as a treatment for Panic Disorder. No bibliographical references have been found which shows evidence for this correlation, and moreover, material which describes the Watsu technique was scarce during the time period in which this paper was written. However, the results from our own incomplete test of Watsu as a part of the treatment for Panic Disorder showed some clear positive signs, which might be an incentive for further tests in this area.

Acknowledgements

We are thankful for the assistance given from Adriana Garcia Orfale and Renata Alqualo, physiotherapists and teachers of the Faculdades de Guarulhos, and from the physiotherapist Lilian Yukiko Yamada.

Bibliographical references

1) GENTIL et al. Pânico, fobias e obsessões, a experiência do projeto AMBAM. São Paulo,
1997
2) CAETANO, D. Impacto sócio-econômico-familiar da doença do pânico. J Brás
Psiq. Vol 36, p 161-165. 1987.
3) AGUIAR, W. M., DUNNINGHAM, W. Farmacoterapia do transtorno do
Pânico. Inform Psiq, v. 1, p. s20-s23. 1995
4) BRUCE, S. E. Are benzodiazepines still the medication of choice for patients with panic disorder with or without agoraphobia? Am J Psychiatry. Vol. 160. n. 8. p.1432-1438. 2003.
5) MACFADDEN, A. M. Avaliação psicodinâmica de mulheres com transtorno do Pânico. Boletim de Psicologia. V. XLIV, p 49-53. 1994.
6) HAGGSTRAM, L. M., LIMA, V. P., FENSTERSEIFER, G A importância do diagnóstico do distúrbio do pânico. R. Psiq. V.15, p. 55-60. 1993.
7) PAPROCKI, J., ROCHA, F. L. Doença do pânico ou distúrbio do pânico. Supl Arq
Brás. Méd. v. 64, p 155-161. 1990
8) DEL PORTO, J. A MAVI, J. J, RAZZOUK, D., PERES, M. F. T.,. Guia de medicina ambulatorial e hospitalar UNIFESP/EPM: psiquiatria. 1 ed. São Paulo: Manole. 256 p. 2002
9) VIDAL, C. E. L. Transtorno do pânico, critérios de diagnóstico. Inform Psiq.
Vol 14 .Supl 1, p s4-s7. 1995.
10) NIXON, R. D. V., BRYANT, R. A. Peritraumatic and persistent panic attacks in acute stress disorder. Behaviour Research and Therapy. Vol. 41. p 1237-1242. 2003.
11) BERNIK, V. Transtorno do pânico. Rev Brás méd. Vol 56. 1999.
12) RAMOS, R. T. As bases biológicas do transtorno do pânico. Rev. Psiq. Clín. V. 1.
n.28. p. 9-11. 2001.
13) CHIRINÉA, V. Jr., ROSIM, G. C. Hidroterapia: um caminho para a solução.
Fisio&terapia. V. 2. n. 10. p. 9. 1998.
14) DEGANI, A. M. Hidroterapia: os efeitos físicos, fisiológicos e terapêuticos da água.
Fisioterapia e m movimento vol XI, n 1, p. 91-105. 1998.
15) RUOTI, R. G. et al. Reabilitação aquática. 1. ed. São Paulo: Manole. 463 p. 2000.
16) BECKER, B. E. Terapia aquática moderna. 1. ed. São Paulo: Manole. 186 p. 2000.
17) Vitorino, D. F. M; Martins, F. L. M.; Souza, A. C.; Galdino, D.; Prado, G. F. Using SF-36 in clinical trials of fibromyalgia patients: determining minimal criterions for clinical improvement. Revista Neurociencias. V. 12. N. 03. 2004.

Se desejar, use os botões abaixo para compartilhar.

Deixe um comentário

O seu endereço de e-mail não será publicado.