Physiotherapy in primary dysmenorrhea: literature review* * Received from the University Center Fransciscano, Santa Maria, RS, Brazil.

Laís Rodrigues Gerzson Juliana Falcão Padilha Melissa Medeiros Braz Andriele Gasparetto About the authors

Abstracts

BACKGROUND AND OBJECTIVES:

Dysmenorrhea is a word derived from the Greek language and means difficult menstrual cycle. It may be classified as primary, leading to poorer quality of life indices of several women. This study aimed at investigating, by means of literature review, the efficacy and accuracy of existing therapies for primary dysmenorrhea, specifically in Physiotherapy.

CONTENTS:

Narrative literature review by querying electronic databases Medline, Scielo, Lilacs, Cochrane library, PEDro and Pubmed), where articles were selected and analyzed from August 2013 to February 2014. For data collection, materials from 2005 to current literature were included using the following keywords: “dysmenorrhea”, “physiotherapy” and their Portuguese equivalent “dismenorreia” and “fisioterapia”, combining them with the operators AND and OR.

CONCLUSION:

Studies were found describing the use of thermotherapy, cryotherapy, transcutaneous electric nerve stimulation and connective tissue massage, Pilates and acupuncture with improvement of such women's symptoms. However, it is clear the need for studies regarding physiotherapeutic maneuvers with further methodological rigor.

Dysmenorrhea; Physiotherapy; Woman's health


JUSTIFICATIVA E OBJETIVOS:

Dismenorreia é uma palavra derivada do grego e significa fluxo menstrual difícil. Pode ser classificada como primária, causando diminuição dos índices de qualidade de vida de muitas mulheres. O objetivo deste estudo foi investigar, por meio de uma revisão bibliográfica, a eficácia e acurácia de tratamentos existentes para dismenorreia primária, especificamente na Fisioterapia.

CONTEÚDO:

Revisão bibliográfica narrativa, por meio da busca em bases de dados eletrônicas (Medline, Scielo, Lilacs, biblioteca Cochrane, PEDro e Pubmed), com artigos selecionados e analisados durante o periodo de agosto de 2013 à fevereiro de 2014. Para a coleta foram incluídos materiais de 2005 até a literatura atual com os seguintes descritores: “dysmenorrhea”, “physiotherapy” e seus equivalentes em português “dismenorreia” e “fisioterapia” combinando-os com os operadores “AND” e “OR”.

CONCLUSÃO:

Encontraram-se trabalhos que descreveram a utilização dos recursos da termoterapia, crioterapia, eletroestimulação elétrica neural transcutânea e massagem do tecido conjuntivo, Pilates e acupuntura, com resultados que apresentam melhoras na sintomatologia dessas mulheres. No entanto, tornase evidente a necessidade do desenvolvimento de estudos referentes às manobras fisioterapêuticas com maior rigor metodológico.

Dismenorreia; Fisioterapia; Saúde da mulher


INTRODUCTION

Menstruation is a periodic and temporary genital bleeding, lasting from menarche to menopause1Brown J, Brown S. Exercise for dysmenorrhoea. Obstet Gynecol. 2010;116(1):186-7.. In addition, it is characteristic of primates and is defined as cyclic uterine hemorrhage dependent on endometrial disintegration and exfoliation, which occurs approximately in a normal cycle of 21 to 45 days, with 2 to 6 days of flow and mean blood loss of 20 to 60mL, in general lasting 40 years2Silva FC, Mukai LS, Vitalle MS. Prevalência de dismenorréia em pacientes avaliadas no centro de atendimento e apoio ao adolescente da Universidade Federal de São Paulo. Rev Paul Pediatr. 2004;22(2):85-8..

Dysmenorrhea, on the other hand, is pelvic or lower abdominal cyclic or recurrent pain, associated to menstruation. It is the most common gynecological complaint among young women, with prevalence between 43 and 93%3Rodrigues AC, Gala S, Neves A, Pinto Conceição, Meirelles C, Frutuoso C, et al. Dismenorreia em adolescentes e jovens adultas, Acta Med Port. 2011;24(2):383-92.. According to symptoms intensity, it is also major cause for school or work absenteeism4Barcelos PR, Conde DM, Deus JM, Martinez EZ. Qualidade de vida de mulheres com dor pélvica crônica: um estudo de corte transversal analítico. Rev Bras Ginecol Obstet. 2010;32(5):247-53.. The word dysmenorrhea comes from the Greek language and means difficult menstrual flow, being one of the most frequent gynecological affections with higher or lower intensity during menstrual cycle5Motta EV, Salomão AJ, Ramos LO. Dismenorreia. Rev Bras Ginecol Obstet. 2000;57(5):369-86..

According to its clinical presentation, primary dysmenorrhea (PD) is characterized by lack of visible structural abnormality or any gynecological pelvic disease and is the most commonly diagnosed type among teenagers3Rodrigues AC, Gala S, Neves A, Pinto Conceição, Meirelles C, Frutuoso C, et al. Dismenorreia em adolescentes e jovens adultas, Acta Med Port. 2011;24(2):383-92.. Functional dysmenorrhea coincides with the onset of regular ovulation cycles, which is more frequent approximately two years after menarche3Rodrigues AC, Gala S, Neves A, Pinto Conceição, Meirelles C, Frutuoso C, et al. Dismenorreia em adolescentes e jovens adultas, Acta Med Port. 2011;24(2):383-92.. Major symptom is lower abdominal or lumbar region pain, followed by other symptoms such as nausea, vomiting, headache and diarrhea6Barbosa IC. Comparação da eficácia e segurança de valdecoxibe e piroxicam no tratamento da dismenorréia primária. Rev Bras Med. 2007;64(7):318-22.. Pain may decrease after puerperal gravid cycle and, due to this, it is suggested that in such patients uterine isthmus is hypertonic, resulting in temporary retention of menstrual flow residues (which causes pressure in this highly innervated area). Approximately 50 to 70% of women have dysmenorrhea symptoms in some moment of life, being that approximately 10% become unable to perform their routine activities3Rodrigues AC, Gala S, Neves A, Pinto Conceição, Meirelles C, Frutuoso C, et al. Dismenorreia em adolescentes e jovens adultas, Acta Med Port. 2011;24(2):383-92..

Many therapies are proposed for dysmenorrhea and include the use of non-steroid anti-inflammatory drugs (NSAIDs), oral contraceptives, vitamins and tocolytic agents1Brown J, Brown S. Exercise for dysmenorrhoea. Obstet Gynecol. 2010;116(1):186-7.. A different treatment option is the practice of physical activities, for improving pelvic and extra-pelvic organs functioning by adjusting metabolism, hydroelectrolytic balance, hemodynamic conditions and blood flow, thus promoting a phenomenon known as analgesia by physical exercise which, by means of endogenous mechanisms and endogenous opioids release, raises pain threshold7Quintana LM, Heinz LN, Portes LA, Alfieri FM. Influência do nível de atividade física na dismenorreia. Rev Bras Ativ Física Saúde. 2010;15(2):101-4.,8Diegoli MS, Diegoli CA, Fonseca AM. Dismenorréia. RBM. 2007;64(3):81-7..

Physiotherapy has a diversity of therapeutic resources aiming at decreasing or eliminating pain in a practical and economic way, and may even undo negative associations surrounding this period, promoting better quality of life9Portal C, Honda S. Protocolo fisioterapêutico aplicado em mulheres que apresentam dismenorréia primária. Universidade da Amazônia. Centro de Ciências Biológicas e da Saúde. Belém; 2006. 1-61p. by means of some analgesic modalities, such as therapeutic exercises (kinesiotherapy), electrotherapy and therapeutic massage1010 Fae AP, Hedioneia MF. Efeitos da massagem do tecido conjuntivo e cinesioterapia no tratamento da dismenorréia primária. Fisioter Brasil. 2010;11(2):1-2..

In light of the above, this study aimed at investigating, by means of literature review, the efficacy and accuracy of existing therapies for PD, specifically in physiotherapy.

CONTENTS

A narrative literature review was carried out, where studies were identified by querying electronic databases Medline, Scielo, Lilacs, Cochrane, PEDro and Pubmed from August 2013 to February 2014. Materials from 2005 until what is presented by current literature were selected for analysis.

Articles were located using the following terms: "dysmenorrhea", "physiotherapy", and their Portuguese equivalents "dismenorreia" and "fisioterapia", combining with operators "AND" and "OR". Inclusion criteria were: (1) articles with complete text; (2) written in Portuguese or in English; (3) published between 2005 and 2014; (4) addressing physiotherapy and/or other complementary therapies to treat dysmenorrhea. There have been no restrictions to the sample to maximize study results. Excluded from the study were: (1) monographs; (2) review articles; (3) events proceedings; (4) dissertations and theses; (5) pharmacological studies or those addressing just this aspect in dysmenorrhea; (6) studies addressing secondary dysmenorrhea; (7) studies outside the studied period and (8) animal studies.

The search has resulted in 210 articles (189 in Pubmed, 7 in Cochrane, 4 in Scielo, 10 in Lilacs, zero in PEDro, zero in Medline). After reading them, 186 articles were excluded for not contemplating the stipulated period or the proposed subject and 10 were repeated articles, remaining 15 articles, the major results of which are shown intable 1.

Table 1
Description of selected texts

In general, the review carried out by the practice of Traditional Chinese Medicine (TCM) therapy, acupressure and acupuncture, has shown improvement in dysmenorrhea pain symptoms. Remaining resources, such as connective tissue massage, abdominal meridian (Hyongrak) massage, transcutaneous electric nerve stimulation (TENS), Pilates and belly dance, have shown how effective they are for dysmenorrhea patients' pain.

Currently, in gynecology, studies have discussed therapeutic ways to minimize discomfort, especially in case of primary dysmenorrhea, however, when it comes to treatment, analgesics are the first line to manage primary dysmenorrhea2626 Doty E, Attaran M. Managing primary dysmenorrhea. J Pediatr Adolesc Gynecol. 2006;19(5):341-4.. They act by decreasing cyclooxygenase pathway activity, inhibiting prostaglandin synthesis. There are studies showing that NSAIDs improve 17 to 95% of women’s complaints, being their gastrointestinal side-effects in general tolerable, but should be avoided in women with risk to developing ulcer2727 Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. BMJ. 2006;332(7550):1134-8.. However, currently NSAIDs only last during pain crisis, providing immediate pain relief with palliative and emergency connotation, thus crisis may be repeated at every menstruation2828 Brito SA, Marques CC, Alves DS, Alexandre AC. Prevalence of dysmenorrhea in undergraduate health courses at an institution of higher education. Rev Enferm UFPE on line. 2012;6(6):1386-94..

However, some women cannot make use of this conventional therapy and others do not respond (10 to 20%)2929 Giraldo IP, Eleutério Júnior J, Linhares IM. Como diagnosticar e tratar dismenorréia. Rev Bras Med. Ed. Moreira Jr 2006;6:164-8.. Added to this, Brazilian women self-medicate, using homemade or pharmacological practices, following prescription of unqualified people, such as neighbors, friends or even written, spoken or broadcasted media3030 Yáñez, N, Bautista RS, Ruiz SJ, Ruiz AM. Prevalencia y factores asociados a dismenorrea en estudiantes de ciencias de la salud. Rev Cienc Salud. 2010;8(3):37-48., which may generate a public health problem.

However, other therapies may be used or be associated to drugs, such as Physiotherapy, which is showing satisfactory results among women with this disorder. There are physiotherapeutic resources to decrease severity of primary dysmenorrhea symptoms or even to eliminate pain. Among them, there are: thermotherapy and cryotherapy; abdominal meridian (Kyongrak) massage; kinesiotherapy; connective tissue massage (CTM); TENS; interferential current; acupuncture; acupressure; collateral meridian acupressure therapy (CMAT); Pilates and auricular acupuncture.

Pilates has been effective for primary dysmenorrhea, as shown by a study by Araujo et al.2323 Araújo LM, Silva JM, Bastos WT, Ventura PL. Diminuição da dor em mulheres com dismenorreia primária, tratadas pelo método Pilates. Rev Dor. 2012;13(2):119-23. with 10 women aged between 18 and 30 years, submitted to the protocol of 16 exercises based on the Pilates method, with ball and on the ground, aimed at the pelvic region. Authors have observed significant decrease in pain intensity reported by participants due to increased blood flow, correction of muscle and postural imbalances and recovery of body and mind vitality3131 Gladwell V, Head S, Haggar M. Does a program of Pilates improve chronic non-specific low-back pain? J Sport Rehabil. 2006;15:338-50..

Thermotherapy was also other recurrent treatment for this disorder. Cold and heat are resources able to decrease or eliminate pain in a practical and economic way, through physiological effects they may produce in the organism when directly applied to the body1616 Araújo IM, Leitão TC, Ventura PL. Estudo comparativo da eficiência do calor e frio no tratamento da dismenorreia primária. Rev Dor. 2010;11(3):218-21.. The speed of the effect of cold on pain suggests that lower temperature may act as another sensory stimulation on pain behavior mechanism, and since cold stimulations are very intense, they may lead to endorphins and enchephalins release. As skin temperature lowers, stimulation to produce heat intensifies the mechanism3131 Gladwell V, Head S, Haggar M. Does a program of Pilates improve chronic non-specific low-back pain? J Sport Rehabil. 2006;15:338-50..

TENS is one of the simplest electrotherapy modalities, being a valuable physical resource to relieve pain induced both by acute and chronic injuries3232 Schulz AP, Chao BC, Gazola F, Pereira GD, Nakanishi KM, Kunz RI, et al. Ação da estimulação elétrica nervosa transcutânea sobre o limiar de dor induzido por pressão. Rev Dor. 2011;12(3):231-4.. This is an alternative, noninvasive, nontoxic method with the major advantage of not having side-effects3333 Walsh DM, Howe TE, Johnson MI, Sluka KA. Transcutaneous electrical nerve stimulation for acute pain. Cochrane Database Syst Rev. 2009;15(2)CD006142.. Oliveira et al.3434 Oliveira RG, Silva JC, Almeida AF, Araújo RC, Pitangui AC. TENS de alta e baixa frequência para dismenorreia primária: estudo preliminar. Conscientiae Saúde. 2012;11(1):149-58. have evaluated high and low frequency TENS effect in women with moderate to severe primary dysmenorrhea. Menstrual pain was measured by the Numeric Rating Scale (NRS), varying from zero to 10, before and soon after the intervention in all groups. At initial evaluation, groups were homogeneous, without significant pain score difference (p=0.875). Intragroup analysis of NRS scale data before and after TENS, has shown that high frequency TENS (HFT) and low frequency TENS (LFT) groups had significant difference (p=0.038; p=0.008). However the TENS placebo (TP) group had no difference (p=0.346). Intergroup analysis has not found significant difference among groups when comparing the first and the second evaluation (p=0.267). So, HFT and LFT were effective to relieve pain, being easy to apply, comfortable and with no adverse effects.

Therapeutic proposals which are being increasingly used by qualified professional derive from TCM, such as acupuncture, acupressure and auricular acupuncture. Studies2121 Liu CZ, Xie JP, Wang LP, Zheng YY, Ma ZB, Yang H, et al. Immediate analgesia effect of single point acupuncture in primary dysmenorrhea: a randomized controlled trial. Pain Med. 2011;12(2):300-7.,2525 Yeh ML, Hung YL, Chen HH, Wang YJ. Auricular acupressure for pain relief in adolescents with dysmenorrhea: a placebo-controlled study. J Altern Complement Med. 2013;19(4):313-8. have shown improved pain in women suffering from primary dysmenorrhea. The study by Yu et al.2020 Yu YP, Ma LX, Ma YX, Ma YX, Liu YQ, Liu CZ, et al. Immediate effect of acupuncture at Sanyinjiao (SP6) and Xuanzhong (GB39) on uterine arterial blood flow in primary dysmenorrhea. J Altern Complement Med. 2010;16(10):1073-8. reports that immediate acupuncture effect on Sanyinjiao point (SP6) provides immediate menstrual flow improvement. A study by Mirbagher-Ajorpaz, Adib-Hajbaghery & Mosaebi2222 Mirbagher-Ajorpaz N, Adib-Hajbaghery M, Mosaebi F. The effects of acupressure on primary dysmenorrhea: a randomized controlled trial. Complement Ther Clin Pract. 2011;17(1):33-6., using a different theory (acupressure at point SP6), has also observed positive pain improvement results.

Another aspect to manage this disease, belly dance, has shown to be positive to relieve pain. This is possibly related to the similarity with kinesiotherapy exercises such as: pelvic anterior and posterior tilt, forward and backward rotations, lateral tilts, pelvic elevation and depression, in addition to stretching and breathing exercises. Such exercises massage internal organs, thus improving blood circulation and metabolism regulation leading to improved health and benefiting legs and internal organs2424 Nascimento MS. Efeito terapêutico da dança do ventre em mulheres com queixas sugestivas de dismenorreia primária. Nova Fisio. 2012;15(87)..

One should also mention connective tissue massage, which suggests menstrual pain decrease because it is a spontaneous stimulation aiming at activating connective tissue mechanical receptors. This stimulation is transmitted by sensory nerves by means of spinal cord sympathetic ganglia and acts by releasing opioids such as encephalin in the spinal cord posterior nerve root, inhibiting pain transmission by thin fibers1919 Reis CA, Hardy E, Sousa MH. Efetividade da massagem do tecido conjuntivo no tratamento da dismenorréia primária em mulheres jovens. Rev Bras Saude Mater Infant. 2010;10(2):247-56..

CONCLUSION

Our findings indicate that Physiotherapy may be indicated to treat women with primary dysmenorrhea for being a low cost and noninvasive alternative. For such, there are several therapeutic resources, such as thermotherapy, cryotherapy, kinesiotherapy, TENS and connective tissue massage, acupuncture and Pilates, among others. Reviewed studies show satisfactory results of physiotherapeutic interventions, although the due methodological rigor is not always present, pointing to the need of further research in the area.

The number of publications on physiotherapeutic techniques is still small, so it is clear the need to develop quantitative, qualitative, randomized and controlled studies with higher methodological rigor with regard to physiotherapeutic maneuvers.

  • *
    Received from the University Center Fransciscano, Santa Maria, RS, Brazil.

References

  • 1
    Brown J, Brown S. Exercise for dysmenorrhoea. Obstet Gynecol. 2010;116(1):186-7.
  • 2
    Silva FC, Mukai LS, Vitalle MS. Prevalência de dismenorréia em pacientes avaliadas no centro de atendimento e apoio ao adolescente da Universidade Federal de São Paulo. Rev Paul Pediatr. 2004;22(2):85-8.
  • 3
    Rodrigues AC, Gala S, Neves A, Pinto Conceição, Meirelles C, Frutuoso C, et al. Dismenorreia em adolescentes e jovens adultas, Acta Med Port. 2011;24(2):383-92.
  • 4
    Barcelos PR, Conde DM, Deus JM, Martinez EZ. Qualidade de vida de mulheres com dor pélvica crônica: um estudo de corte transversal analítico. Rev Bras Ginecol Obstet. 2010;32(5):247-53.
  • 5
    Motta EV, Salomão AJ, Ramos LO. Dismenorreia. Rev Bras Ginecol Obstet. 2000;57(5):369-86.
  • 6
    Barbosa IC. Comparação da eficácia e segurança de valdecoxibe e piroxicam no tratamento da dismenorréia primária. Rev Bras Med. 2007;64(7):318-22.
  • 7
    Quintana LM, Heinz LN, Portes LA, Alfieri FM. Influência do nível de atividade física na dismenorreia. Rev Bras Ativ Física Saúde. 2010;15(2):101-4.
  • 8
    Diegoli MS, Diegoli CA, Fonseca AM. Dismenorréia. RBM. 2007;64(3):81-7.
  • 9
    Portal C, Honda S. Protocolo fisioterapêutico aplicado em mulheres que apresentam dismenorréia primária. Universidade da Amazônia. Centro de Ciências Biológicas e da Saúde. Belém; 2006. 1-61p.
  • 10
    Fae AP, Hedioneia MF. Efeitos da massagem do tecido conjuntivo e cinesioterapia no tratamento da dismenorréia primária. Fisioter Brasil. 2010;11(2):1-2.
  • 11
    Kim JS, Jo YJ, Hwang SK. The effects of abdominal meridian massage on menstrual cramps and dysmenorrhea in full-time employed women. Taehan Kanho Hakhoe Chi. 2005;35(7):1325-32.
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    Schiøtz HA, Jettestad M, Al-Heeti D. Treatment of dysmenorrhoea with a new TENS device (OVA). J Obstet Gynaecol. 2007;27(7):726-8.
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    Tugay N, Akbayrak T, Demirtürk F, Karakaya IC, Kocaacar O, Tugay U, et al. Effectiveness of transcutaneous electrical nerve stimulation and interferential current in primary dysmenorrhea. Pain Med. 2007;8(4):295-300.
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    Guo A, Meng Q. Acupuncture combined with spinal tui na for treatment of primary dysmenorrhea in 30 cases. J Tradit Chin Med. 2008;28(1):7-9.
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    Witt CL, Reinhold T, Brinkhaus B, Roll S, Jena S, Willich SN. Acupuncture in patients with dysmenorrhea: a randomized study on clinical effectiveness and cost-effectiveness in usual care. Am J Obstet Gynecol. 2008;198(2):166.e1-166.e8.
  • 16
    Araújo IM, Leitão TC, Ventura PL. Estudo comparativo da eficiência do calor e frio no tratamento da dismenorreia primária. Rev Dor. 2010;11(3):218-21.
  • 17
    Bazarganipour F, Lamyian M, Heshmat R, Abadi MA, Taghavi A. A randomized clinical trial of the efficacy of applying a simple acupressure protocol to the Taichong point in relieving dysmenorrhea. Int J Gynaecol Obstet. 2010;111(2):105-9.
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    Lin JA, Wong CS, Lee MS, Ko SC, Chan SM, Chen JJ, Chen TL. Successful treatment of primary dysmenorrhea by collateral meridian acupressure therapy. J Manipulative Physiol Ther. 2010;33(1):70-5.
  • 19
    Reis CA, Hardy E, Sousa MH. Efetividade da massagem do tecido conjuntivo no tratamento da dismenorréia primária em mulheres jovens. Rev Bras Saude Mater Infant. 2010;10(2):247-56.
  • 20
    Yu YP, Ma LX, Ma YX, Ma YX, Liu YQ, Liu CZ, et al. Immediate effect of acupuncture at Sanyinjiao (SP6) and Xuanzhong (GB39) on uterine arterial blood flow in primary dysmenorrhea. J Altern Complement Med. 2010;16(10):1073-8.
  • 21
    Liu CZ, Xie JP, Wang LP, Zheng YY, Ma ZB, Yang H, et al. Immediate analgesia effect of single point acupuncture in primary dysmenorrhea: a randomized controlled trial. Pain Med. 2011;12(2):300-7.
  • 22
    Mirbagher-Ajorpaz N, Adib-Hajbaghery M, Mosaebi F. The effects of acupressure on primary dysmenorrhea: a randomized controlled trial. Complement Ther Clin Pract. 2011;17(1):33-6.
  • 23
    Araújo LM, Silva JM, Bastos WT, Ventura PL. Diminuição da dor em mulheres com dismenorreia primária, tratadas pelo método Pilates. Rev Dor. 2012;13(2):119-23.
  • 24
    Nascimento MS. Efeito terapêutico da dança do ventre em mulheres com queixas sugestivas de dismenorreia primária. Nova Fisio. 2012;15(87).
  • 25
    Yeh ML, Hung YL, Chen HH, Wang YJ. Auricular acupressure for pain relief in adolescents with dysmenorrhea: a placebo-controlled study. J Altern Complement Med. 2013;19(4):313-8.
  • 26
    Doty E, Attaran M. Managing primary dysmenorrhea. J Pediatr Adolesc Gynecol. 2006;19(5):341-4.
  • 27
    Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. BMJ. 2006;332(7550):1134-8.
  • 28
    Brito SA, Marques CC, Alves DS, Alexandre AC. Prevalence of dysmenorrhea in undergraduate health courses at an institution of higher education. Rev Enferm UFPE on line. 2012;6(6):1386-94.
  • 29
    Giraldo IP, Eleutério Júnior J, Linhares IM. Como diagnosticar e tratar dismenorréia. Rev Bras Med. Ed. Moreira Jr 2006;6:164-8.
  • 30
    Yáñez, N, Bautista RS, Ruiz SJ, Ruiz AM. Prevalencia y factores asociados a dismenorrea en estudiantes de ciencias de la salud. Rev Cienc Salud. 2010;8(3):37-48.
  • 31
    Gladwell V, Head S, Haggar M. Does a program of Pilates improve chronic non-specific low-back pain? J Sport Rehabil. 2006;15:338-50.
  • 32
    Schulz AP, Chao BC, Gazola F, Pereira GD, Nakanishi KM, Kunz RI, et al. Ação da estimulação elétrica nervosa transcutânea sobre o limiar de dor induzido por pressão. Rev Dor. 2011;12(3):231-4.
  • 33
    Walsh DM, Howe TE, Johnson MI, Sluka KA. Transcutaneous electrical nerve stimulation for acute pain. Cochrane Database Syst Rev. 2009;15(2)CD006142.
  • 34
    Oliveira RG, Silva JC, Almeida AF, Araújo RC, Pitangui AC. TENS de alta e baixa frequência para dismenorreia primária: estudo preliminar. Conscientiae Saúde. 2012;11(1):149-58.

Publication Dates

  • Publication in this collection
    2014

History

  • Received
    06 May 2014
  • Accepted
    22 Sept 2014
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