|Year : 2021 | Volume
| Issue : 3 | Page : 284-290
Comparative evaluation of effect of two relaxation breathing exercises on anxiety during buccal infiltration anesthesia in children aged 6-12 years: A randomized clinical study
Seema Bargale, Jayesh Rupesh Khandelwal, Bhavna Haresh Dave, Anshula Neeraj Deshpande, Susmita Shrenik Shah, Deepika Narasimha Chari
Department of Pediatric and Preventive Dentistry, KM Shah Dental College and Hospital, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
|Date of Submission||26-Nov-2020|
|Date of Decision||20-Feb-2021|
|Date of Acceptance||27-Sep-2021|
|Date of Web Publication||22-Nov-2021|
Dr. Seema Bargale
Department of Pediatric and Preventive Dentistry, KM Shah Dental College and Hospital, Sumandeep Vidyapeeth, Vadodara, Gujarat
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Dental procedures, especially local anesthetic administration, are a source of great anxiety to children. Diaphragmatic breathing is defined as an efficient integrative body–mind training for dealing with stress and psychosomatic conditions. Pinwheel exercise is also a highly effective technique of “play therapy.” Aim: This study aimed to compare dental anxiety using pinwheel breathing exercise and diaphragmatic breathing exercise during buccal infiltration anesthesia. Methodology: Sixty children in the age group of 6–12 years with Frankel's behavior rating score of 3 who required buccal infiltration local anesthesia were selected. Subjects were divided randomly into two groups, i.e., Group A: children who performed pinwheel breathing exercise and Group B: children who performed diaphragmatic breathing exercise. The level of anxiety of the patients was recorded using an animated emoji scale. The data were analyzed using IBM SPSS version 20 software with paired t-test and Chi-square test. Results: There was a significant reduction in dental anxiety score from score 1 (before the anesthetic procedure) to score 2 (after the anesthetic procedure) in both the groups. On intergroup analysis, children who performed pinwheel breathing exercise (Group A) showed higher values than children who performed deep breathing exercise without pinwheel (Group B) with a t value of 1.42 but was not statistically significant with a P value of 0.161. Conclusion: Pinwheel breathing exercise as well as diaphragmatic breathing exercise proved to be significantly effective in reducing dental anxiety during local anesthesia.
Keywords: Animated emoji scale, buccal infiltration, dental anxiety, diaphragmatic breathing exercise, pinwheel breathing exercise
|How to cite this article:|
Bargale S, Khandelwal JR, Dave BH, Deshpande AN, Shah SS, Chari DN. Comparative evaluation of effect of two relaxation breathing exercises on anxiety during buccal infiltration anesthesia in children aged 6-12 years: A randomized clinical study. J Indian Soc Pedod Prev Dent 2021;39:284-90
|How to cite this URL:|
Bargale S, Khandelwal JR, Dave BH, Deshpande AN, Shah SS, Chari DN. Comparative evaluation of effect of two relaxation breathing exercises on anxiety during buccal infiltration anesthesia in children aged 6-12 years: A randomized clinical study. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2021 Dec 5];39:284-90. Available from: https://www.jisppd.com/text.asp?2021/39/3/284/330715
| Introduction|| |
Dental anxiety is a dynamic condition in several respects, and no single variable can account for its development exclusively. The literature has a series of factors which have always been linked to a higher incidence of dentistry, including characteristics of the individual; pain anxiety; past dental trauma, particularly in children (condition); and the influence of family members of peers with dental anxieties, which generate fear in one person (vicarial learning) and blood damage. Dental anxiety prevalence is 5%–20% in most populations, which is seen more in children, and this appears to decrease as the age progresses.,
Children are particularly anxious about dental procedures and, in particular, about local anesthetics (LAs). In children undergoing dental care, the sight and feeling of the anesthetic needle have been identified as the most fear-eliciting stimuli. The practitioner can therefore reduce anxiety in such a way that children are positively enthused for subsequent dental visits. Therefore, behavior guidance is a core aspect of pediatric dental practice.
Cognitive behavioral methods such as distraction, relaxation strategies, and coping mechanisms are frequently reported to alleviate dental procedural pain and anxiety. Distraction is a strategy that reduces the child's attention from painful stimuli through the engagement of other senses. The pinwheel is a deep breathing exercise used to relieve pain in young children as a distraction technique., It is used for the control of pediatric pain as an effective distraction technique during shorter operations such as immunizations, dermal wart cryotherapy, and for the reduction of experiences of pain in children with chronic conditions such as epidermolysis bullosa and cancer. The pinwheel acts as a focal point that enhances concentration and can be productive when used before testing or other tasks involving composure and coordination.
Breathing practice, also known as “diaphragmatic breathing” or “deep breathing,” is defined as an effective integrative body–mind training to deal with stress and psychosomatic conditions. In conjunction with meditation and ancient east Asian religions (such as the Buddhism) and martial arts, the benefits of diaphragmatic breathing were investigated. It is regarded as a core part of yoga and Tai Chi Chuan, which aims to enhance social and emotional balance,, as well as special rhythmic movements and positions.
Hence, this study was aimed to evaluate and compare dental anxiety using pinwheel breathing exercise and deep breathing exercise without pinwheel during buccal infiltration anesthesia in children aged 6–12 years.
| Methodology|| |
This study was conducted as a double-blinded, randomized clinical study at the Department of Pediatric and Preventive Dentistry and was initiated after the approval of ethical committee of institute (SVIEC/ON/DENT/RP/20002). Children between 6 and 12 years of age who required dental treatment under buccal infiltration anesthesia and whose parents gave informed consent were selected for the study. Children selected were with good systemic health and had no allergy for local anesthesia. Children falling under Frankl's behavior rating scale 3, i.e., (positive: acceptance of treatment; cautious behavior at times; and willingness to comply with dentist, at times with reservation, but patient follows dentist's instruction co-operatively) were selected so as to standardize the study subjects. Children suffering from any illness or requiring special medical care, presenting with acute pain, and requiring emergency dental treatment were excluded from the study.
Details of examination
The clinical examination of the selected children was carried out expert by the principal investigator to limit the variability of the examiner. The demographic details such as name, age, and medical history were recorded.
Methods of randomization
All the children were screened, and sixty children were carefully selected based on the inclusion and exclusion criteria. The subjects were made to pick up a chit from one fish bowl consisting of 60 chits that had either Group A (30 chits) or Group B (30 chits) in the bowl. The subject then handed over the chit to the administrator. The administrator kept a record of it separately and proceeded as per the allotted group [Figure 1].
|Figure 1: The CONSORT diagram showing the flowchart for a randomized controlled study|
Click here to view
- Group A: Children who performed pinwheel breathing exercise
- Group B: Children who performed deep breathing exercise without pinwheel.
The subject was positioned in an erect position on the dental chair. The subject and parents were explained about the entire procedure. All the instruments were sterilized and arranged prior to the procedure.
Administration of local anesthesia
Topical anesthetic gel containing 2% lignocaine (Easycainne®, Miraculus Pharama Pvt Ltd, Mumbai, Maharastra, India) was applied to the injection site using a sterile cotton applicator tip after drying with a cotton gauze. The benefit of using topical anesthetic was communicated to the child prior to the application using appropriate euphemisms. The gel was applied after drying the injection site with a sterile cotton gauze. The gel was rubbed on to the mucosa under moderate pressure for 30 s to increase the depth of penetration. After 3 min, the excess topical anesthetic was removed using a sterile cotton gauze. Then, the LA was administered by the buccal infiltration technique using a 27-G short needle syringe (Dispovan, Hindustan Syringes & Medical Devices Ltd, Faridabad, Haryana, India). One milliliter of 2% lignocaine with 1:200,000 units adrenaline was injected (Xylum-A Regain Laboratories Ltd, Hisar, Haryana, India). The standard technique of buccal infiltration was followed keeping the rate of injection as 0.8 mL/min. During injection, care was taken to keep the needle out of direct sight of the child. The lip/cheek was stretched to keep the tissue taut. At the height of the mucobuccal fold above the target tooth, the syringe was aligned along the long axis of the tooth with the needle bevel facing the bone. The depth of penetration was 2–3 mm. The needle was penetrated slowly into the tissue using low-speed continuous injection, so as to minimize pain. The needle was then withdrawn and made safe. A single investigator carried out all infiltrations.
Group A (pinwheel breathing exercise)
Group A comprised thirty child patients who were made to practice pinwheel breathing exercise before and after the local anesthesia procedure. With a pinwheel held in front of the child's face, instruction was given to the child to take a deep, slow breath in. Then, the child was instructed to hold the breath in for 2 s. After this, the child slowly released the breath by blowing the pinwheel. Repetitions were done until the child's satisfaction [Figure 2].
Group B (diaphragmatic breathing exercise)
Group B comprised thirty child patients who were made to practice diaphragmatic breathing exercise before and after the local anesthesia procedure. The subject was made to sit comfortably, with knees bent and the shoulders, head, and neck relaxed. The subject's one hand was placed on the upper chest and the other just below the rib cage. This allowed the child to feel the diaphragm move as he/she breathed. The subject was instructed to breathe in slowly through the nose so that the stomach would move out against his/her hand. The hand on the subject's chest remained as still as possible. Then, the subject was instructed to exhale through the pursed lips. The hand on the subject's upper chest must remain as still as possible [Figure 3].
Method of blinding
It was a double-blinded study where the statistician and the co-investigator were blinded. He/she was unaware about which type of distraction method was used on the child patient in the study.
Dental anxiety was measured preoperatively, i.e., before the anesthetic procedure and postoperatively, i.e., after the anesthetic procedure by a co-investigator who was blinded for the remaining procedure of the study. An animated emoji scale (AES) was used to assess dental anxiety. The AES has five animated emoji face graphic exchange formats that show distinct feelings ranging from very happy/laughing to very unhappy/sad and crying (most positive to most negative feelings). The child was asked to select one of these animated emojis that best suited their feelings at that moment on the electronic screen (laptop). As shown in [Figure 4], the scale had scores from 1 (very happy emoji) to 5 (very unhappy emoji).
Data collected were entered into a computer and analyzed using the SPSS software version 16 (SPSS Inc., IBM, Chicago, USA). The results were presented as mean ± standard deviation on continuous measurements and the results were presented in number (percent) on categorical measurements. For intragroup comparison, the paired t-test and an independent t-test for intergroup analysis were used.
| Results|| |
A total of 60 children (29 males and 31 females) aged 6–12 years participated in the study. The mean age of the participants in pinwheel breathing exercise group (Group A) and diaphragmatic breathing exercise group (Group B) was 8.53 ± 1.94 and 8.37 ± 1.85 years, respectively. Data revealed that both groups were similar in demographic characteristics including sex and age range [Table 1].
[Table 2] depicts the intragroup comparison of dental anxiety scores using AES. In pinwheel breathing exercise group, the mean value of dental anxiety score before the anesthetic procedure was 2.9 ± 0.76 and the dental anxiety score after the anesthetic procedure was 1.5 ± 0.63. The mean values of dental anxiety before the anesthetic procedure were higher than the mean values of dental anxiety after the procedure with a difference of 1.4 ± 0.77, which was statistically significant (P < 0.001). In the diaphragmatic breathing exercise group, the mean value of dental anxiety score before the anesthetic procedure was 2.8 ± 0.76 and the dental anxiety score after the anesthetic procedure was 1.67 ± 0.48. The mean values of dental anxiety before the anesthetic procedure were higher than the mean values of dental anxiety after the procedure with a difference of 1.13 ± 0.68, which was statistically significant (P < 0.001).
|Table 2: Intragroup analysis of dental anxiety scores assessed using an animated emoji scale (paired t-test)|
Click here to view
[Table 3] depicts the intergroup comparison of dental anxiety scores using AES. The mean values of dental anxiety score before anesthetic procedure for pinwheel breathing exercise and diaphragmatic breathing exercise group were 2.9 ± 0.76 and 2.8 ± 0.76, respectively. This showed that dental anxiety score before anesthetic procedure was higher in pinwheel breathing exercise group, which was statistically not significant (P > 0.001). The mean values of dental anxiety score after anesthetic procedure for pinwheel breathing exercise and diaphragmatic breathing exercise group were 1.5 ± 0.63 and 1.67 ± 0.48, respectively. This showed that dental anxiety score after anesthetic procedure was higher in the diaphragmatic breathing exercise group, which was statistically not significant (P > 0.001). Comparison of the difference of dental anxiety scores before and after the anesthetic procedure between the pinwheel breathing exercise group and diaphragmatic breathing exercise group showed that the difference was higher in the pinwheel breathing exercise group, which was statistically not significant (P > 0.001).
|Table 3: Intergroup analysis of dental anxiety scores assessed using an animated emoji scale (independent t-test)|
Click here to view
| Discussion|| |
Children's dental anxiety is a very common problem that occurs primarily in childhood and adolescence, and sometimes distresses the infant, parents, and dental practitioners. In this study, dental anxiety was measured in 6–12-year-old children, as there is a high level of prevalence of dental anxiety (84.5%) in this age group of children, according to Kumar et al. who evaluated dental anxiety among 6- to 12-year-old children in South Indian population. These findings were in accordance with the study done by de Menezes Abreu et al. who investigated 302 children in the age group of 6–7 years.
LAs are the most frequently used drugs in medicine and dentistry. The injection of LAs is sometimes the only perceived painful aspect of the medical or dental operation, and fear associated with LA injection has been identified as a factor that induces anxiety in children and prevents dental treatment. There are numerous local anesthesia administration strategies that include nerve block, local penetration, and injection of periodontal ligament. Kaufman et al. found local infiltration technique for local anesthesia administration to be least painful and causing less discomfort. Hence, local infiltration technique was used in this study for local anesthesia administration and buccal infiltration injection was selected for every participant to standardize the treatment protocol and avoid further bias.
Due to its difficulty, it is not easy to assess dental anxiety, particularly in young children who still lack the ability to either understand or interpret the signs of anxiety or answer questionnaires on this subject. A clinically appropriate, time-saving, appealing scale should be easily incorporated in younger children with minimal cognitive and linguistic abilities and should include a scoring system. A new anxiety scale, AES, was developed using motion emoticons/animojis by Setty et al., taking into account the abovementioned points. This was focused on the new generation's interest in multimedia and preference toward motion pictures on electronic devices rather than paper-based cartoons. In 102 healthy children aged 4–14 years, whose dental anxiety during their first dental visit was evaluated using animated emoji scale (AES), venham picture test (VPT), and facial image scale (FIS), and their scale preference was documented, Setty et al. validated this new scale. Dental anxiety was analogous to that measured with VPT and FIS when measured with that of AES. AES has proven to be a straightforward, attractive, simple, easy, and efficient method for measuring children's dental anxiety during their dental visit.
The pinwheel serves as a tool for opportunities. Almost every kid can remember watching the colors go around and around. The “toy” also makes this breath available because as an emphasis on the long slow exhale, it becomes a little more lighthearted pinwheel breathing. It is a releasing breath that helps control the nervous system and relaxes anxieties. Pinwheel breathing exercise is also a highly successful “play therapy” method used by therapists to engage with intensely anxious kids and manage them. Play therapy methods have been used to ease anxiety and guide children's actions during elective surgery. The pinwheel breathing exercise is an adaptation of a deep breathing exercise intended to teach children synchronized breathing in the shape of a pinwheel using a reinforcer, thereby fostering the nervous child's participation. Hence, we used pinwheel breathing exercise as a novel method to reduce dental anxiety in children during local anesthesia administration. There was a signification reduction between dental anxiety scores after the local anesthesia administration and dental anxiety scores before the local anesthesia administration. This exercise is a low-cost, easy-to-use cognitive behavioral guidance technique that does not have any side effects. This was contrary to the study conducted by Sridhar et al. who evaluated the effectiveness of bubble breath exercise which had a similar principle in reducing anxiety and found that this exercise was not effective in reducing dental anxiety in children aged 7–11 years during maxillary buccal infiltration.
Relaxation exercises have been proven to improve vagal function, increase the development of antipain neurotransmitters such as serotonin, and reduce stress hormone levels. The “relaxation response” is known as this qualified physiological response of the body to stressful conditions. Diaphragmatic breathing is a technique of breath conditioning (mainly involving diaphragm muscle involvement), characterized by an increased depth of both inhalation and exhalation and a decreased breath duration over an established period of time (e.g. 2–4 min). This form of respiration supplies the body with more oxygen, thus lowering the heart rate. Breathing relaxation is easy to perform and can be used by anxious patients in the dental chair immediately prior to treatment or at home. Psychological studies have shown that the practice of respiration is an important nonpharmacological response to emotional enhancement, including a decrease in anxiety, depression, and stress. Ma et al. evaluated the effect of diaphragmatic breathing on cognition, affect, and cortisol responses to stress in healthy adults and found that diaphragmatic breathing practice improved cognitive performance and reduced negative subjective and physiological consequences of stress (anxiety) in healthy adults. Based on the evidence showing the efficacy of diaphragmatic breathing in reducing fear and anxiety in the general population, we used as it as a breathing modification technique for reducing dental anxiety in children aged 6–12-year-old for the first time. Children performing diaphragmatic breathing exercise showed significant reduction in dental anxiety scores when compared before and after local anesthesia administration.
When pinwheel breathing exercise and diaphragmatic breathing exercise were compared, there was greater reduction in dental anxiety scores after the local anesthesia administration in children who performed pinwheel breathing exercise, although it was not statistically significant. This may be due to the fact that, pinwheel breathing exercise also helped in effectively distracting the child, by shifting the attention of the child away from the source of pain, when the child was engaged in deep breathing, as if blowing the pinwheel. In addition, the technique was easily adapted by school-aged children and thus was both clinician and patient friendly.
Further studies are required in this field, particularly involving children with high dental anxiety and dental behavior management problems. The results of this study suggest that the pinwheel exercise may be used as a relaxation as well as distraction therapy in the management of procedural anxiety to ensure child's psychological well-being, which is an important goal of pediatric dentistry. Furthermore, diaphragmatic breathing exercise proved to be beneficial in managing procedural anxiety and can be used in routine pediatric dental practice.
| Conclusion|| |
- Pinwheel breathing exercise and diaphragmatic breathing exercise proved to be effective in reducing dental anxiety after local anesthesia administration in children aged 6–12 years old
- When the efficacy of both the exercises was compared, pinwheel breathing exercise proved to be more effective than diaphragmatic breathing exercise in reducing dental anxiety after local anesthesia administration, which was not found to be statistically significant.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Doerr PA, Lang WP, Nyquist LV, Ronis DL. Factors associated with dental anxiety. J Am Dent Assoc 1998;129:1111-9.
Gatchel RJ, Ingersoll BD, Bowman L, Robertson MC, Walker C. The prevalence of dental fear and avoidance: A recent survey study. J Am Dent Assoc 1983;107:609-10.
Locker D, Liddell AM. Correlates of dental anxiety among older adults. J Dent Res 1991;70:198-203.
Taani DQ, El-Qaderi SS, Abu Alhaija ES. Dental anxiety in children and its relationship to dental caries and gingival condition. Int J Dent Hyg 2005;3:83-7.
Klingberg G, Vannas Löfqvist L, Bjarnason S, Norén JG. Dental behavior management problems in Swedish children. Community Dent Oral Epidemiol 1994;22:201-5.
Clinical Affairs Committee-Behavior Management Subcommittee, American Academy of Pediatric Dentistry. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent 2015;37:57-70.
Jacobs A, Price HN, Popenhagen MP. Blowing away the pain: A technique for pediatric pain management. Pediatr Dermatol 2014;31:757-8.
Peretz B, Gluck GM. Assessing an active distracting technique for local anesthetic injection in pediatric dental patients: Repeated deep breathing and blowing out air. J Clin Pediatr Dent 1999;24:5-8.
Chieng YJ, Chan WC, Klainin-Yobas P, He HG. Perioperative anxiety and postoperative pain in children and adolescents undergoing elective surgical procedures: A quantitative systematic review. J Adv Nurs 2014;70:243-55.
French GM, Painter EC, Coury DL. Blowing away shot pain: A technique for pain management during immunization. Pediatrics 1994;93:384-8.
Kool R, Lawver T. Play therapy: Considerations and applications for the practitioner. Psychiatry (Edgmont) 2010;7:19-24.
Kuppenheimer WG, Brown RT. Painful procedures in pediatric cancer. A comparison of interventions. Clin Psychol Rev 2002;22:753-86.
Ma X, Yue ZQ, Gong ZQ, Zhang H, Duan NY, Shi YT, et al.
The effect of diaphragmatic breathing on attention, negative affect and stress in healthy adults. Front Psychol 2017;8:874.
Lehrer P, Karavidas MK, Lu SE, Coyle SM, Oikawa LO, Macor M, et al.
Voluntarily produced increases in heart rate variability modulate autonomic effects of endotoxin induced systemic inflammation: An exploratory study. Appl Psychophysiol Biofeedback 2010;35:303-15.
Sargunaraj D, Lehrer PM, Hochron SM, Rausch L, Edelberg R, Porges SW. Cardiac rhythm effects of. 125-Hz paced breathing through a resistive load: Implications for paced breathing therapy and the polyvagal theory. Biofeedback Self Regul 1996;21:131-47.
Beauchaine T. Vagal tone, development, and Gray's motivational theory: Toward an integrated model of autonomic nervous system functioning in psychopathology. Dev Psychopathol 2001;13:183-214.
Tandon S. Textbook of Pedodontics. 2nd
ed. Hyderabad: Paras Medical Publisher; 2008.
Setty JV, Srinivasan I, Radhakrishna S, Melwani AM, Dr MK. Use of an animated emoji scale as a novel tool for anxiety assessment in children. J Dent Anesth Pain Med 2019;19:227-33.
Locker D, Thomson WM, Poulton R. Onset of and patterns of change in dental anxiety in adolescence and early adulthood: A birth cohort study. Community Dent Health 2001;18:99-104.
Locker D, Liddell A, Dempster L, Shapiro D. Age of onset of dental anxiety. J Dent Res 1999;78:790-6.
Kumar V, Goud EV, Turagam N, Mudrakola DP, Ealla KK, Bhoopathi PH. Prevalence of dental anxiety level in 6- to 12-year- old south Indian children. J Pharm Bioallied Sci 2019;11:S321-4.
de Menezes Abreu DM, Leal SC, Mulder J, Frencken JE. Patterns of dental anxiety in children after sequential dental visits. Eur Arch Paediatr Dent 2011;12:298-302.
Milgrom P, Coldwell SE, Getz T, Weinstein P, Ramsay DS. Four dimensions of fear of dental injections. J Am Dent Assoc 1997;128:756-66.
Kaufman E, Epstein JB, Naveh E, Gorsky M, Gross A, Cohen G. A survey of pain, pressure, and discomfort induced by commonly used oral local anesthesia injections. Anesth Prog 2005;52:122-7.
Newton JT, Buck DJ. Anxiety and pain measures in dentistry: A guide to their quality and application. J Am Dent Assoc 2000;131:1449-57.
Li WH, Chung JO, Ho KY, Kwok BM. Play interventions to reduce anxiety and negative emotions in hospitalized children. BMC Pediatr 2016;16:36.
Hall TM, Kaduson HG, Schaefer CE. Fifteen effective play therapy techniques. Prof Psychol Res Pr 2002;33:515-22.
Sridhar S, Suprabha BS, Shenoy R, Shwetha KT, Rao A. Effect of a relaxation training exercise on behaviour, anxiety, and pain during buccal infiltration anaesthesia in children: Randomized clinical trial. Int J Paediatr Dent 2019;29:596-602.
Jacobs GD. The physiology of mind-body interactions: The stress response and the relaxation response. J Altern Complement Med 2001;7 Suppl 1:S83-92.
Milgrom P, Weinstein P, Heaton LJ. Treating Fearful Dental Patients: A Patient Management Handbook. 3rd
ed. Seattle (WA): Dental Behavioral Resources; 2009.
Armfield JM, Heaton LJ. Management of fear and anxiety in the dental clinic: A review. Aust Dent J 2013;58:390-407.
Stromberg SE, Russell ME, Carlson CR. Diaphragmatic breathing and its effectiveness for the management of motion sickness. Aerosp Med Hum Perform 2015;86:452-7.
Brown RP, Gerbarg PL. Sudarshan Kriya Yogic breathing in the treatment of stress, anxiety, and depression. Part II – Clinical applications and guidelines. J Altern Complement Med 2005;11:711-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]