Volume 13, Issue 2 (7-2018)                   sija 2018, 13(2): 250-261 | Back to browse issues page

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Anbari S, Estaji Z, Rastaqhi S. Assessment Effect of Rosa Damascena Juice Aromatherapy on Elderly Chronic Musculoskeletal Pain in Sabzevar Retirement Clubs. sija. 2018; 13 (2) :250-261
URL: http://salmandj.uswr.ac.ir/article-1-1374-en.html
1- Master Student of Gerontology Department of Nursing, School of Nursing & Midwifery, Iranian Research Center on Healthy Aging, Sabzevar University of Medical Sciences, Sabzevar, Iran.
2- MSc. Sabzevar Sabzevar University of Medical Sciences , z.estaji@yahoo.com
3- msc of Statistics Department of Biostatistics & Epidemiology, School of Health, Sabzevar University of Medical Sciences, Sabzevar, Iran.
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Extended Abstract
1. Objectives

Old age is a critical period of human life [1]. One of the major health problems of aging is chronic pain. Thus, the most common issue posed to the medical staff is chronic pain in the elderly [2]. Musculoskeletal pain is the primary cause of disability in the elderly [3]. Pain control is considered such a critical component of care, such that the American Pain Society has devised the phrase “pain as the fifth vital sign” to emphasize its importance and increase the awareness of the health team members about pain control [4]
Some methods with minimal complications are used as nursing for pain relief [5]. Aromatherapy is one of the ways to reduce the pain during this period; it is the second method of complementary medicine, and along with other health care, it is an opportunity for nurses to resolve the patient complaints [6]. The present study investigated the effect of the inhaled rose extract on chronic musculoskeletal pain in the elderly. 
2. Methods and Materials
This study is a clinical trial. The sampling method was random assignment of 60 elderly individuals with chronic musculoskeletal pain. The subjects were members of Retirement Centers of Sabzevar City in 2016. 
The subjects were randomly were divided into two groups: intervention (n=31) and control group (n=29). The pain was measured in both groups by telephone. The McGill Pain Questionnaire has been valid and reliable in previous studies was utilized before intervention with an interview and once a week on Thursday during the intervention. Moreover, the questionnaire was completed by the interview method at the subject’s home by obtaining the permission of the individual by phone and in advance coordination. In addition, the strategy of the study was explained to the elderly. Three copies of the questionnaire and an extract with a dropper, a piece of linen, and an explanation card were provided to each participant, explaining the study procedure and its starting date in order to complete the questionnaire by themselves and the researcher during phone calls. A specific day and one subject were considered for starting the intervention for simultaneous use of extracts, and the elderly were asked to start the aromatherapy technique on the same day. Follow-ups were accomplished via phone calls.
In the intervention group, the rose extract was inhaled using linen stuffed with three drops of extracts from 9:00 pm to 6:00 am at 25 cm, one time daily for three weeks. In the control group, sweet almond oil was used similarly. The contact number of the researcher was provided to the subjects in case of any queries and or putative complications and allergies. Data were analyzed using the SPSS 20 software with a significance level of P<0.05.
3. Results
The distribution frequency of age and gender did not reveal any difference between the two groups and were homogeneous. The mean of chronic pain in the elderly was based on the knee pain that was most frequent, approximately 70%. Inhaling the rose extract was not effective on the sensory and emotional side of the chronic pain in men and women. However, a statistically significant difference between men and was noted in the sensory dimension of chronic pain (P<0.05) but not in terms of the emotional dimension.
The results of repeated measures analysis of variance (RM-ANOVA) for the emotional and emotional dimension of chronic pain revealed that the passage of time exerted a significant effect on pain. However, the interactive effect was observed between the passage of time (before intervention, first week, second week, and third week) and the studied groups (control and intervention groups) on the sensational and emotional sides of chronic pain. Furthermore, the inhalation of the rose extract on the Present Pain Intensity (PPI) and continued chronic pain in women and men was not effective. Moreover, the inhalation effect on PPI and continuity of chronic pain was statistically significant in the comparison between men and women (P<0.05). Also, the results of RM-ANOVA for PPI and the persistence of chronic pain showed that the passage of time had a statistically significant effect on pain. However, the interactive effect between the passage of time (before the intervention, first week, second week, and third week), and the groups were examined (control and intervention groups), and no significant effect was observed on the severity of PPI and the continuation of chronic pain.
In the sensory dimension of chronic pain, i.e., the most frequent type of pain, slight pain and feeling hot and burning in the control group was 51.7% and 41.4%, respectively and that in the intervention group was 67.7% and 58.1%, respectively. In the emotional dimension, the most frequent type of pain type, tired and boring in the control group was 96.6% and 62.1%, respectively, and that in the intervention group was 96.8% and 58.1%, respectively. The second most chronic pain site in the elderly was back pain with 36.7%. In addition, 70% of the elderly reported pain in more than one area. The comparison of the pain score between two genders in chi-square test showed that pain in women (74.2%) was more than that in men (44.8%).
4. Conclusion
The present study showed that the aromatherapy using rose extract reduces the sensory dimension of musculoskeletal pain among men and women, although additional studies are essential. Interestingly, aromatherapy of rose extract can be used as a non-pharmaceutical strategy along with other therapies in order to reduce pain and promote a sense of peace and satisfaction in the elderly as it is a simple, safe, affordable, and economical, and hence, recommended.
The current findings can be valuable in planning with effective management of chronic pain by researchers, officials, and custodians. In addition, due to the increasing inclination of the individuals and healthcare systems to complementary medicine, managers can organize training courses regarding the therapeutic effects of complementary and alternative therapies, such as aromatherapy and inhalation of rose extract, and provide training to the personnel.
Ethical Considerations
Compliance with ethical guidelines

This research was approved by the Ethics Committee of Sabzevar University of Medical Sciences with the code of IR.MEDSAB.REC.1395.77. The elderly  filled the informed consent and then they were categorized into two groups of intervention and control.
Funding
This research was extracted from the MSc. thesis of Somayyeh Anbari on Department of Nursing, School of Nursing & Midwifery, Iranian Research Center on Healthy Aging, Sabzevar University of Medical Science.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgements
The researcher appreciates all the elderly who have been able to do the study by expanding their research conditions. He is also appreciated by the deputy research director of Sabzevar University of Medical Sciences and respected professors who have facilitated the study with their spiritual support.

 
References
  1. Fotoukian Z, Mohammadi Shahboulaghi F, Fallahi Khoshknab M. [Analytical on empowerment interventions in older people with chronic disease: A review literature (Persian)]. Journal of Health Promotion Management. 2013; 2(4):65-76.
  2. Alizadeh M, Hoseini M, Shojaeizadeh D, Rahimi A, Arshinchi M, Rohani H. [Assessing anxiety, depression and psychological wellbeing status of urban elderly under represent of Tehran Metropolitan City (Persian)]. Iranian Journal of Ageing. 2012; 7(3):66-73.
  3. Shirazi M, Manoochehri H, Zagheri Tafreshi M, Zayeri F, Alipour V. [Prevalence of chronic pain and its characteristics among elderly people in Ahvaz city: A cross sectional study (Persian)]. Iranian Journal of Geriatric Nursing. 2015; 2(1):62-78.
  4. Gharaee Ardakani S, Azad Falah P, Tavalaee A. [The effectiveness of acceptance and commitment therapy on pain experience in women with chronic pain (Persian)]. Journal of Clinical Psychology. 2012; 4(2):39-50. [DOI:10.22075/JCP.2017.2087] 
  5. Shirazi M, Manoochehri H, Zagheri T, Zayeri F, Alipour V. Explaining of chronic pain management process in older people: A grounded theory Study. Medical-Surgical Nursing Journal. 2016; 4 (4):1-10.
  6. Saeidiyan asl M. [Comparative Effectiveness of Treatments based on management attention and relaxation, reducing pain perception in elderly patients with chronic pain (Persian)] [MSc. thesis]. Shiraz: University of Shiraz; 2011.
  7. Mohammadi F, Mohammadkhani P, Dolatshahi B, Asghari M A. [The effects of “mindfulness meditation for pain management” on the severity of perceived pain and disability in patients with chronic pain (Persian)]. Iranian Journal of Ageing. 2011; 6(1):59-66 
  8. Cimmino MA, Ferrone C, Cutolo M. Epidemiology of chronic musculoskeletal pain. Best Practice & Research Clinical Rheumatology. 2011; 25(2):173-83. [DOI:10.1016/j.berh.2010.01.012]
  9. Stubbs B, Schofield P, Patchay S, Leveille S. Musculoskeletal pain characteristics associated with lower balance confidence in community-dwelling older adults. Physiotherapy. 2016; 102(2):152-8.  [DOI:10.1016/j.physio.2015.03.3721]
  10. Salamati A, Mashouf S, Sahbaei F, Mojab F. Effects of inhalation of lavender essential oil on open-heart surgery pain. Iranian Journal of Pharmaceutical Research. 2014; 13(4):1257-61. [PMID] [PMCID]
  11. Roozbahani N, Attarha M, Akbari Torkestani N, Amiri Farahani L, Heidari T. [The effect of rose water aromatherapy on reducing labor pain in primiparous women (Persian)]. Complementary Medicine Journal of Faculty of Nursing & Midwifery. 2015; 5(1):1042-53.
  12. PDQ Integrative, Alternative, and Complementary Therapies Editorial Board. Aromatherapy and essential oils (PDQ®): Health professional version. Rockville, Maryland: National Cancer Institute; 2015.
  13. Ganjloo J MN, Najafi S, Rakhshani M.H. [The Effects of inhaling lavender oil on patients’ anxiety with myocardial infarction (Persian)]. Quarterly Journal of Sabzevar University of Medical Sciences. 2015; 21(6):1064-72.
  14. Martins DF, Emer AA, Batisti AP, Donatello N, Carlesso MG, Mazzardo-Martins L, et al. Inhalation of Cedrus atlantica essential oil alleviates pain behavior through activation of descending pain modulation pathways in a mouse model of postoperative pain. Journal of Ethnopharmacology. 2015; 175:30-8. [DOI:10.1016/j.jep.2015.08.048]
  15. Aliasgharpour M, Mohammadi N, Kazemnejad A, Abbaszadeh R. [Comparison the effect of lidocaine gel and inhalation of lavender aromatherapy on pain score of arteriovenous fistula puncture in hemodialysis patients (Persian)]. Complementary Medicine Journal of Faculty of Nursing & Midwifery. 2015; 4(4):1000-11.
  16. Sadeghi Aval Shahr H, Saadat M, Kheirkhah M, Saadat E. The effect of self-aromatherapy massage of the abdomen on the primary dysmenorrhoea. Journal of Obstetrics and Gynaecology. 2015; 35(4):382-5. [DOI:10.3109/01443615.2014.958449]
  17. Sköld M, Hagvall L, Karlberg AT. Autoxidation of linalyl acetate, the main component of lavender oil, creates potent contact allergens. Contact Dermatitis. 2008; 58(1):9-14. [DOI:10.1111/j.1600-0536.2007.01262.x]
  18. Tabaei As, Rezaei M. [Study of flower yield variation in rosa damascena mill. From western regions of Iran (Persian)]. Iranian Journal of Medicinal and Aromatic Plants. 2004; 20(3):333-44.
  19. Maryam Marofi M, Siros Fard M. [The effect of aromatherapy with Rosa damascene mill and pelargonium graveolens on post-operative pain intensity in pediatric (Persian)]. Anesthesiology and Pain. 2015; 5(3):64-73.
  20. Davari M, Mosharraf S. [Aromatherapy effect of lavander essence and mefenamic acid on dysmenorrhea: A clinical trial (Persian)]. Journal of Research Development in Nursing and Midwifery. 2014; 11(2):8-14.
  21. Jaafarnejad F, Hoseini S.F, Mazloom S.R, Hami M. [Comparison of the evaluation of severity of cyclical mastalgia using the Visual Analogue Scale (VAS) and modified McGill pain questionnaire (M-MPQ) (Persian)]. Iranian Women’s Midwifery and Infertility Journal. 2012; 15(39):9-15.
  22. Tanhaee Z, Fathi Ashtiani A, Amini M, Vahedi H. [Validation of a revised version of the Short-form Mc-Gill Pain Questionnaire (SF-MPQ-2) for IBS patients (Persian)]. Govaresh. 2012; 17(2):91-7.
  23. Quinn F, Hughes CM, Baxter G. Reflexology in the management of low back pain: a pilot randomised controlled trial. Complementary Therapies in Medicine. 2008; 16(1):3-8. [DOI:10.1016/j.ctim.2007.05.001]
  24. Nazemzadeh M, Jalalodini A, Rezvani Amin M, Yousefian N, Poornamdar Z, Ghaljeh M. [The effect of foot reflexology massage on pain intensity in patients with chronic low back pain visited to physical therapy unit in Baghiathallah hospital in Tehran (Persian)]. Complementary Medicine Journal of Faculty of Nursing & Midwifery. 2012; 2(3):204-11
  25. Zahedifard T, Firozi M. [Assessment of the articles related to primary dysmenorrhea in dimension of menstrual pain assessment tools (Persian)]. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2016; 19(4):17-27.
  26. Pereira LV, Pereira Gde A, Moura LA, Fernandes RR. Pain intensity among institutionalized elderly: a comparison between numerical scales and verbal descriptors. Revista da Escola de Enfermagem da USP. 2015; 49(5):804-10. [DOI:10.1590/S0080-623420150000500014]
  27. Bernfort L, Gerdle B, Rahmqvist M, Husberg M, Levin L-Å. Severity of chronic pain in an elderly population in Sweden—impact on costs and quality of life. Pain. 2015; 156(3):521-7. [DOI:10.1097/01.j.pain.0000460336.31600.01]
  28. Taghipour Dm, Hosseini S, Kia K, Abbaspour M, Ghadimi R. [Prevalence of musculoskeletal pain and it’s correlation to functional disability in elderly (Persian)]. Knowledge and Health. 2013; 8(2):76-82.
  29. Chen Q, Hayman LL, Shmerling RH, Bean JF, Leveille SG. Characteristics of chronic pain associated with sleep difficulty in older adults: The Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston study. Journal of the American Geriatrics Society. 2011; 59(8):1385-92. [DOI:10.1111/j.1532-5415.2011.03544.x]
  30. Pizzo PA, Clark NM. Alleviating suffering 101—pain relief in the United States. New England Journal of Medicine. 2012; 366(3):197-9. [DOI:10.1056/NEJMp1109084]
  31. Santos FC, Moraes NSd, Pastore A, Cendoroglo MS. Chronic pain in long-lived elderly: prevalence, characteristics, measurements and correlation with serum vitamin D level. Revista Dor. 2015; 16(3):171-5. [DOI:10.5935/1806-0013.20150034]
  32. Paddock C. Women’s finer sense of smell may be due to more brain cells [Internet]. 2014 [Updated 6 November 2014]. Available from: www.medicalnewstoday.com/articles/284991.php
  33. Alipour M, Hosseini SR, Saadat P, Bijani A. The relationship between chronic musculoskeletal pain and vitamin d deficiency in the elderly population of Amirkola, Iran. Journal of Babol University of Medical Sciences. 2015; 17(10):7-14.
Type of Study: Research | Subject: nursing
Received: 2017/12/30 | Accepted: 2018/05/05 | Published: 2018/06/22

References
1. Fotoukian Z, Mohammadi Shahboulaghi F, Fallahi Khoshknab M. [Analytical on empowerment interventions in older people with chronic disease: A review literature (Persian)]. Journal of Health Promotion Management. 2013; 2(4):65-76.
2. Alizadeh M, Hoseini M, Shojaeizadeh D, Rahimi A, Arshinchi M, Rohani H. [Assessing anxiety, depression and psychological wellbeing status of urban elderly under represent of Tehran Metropolitan City (Persian)]. Iranian Journal of Ageing. 2012; 7(3):66-73.
3. Shirazi M, Manoochehri H, Zagheri Tafreshi M, Zayeri F, Alipour V. [Prevalence of chronic pain and its characteristics among elderly people in Ahvaz city: A cross sectional study (Persian)]. Iranian Journal of Geriatric Nursing. 2015; 2(1):62-78.
4. Gharaee Ardakani S, Azad Falah P, Tavalaee A. [The effectiveness of acceptance and commitment therapy on pain experience in women with chronic pain (Persian)]. Journal of Clinical Psychology. 2012; 4(2):39-50. [DOI:10.22075/JCP.2017.2087]
5. Shirazi M, Manoochehri H, Zagheri T, Zayeri F, Alipour V. Explaining of chronic pain management process in older people: A grounded theory Study. Medical-Surgical Nursing Journal. 2016; 4 (4):1-10.
6. Saeidiyan asl M. [Comparative Effectiveness of Treatments based on management attention and relaxation, reducing pain perception in elderly patients with chronic pain (Persian)] [MSc. thesis]. Shiraz: University of Shiraz; 2011.
7. Mohammadi F, Mohammadkhani P, Dolatshahi B, Asghari M A. [The effects of "mindfulness meditation for pain management" on the severity of perceived pain and disability in patients with chronic pain (Persian)]. Iranian Journal of Ageing. 2011; 6(1):59-66
8. Cimmino MA, Ferrone C, Cutolo M. Epidemiology of chronic musculoskeletal pain. Best Practice & Research Clinical Rheumatology. 2011; 25(2):173-83. [DOI:10.1016/j.berh.2010.01.012] [DOI:10.1016/j.berh.2010.01.012]
9. Stubbs B, Schofield P, Patchay S, Leveille S. Musculoskeletal pain characteristics associated with lower balance confidence in community-dwelling older adults. Physiotherapy. 2016; 102(2):152-8. [DOI:10.1016/j.physio.2015.03.3721] [DOI:10.1016/j.physio.2015.03.3721]
10. Salamati A, Mashouf S, Sahbaei F, Mojab F. Effects of inhalation of lavender essential oil on open-heart surgery pain. Iranian Journal of Pharmaceutical Research. 2014; 13(4):1257-61. [PMID] [PMCID] [PMID] [PMCID]
11. Roozbahani N, Attarha M, Akbari Torkestani N, Amiri Farahani L, Heidari T. [The effect of rose water aromatherapy on reducing labor pain in primiparous women (Persian)]. Complementary Medicine Journal of Faculty of Nursing & Midwifery. 2015; 5(1):1042-53.
12. PDQ Integrative, Alternative, and Complementary Therapies Editorial Board. Aromatherapy and essential oils (PDQ®): Health professional version. Rockville, Maryland: National Cancer Institute; 2015.
13. Ganjloo J MN, Najafi S, Rakhshani M.H. [The Effects of inhaling lavender oil on patients' anxiety with myocardial infarction (Persian)]. Quarterly Journal of Sabzevar University of Medical Sciences. 2015; 21(6):1064-72.
14. Martins DF, Emer AA, Batisti AP, Donatello N, Carlesso MG, Mazzardo-Martins L, et al. Inhalation of Cedrus atlantica essential oil alleviates pain behavior through activation of descending pain modulation pathways in a mouse model of postoperative pain. Journal of Ethnopharmacology. 2015; 175:30-8. [DOI:10.1016/j.jep.2015.08.048] [DOI:10.1016/j.jep.2015.08.048]
15. Aliasgharpour M, Mohammadi N, Kazemnejad A, Abbaszadeh R. [Comparison the effect of lidocaine gel and inhalation of lavender aromatherapy on pain score of arteriovenous fistula puncture in hemodialysis patients (Persian)]. Complementary Medicine Journal of Faculty of Nursing & Midwifery. 2015; 4(4):1000-11.
16. Sadeghi Aval Shahr H, Saadat M, Kheirkhah M, Saadat E. The effect of self-aromatherapy massage of the abdomen on the primary dysmenorrhoea. Journal of Obstetrics and Gynaecology. 2015; 35(4):382-5. [DOI:10.3109/01443615.2014.958449] [DOI:10.3109/01443615.2014.958449]
17. Sköld M, Hagvall L, Karlberg AT. Autoxidation of linalyl acetate, the main component of lavender oil, creates potent contact allergens. Contact Dermatitis. 2008; 58(1):9-14. [DOI:10.1111/j.1600-0536.2007.01262.x] [DOI:10.1111/j.1600-0536.2007.01262.x]
18. Tabaei As, Rezaei M. [Study of flower yield variation in rosa damascena mill. From western regions of Iran (Persian)]. Iranian Journal of Medicinal and Aromatic Plants. 2004; 20(3):333-44.
19. Maryam Marofi M, Siros Fard M. [The effect of aromatherapy with Rosa damascene mill and pelargonium graveolens on post-operative pain intensity in pediatric (Persian)]. Anesthesiology and Pain. 2015; 5(3):64-73.
20. Davari M, Mosharraf S. [Aromatherapy effect of lavander essence and mefenamic acid on dysmenorrhea: A clinical trial (Persian)]. Journal of Research Development in Nursing and Midwifery. 2014; 11(2):8-14.
21. Jaafarnejad F, Hoseini S.F, Mazloom S.R, Hami M. [Comparison of the evaluation of severity of cyclical mastalgia using the Visual Analogue Scale (VAS) and modified McGill pain questionnaire (M-MPQ) (Persian)]. Iranian Women's Midwifery and Infertility Journal. 2012; 15(39):9-15.
22. Tanhaee Z, Fathi Ashtiani A, Amini M, Vahedi H. [Validation of a revised version of the Short-form Mc-Gill Pain Questionnaire (SF-MPQ-2) for IBS patients (Persian)]. Govaresh. 2012; 17(2):91-7.
23. Quinn F, Hughes CM, Baxter G. Reflexology in the management of low back pain: a pilot randomised controlled trial. Complementary Therapies in Medicine. 2008; 16(1):3-8. [DOI:10.1016/j.ctim.2007.05.001] [DOI:10.1016/j.ctim.2007.05.001]
24. Nazemzadeh M, Jalalodini A, Rezvani Amin M, Yousefian N, Poornamdar Z, Ghaljeh M. [The effect of foot reflexology massage on pain intensity in patients with chronic low back pain visited to physical therapy unit in Baghiathallah hospital in Tehran (Persian)]. Complementary Medicine Journal of Faculty of Nursing & Midwifery. 2012; 2(3):204-11
25. Zahedifard T, Firozi M. [Assessment of the articles related to primary dysmenorrhea in dimension of menstrual pain assessment tools (Persian)]. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2016; 19(4):17-27.
26. Pereira LV, Pereira Gde A, Moura LA, Fernandes RR. Pain intensity among institutionalized elderly: a comparison between numerical scales and verbal descriptors. Revista da Escola de Enfermagem da USP. 2015; 49(5):804-10. [DOI:10.1590/S0080-623420150000500014] [DOI:10.1590/S0080-623420150000500014]
27. Bernfort L, Gerdle B, Rahmqvist M, Husberg M, Levin L-Å. Severity of chronic pain in an elderly population in Sweden—impact on costs and quality of life. Pain. 2015; 156(3):521-7. [DOI:10.1097/01.j.pain.0000460336.31600.01] [DOI:10.1097/01.j.pain.0000460336.31600.01]
28. Taghipour Dm, Hosseini S, Kia K, Abbaspour M, Ghadimi R. [Prevalence of musculoskeletal pain and it's correlation to functional disability in elderly (Persian)]. Knowledge and Health. 2013; 8(2):76-82.
29. Chen Q, Hayman LL, Shmerling RH, Bean JF, Leveille SG. Characteristics of chronic pain associated with sleep difficulty in older adults: The Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston study. Journal of the American Geriatrics Society. 2011; 59(8):1385-92. [DOI:10.1111/j.1532-5415.2011.03544.x] [DOI:10.1111/j.1532-5415.2011.03544.x]
30. Pizzo PA, Clark NM. Alleviating suffering 101—pain relief in the United States. New England Journal of Medicine. 2012; 366(3):197-9. [DOI:10.1056/NEJMp1109084] [DOI:10.1056/NEJMp1109084]
31. Santos FC, Moraes NSd, Pastore A, Cendoroglo MS. Chronic pain in long-lived elderly: prevalence, characteristics, measurements and correlation with serum vitamin D level. Revista Dor. 2015; 16(3):171-5. [DOI:10.5935/1806-0013.20150034] [DOI:10.5935/1806-0013.20150034]
32. Paddock C. Women's finer sense of smell may be due to more brain cells [Internet]. 2014 [Updated 6 November 2014]. Available from: www.medicalnewstoday.com/articles/284991.php
33. Alipour M, Hosseini SR, Saadat P, Bijani A. The relationship between chronic musculoskeletal pain and vitamin d deficiency in the elderly population of Amirkola, Iran. Journal of Babol University of Medical Sciences. 2015; 17(10):7-14.

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