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SUBSTANCE ABUSE AND EXERCISE

Yıl 2023, Cilt: 8 Sayı: 1, 70 - 78, 24.03.2023
https://doi.org/10.52881/gsbdergi.1190904

Öz

Substance abuse is a global public health problem that affects millions of people all over the world. Substance abuse causes serious psychiatric and medical problems, negatively affecting the quality of life. Substance abuse treatment may differ according to the type of substance used, the duration of use, and the problems that may occur. Treatment approaches consist of short-term and long-term treatments. Exercise approaches are used in both short-term and long-term treatment. With exercise training, physical fitness and functional capacity, psychological health and well-being, social functioning and general health perceptions, including variables that are related quality of life is reported to have achieved significant improvements in terms of various aspects. With exercise, dopamine homeostasis is induced, which is important for the cessation of substance use and the prevention of relapse. The aim of this review is to compile studies on the effects of neurophysiological changes caused by different substance abuse such as nicotine, cocaine, methamphetamine, opioids and alcohol and to examine the effectiveness of aerobic exercises such as yoga, pilates, tai chi, qigong, group evercises, dance-movement therapy and anaerobic exercises. With regular exercise, successful results are achieved in the treatment of addiction, reducing addictive behaviors and preventing relapse. Addicted individuals have difficulty prioritizing and maintaining an exercise program. However, they are quite positive to exercise as part of treatment. After literatüre review it was thought that it is necessary to understand the preferences of individuals and to make individual-specific arrangements in order to increase participation in exercise programs.

Kaynakça

  • 1. Degenhardt L, Hall W. Extent of illicit drug use and dependence, and their contribution to the global burden of disease. Lancet. 2012; 379(9810):55-70.
  • 2. World Drug Report 2021 [Available from: https://www.unodc.org/unodc/en/data-and-analysis/wdr2021.html.]
  • 3. Brellenthin AG, Koltyn KF. Exercise as an adjunctive treatment for cannabis use disorder. Am J Drug Alcohol Ab. 2016; 42(5):481-9.
  • 4. Colledge F, Gerber M, Pühse U, Ludyga S. Anaerobic exercise training in the therapy of substance use disorders: a systematic review. Front Psychiatry. 2018; 9:644.
  • 5. Demirdel E, Aşkın BG, Çıtlak B, Zorlu FZ. Madde Bağımlılığı Tedavisinde Egzersiz. Türkiye Sağlık Araştırmaları Dergisi. 2021; 2(2):51-62.
  • 6. Sarkar S, Varshney M. Yoga and substance use disorders: A narrative review. Asian J Psychiatr. 2017; 25:191-6.
  • 7. Zschucke E, Heinz A, Ströhle A. Exercise and physical activity in the therapy of substance use disorders. ScientificWorldJournal. 2012; 2012.
  • 8. Marrero‐Cristobal G, Gelpi‐Dominguez U, Morales‐Silva R, Alvarado‐Torres J, Perez‐Torres J, Perez‐Perez Y, et al. Aerobic exercise as a promising nonpharmacological therapy for the treatment of substance use disorders. J Neurosci Res. 2022; 100(8):1602-42.
  • 9. Park S-S, Shin M-S, Park H-S, Kim T-W, Kim C-J, Lim B-V. Treadmill exercise ameliorates nicotine withdrawal-induced symptoms. J Exerc Rehabil. 2019; 15(3):383.
  • 10. Miladi-Gorji H, Rashidy-Pour A, Fathollahi Y, Akhavan MM, Semnanian S, Safari M. Voluntary exercise ameliorates cognitive deficits in morphine dependent rats: the role of hippocampal brain-derived neurotrophic factor. Neurobiol Learn Mem. 2011; 96(3):479-91.
  • 11. Archer T, Badgaiyan RD, Blum K. Physical exercise interventions for drug addictive disorders. J Reward Defic Syndr Addict Sci. 2017; 3(1):17.
  • 12. Lynch WJ, Robinson AM, Abel J, Smith MA. Exercise as a prevention for substance use disorder: a review of sex differences and neurobiological mechanisms. Curr Addict Rep. 2017; 4(4):455-66.
  • 13. Jain A. Treating nicotine addiction. BMJ. 2003; 327(7428):1394-5.
  • 14. De Jesus S, Prapavessis H. Smoking behaviour and sensations during the pre-quit period of an exercise-aided smoking cessation intervention. Addict Behav. 2018; 81:143-9.
  • 15. Bernard P, Ninot G, Cyprien F, Courtet P, Guillaume S, Georgescu V, et al. Exercise and counseling for smoking cessation in smokers with depressive symptoms: a randomized controlled pilot trial. J Dual Diagn. 2015; 11(3-4):205-16.
  • 16. Allen A, Carlson SC, Bosch TA, Eberly LE, Okuyemi K, Nair U, et al. High Intensity Interval Training and Continuous Aerobic Exercise Interventions to Promote Self-Initiated Quit Attempts in Young Adults Who Smoke: Feasibility, Acceptability, and Lessons Learned from a Randomized Pilot Trial. J Addict Med. 2018; 12(5):373.
  • 17. De La Garza II R, Yoon JH, Thompson-Lake DG, Haile CN, Eisenhofer JD, Newton TF, et al. Treadmill exercise improves fitness and reduces craving and use of cocaine in individuals with concurrent cocaine and tobacco-use disorder. Psychiatry Res. 2016; 245:133-40.
  • 18. Park M, Levine H, Toborek M. Exercise protects against methamphetamine-induced aberrant neurogenesis. Sci Rep. 2016; 6(1):1-14.
  • 19. Dolezal BA, Chudzynski J, Storer TW, Abrazado M, Penate J, Mooney L, et al. Eight weeks of exercise training improves fitness measures in methamphetamine-dependent individuals in residential treatment. J Addict Med. 2013; 7(2):122.
  • 20. Wang D, Zhu T, Chen J, Lu Y, Zhou C, Chang Y-K. Acute aerobic exercise ameliorates cravings and inhibitory control in heroin addicts: Evidence from event-related potentials and frequency bands. Front Psychol. 2020; 11:561590.
  • 21. Neale J, Nettleton S, Pickering L. Heroin users’ views and experiences of physical activity, sport and exercise. Int J Drug Policy. 2012; 23(2):120-7.
  • 22. Rao R, Topiwala A. Alcohol use disorders and the brain. Addiction. 2020; 115(8):1580-9.
  • 23. Karoly HC, Stevens CJ, Thayer RE, Magnan RE, Bryan AD, Hutchison KE. Aerobic exercise moderates the effect of heavy alcohol consumption on white matter damage. Alcohol Clin Exp Res. 2013; 37(9):1508-15.
  • 24. Brown RA, Abrantes AM, Minami H, Read JP, Marcus BH, Jakicic JM, et al. A preliminary, randomized trial of aerobic exercise for alcohol dependence. J Subst Abuse Treat. 2014; 47(1):1-9.
  • 25. Nespor K, Prokes B. Physical exercise and yoga in prevention and treatment of addictive diseases. Cas Lek Cesk. 2005; 144:53-5.
  • 26. Abrantes AM, Battle CL, Strong DR, Ing E, Dubreuil ME, Gordon A, et al. Exercise preferences of patients in substance abuse treatment. Ment Health Phys Act. 2011; 4(2):79-87.
  • 27. Abrantes AM, Blevins CE. Exercise in the context of substance use treatment: key issues and future directions. Curr Opin Psychol. 2019; 30:103-8.
  • 28. Simonton AJ, Young CC, Brown RA. Physical activity preferences and attitudes of individuals with substance use disorders: A Review of the literature. Issues Ment Health Nurs. 2018; 39(8):657-66.
  • 29. Liu X-X, Wang S. Effect of aerobic exercise on executive function in individuals with methamphetamine use disorder: Modulation by the autonomic nervous system. Psychiatry Res. 2021; 306:114241.
  • 30. Govindaraj R, Karmani S, Varambally S, Gangadhar B. Yoga and physical exercise–a review and comparison. Int Rev Psychiatry. 2016; 28(3):242-53.
  • 31. Telles S, Naveen K. Yoga for rehabilitation: an overview. 1997.
  • 32. Shaffer H, LaSalvia T, Stein J. Comparing Hatha yoga with dynamic group psychotherapy for enhancing methadone maintenance treatment: a randomized clinical trial. Altern Ther Health Med. 1997; 3:57-67.
  • 33. Zhuang S-M, An S-H, Zhao Y. Yoga effects on mood and quality of life in Chinese women undergoing heroin detoxification: a randomized controlled trial. Nurs Res. 2013; 62(4):260-8.
  • 34. Kloubec J. Pilates: how does it work and who needs it? Muscles Ligaments Tendons J. 2011; 1(2):61.
  • 35. Fakhrpour R, Yavari Y, Saberi Y. The Effect of Eight Weeks of Pilates Training on Total Antioxidant Capacity and C-reactive Protein in the Blood in Men Addicted to Methamphetamine who are Quitting. Journal of Health Promotion Management. 2021; 10(2):46-52.
  • 36. Larkey L, Jahnke R, Etnier J, Gonzalez J. Meditative movement as a category of exercise: implications for research. J Phys Act Health. 2009; 6(2):230-8.
  • 37. Liu F, Cui J, Liu X, Chen KW, Chen X, Li R. The effect of tai chi and Qigong exercise on depression and anxiety of individuals with substance use disorders: a systematic review and meta-analysis. BMC Complement Med Ther. 2020; 20(1):1-11.
  • 38. Kirane K. Dance/movement therapy: a unique response to the opioid crisis. Am J Dance Ther. 2018; 40:12-7.
  • 39. Fisher B. Dance/movement therapy: Its use in a 28-day substance abuse program. Arts Psychother. 1990; 17:325-331.
  • 40. Gönen T, Yakut Y. The effect of individual exercise and group exercise training on physical performance in healthy women. BSJ Health Sci. 2022; 5(3):526-532.
  • 41. Muller AE, Clausen T. Group exercise to improve quality of life among substance use disorder patients. Scand J Public Health. 2015; 43(2):146-52.

EGZERSİZİN NİKOTİN, KOKAİN, METAMFETAMİN, OPİOİDLER VE ALKOL GİBİ MADDE BAĞIMLILIKLARINDAKİ YERİ

Yıl 2023, Cilt: 8 Sayı: 1, 70 - 78, 24.03.2023
https://doi.org/10.52881/gsbdergi.1190904

Öz

Madde bağımlılığı tüm dünyada milyonlarca kişiyi etkileyen küresel bir halk sağlığı sorunudur Madde bağımlılığı, ciddi psikiyatrik ve tıbbi sorunlara neden olarak, yaşam kalitesini olumsuz yönde etkiler. Madde bağımlılığı tedavisi, kullanılan maddenin türüne, kullanım süresine ve görülebilecek problemlere göre farklılık gösterebilir. Tedavi yaklaşımları kısa ve uzun vadeli tedavilerden oluşmaktadır. Egzersiz yaklaşımları hem kısa hem de uzun vadeli tedavide kullanılmaktadır. Egzersiz eğitimleri ile, fiziksel uygunluk ve fonksiyonel kapasite, psikolojik sağlık ve iyi olma hali, sosyal işlevsellik ve genel sağlık algıları dâhil olmak üzere yaşam kalitesi değişkenleriyle ilgili çeşitli yönler açısından belirgin iyileşmeler sağlandığı rapor edilmiştir. Egzersiz ile, dopamin homeostazı indüklenir, bu da madde kullanımının bırakılması ve nüksün önlenmesi açısından önemlidir. Bu derlemenin amacı; egzersizin nikotin, kokain, metamfetamin, opioidler ve alkol gibi farklı madde bağımlılıklarının neden olduğu nörofizyolojik değişiklikler üzerindeki etkilerine ilişkin çalışmaları derlemek ve madde kullanımının veya nüksünün önlenmesi açısından yoga, pilates, tai chi, qigong, grup egzersizleri, dans-hareket terapisi gibi aerobik egzersizlerin ve anerobik egzersizlerin etkinliğini incelemektir. Düzenli egzersiz ile bağımlılığın tedavisinde, bağımlılık davranışlarının azaltılmasında ve nüksün önlenmesinde başarılı sonuçlara ulaşılmaktadır. Bağımlı bireyler, bir egzersiz programını öncelik sırasına koymada ve devam ettirmede zorlanmaktadırlar. Ancak tedavinin bir parçası olarak egzersize oldukça olumludur. Literatür incelemesi sonunda egzersiz programlarına katılımı artırmak için bireylerin tercihlerini anlamak ve bireye özel düzenlemelerin gerekli olduğu düşünüldü.

Kaynakça

  • 1. Degenhardt L, Hall W. Extent of illicit drug use and dependence, and their contribution to the global burden of disease. Lancet. 2012; 379(9810):55-70.
  • 2. World Drug Report 2021 [Available from: https://www.unodc.org/unodc/en/data-and-analysis/wdr2021.html.]
  • 3. Brellenthin AG, Koltyn KF. Exercise as an adjunctive treatment for cannabis use disorder. Am J Drug Alcohol Ab. 2016; 42(5):481-9.
  • 4. Colledge F, Gerber M, Pühse U, Ludyga S. Anaerobic exercise training in the therapy of substance use disorders: a systematic review. Front Psychiatry. 2018; 9:644.
  • 5. Demirdel E, Aşkın BG, Çıtlak B, Zorlu FZ. Madde Bağımlılığı Tedavisinde Egzersiz. Türkiye Sağlık Araştırmaları Dergisi. 2021; 2(2):51-62.
  • 6. Sarkar S, Varshney M. Yoga and substance use disorders: A narrative review. Asian J Psychiatr. 2017; 25:191-6.
  • 7. Zschucke E, Heinz A, Ströhle A. Exercise and physical activity in the therapy of substance use disorders. ScientificWorldJournal. 2012; 2012.
  • 8. Marrero‐Cristobal G, Gelpi‐Dominguez U, Morales‐Silva R, Alvarado‐Torres J, Perez‐Torres J, Perez‐Perez Y, et al. Aerobic exercise as a promising nonpharmacological therapy for the treatment of substance use disorders. J Neurosci Res. 2022; 100(8):1602-42.
  • 9. Park S-S, Shin M-S, Park H-S, Kim T-W, Kim C-J, Lim B-V. Treadmill exercise ameliorates nicotine withdrawal-induced symptoms. J Exerc Rehabil. 2019; 15(3):383.
  • 10. Miladi-Gorji H, Rashidy-Pour A, Fathollahi Y, Akhavan MM, Semnanian S, Safari M. Voluntary exercise ameliorates cognitive deficits in morphine dependent rats: the role of hippocampal brain-derived neurotrophic factor. Neurobiol Learn Mem. 2011; 96(3):479-91.
  • 11. Archer T, Badgaiyan RD, Blum K. Physical exercise interventions for drug addictive disorders. J Reward Defic Syndr Addict Sci. 2017; 3(1):17.
  • 12. Lynch WJ, Robinson AM, Abel J, Smith MA. Exercise as a prevention for substance use disorder: a review of sex differences and neurobiological mechanisms. Curr Addict Rep. 2017; 4(4):455-66.
  • 13. Jain A. Treating nicotine addiction. BMJ. 2003; 327(7428):1394-5.
  • 14. De Jesus S, Prapavessis H. Smoking behaviour and sensations during the pre-quit period of an exercise-aided smoking cessation intervention. Addict Behav. 2018; 81:143-9.
  • 15. Bernard P, Ninot G, Cyprien F, Courtet P, Guillaume S, Georgescu V, et al. Exercise and counseling for smoking cessation in smokers with depressive symptoms: a randomized controlled pilot trial. J Dual Diagn. 2015; 11(3-4):205-16.
  • 16. Allen A, Carlson SC, Bosch TA, Eberly LE, Okuyemi K, Nair U, et al. High Intensity Interval Training and Continuous Aerobic Exercise Interventions to Promote Self-Initiated Quit Attempts in Young Adults Who Smoke: Feasibility, Acceptability, and Lessons Learned from a Randomized Pilot Trial. J Addict Med. 2018; 12(5):373.
  • 17. De La Garza II R, Yoon JH, Thompson-Lake DG, Haile CN, Eisenhofer JD, Newton TF, et al. Treadmill exercise improves fitness and reduces craving and use of cocaine in individuals with concurrent cocaine and tobacco-use disorder. Psychiatry Res. 2016; 245:133-40.
  • 18. Park M, Levine H, Toborek M. Exercise protects against methamphetamine-induced aberrant neurogenesis. Sci Rep. 2016; 6(1):1-14.
  • 19. Dolezal BA, Chudzynski J, Storer TW, Abrazado M, Penate J, Mooney L, et al. Eight weeks of exercise training improves fitness measures in methamphetamine-dependent individuals in residential treatment. J Addict Med. 2013; 7(2):122.
  • 20. Wang D, Zhu T, Chen J, Lu Y, Zhou C, Chang Y-K. Acute aerobic exercise ameliorates cravings and inhibitory control in heroin addicts: Evidence from event-related potentials and frequency bands. Front Psychol. 2020; 11:561590.
  • 21. Neale J, Nettleton S, Pickering L. Heroin users’ views and experiences of physical activity, sport and exercise. Int J Drug Policy. 2012; 23(2):120-7.
  • 22. Rao R, Topiwala A. Alcohol use disorders and the brain. Addiction. 2020; 115(8):1580-9.
  • 23. Karoly HC, Stevens CJ, Thayer RE, Magnan RE, Bryan AD, Hutchison KE. Aerobic exercise moderates the effect of heavy alcohol consumption on white matter damage. Alcohol Clin Exp Res. 2013; 37(9):1508-15.
  • 24. Brown RA, Abrantes AM, Minami H, Read JP, Marcus BH, Jakicic JM, et al. A preliminary, randomized trial of aerobic exercise for alcohol dependence. J Subst Abuse Treat. 2014; 47(1):1-9.
  • 25. Nespor K, Prokes B. Physical exercise and yoga in prevention and treatment of addictive diseases. Cas Lek Cesk. 2005; 144:53-5.
  • 26. Abrantes AM, Battle CL, Strong DR, Ing E, Dubreuil ME, Gordon A, et al. Exercise preferences of patients in substance abuse treatment. Ment Health Phys Act. 2011; 4(2):79-87.
  • 27. Abrantes AM, Blevins CE. Exercise in the context of substance use treatment: key issues and future directions. Curr Opin Psychol. 2019; 30:103-8.
  • 28. Simonton AJ, Young CC, Brown RA. Physical activity preferences and attitudes of individuals with substance use disorders: A Review of the literature. Issues Ment Health Nurs. 2018; 39(8):657-66.
  • 29. Liu X-X, Wang S. Effect of aerobic exercise on executive function in individuals with methamphetamine use disorder: Modulation by the autonomic nervous system. Psychiatry Res. 2021; 306:114241.
  • 30. Govindaraj R, Karmani S, Varambally S, Gangadhar B. Yoga and physical exercise–a review and comparison. Int Rev Psychiatry. 2016; 28(3):242-53.
  • 31. Telles S, Naveen K. Yoga for rehabilitation: an overview. 1997.
  • 32. Shaffer H, LaSalvia T, Stein J. Comparing Hatha yoga with dynamic group psychotherapy for enhancing methadone maintenance treatment: a randomized clinical trial. Altern Ther Health Med. 1997; 3:57-67.
  • 33. Zhuang S-M, An S-H, Zhao Y. Yoga effects on mood and quality of life in Chinese women undergoing heroin detoxification: a randomized controlled trial. Nurs Res. 2013; 62(4):260-8.
  • 34. Kloubec J. Pilates: how does it work and who needs it? Muscles Ligaments Tendons J. 2011; 1(2):61.
  • 35. Fakhrpour R, Yavari Y, Saberi Y. The Effect of Eight Weeks of Pilates Training on Total Antioxidant Capacity and C-reactive Protein in the Blood in Men Addicted to Methamphetamine who are Quitting. Journal of Health Promotion Management. 2021; 10(2):46-52.
  • 36. Larkey L, Jahnke R, Etnier J, Gonzalez J. Meditative movement as a category of exercise: implications for research. J Phys Act Health. 2009; 6(2):230-8.
  • 37. Liu F, Cui J, Liu X, Chen KW, Chen X, Li R. The effect of tai chi and Qigong exercise on depression and anxiety of individuals with substance use disorders: a systematic review and meta-analysis. BMC Complement Med Ther. 2020; 20(1):1-11.
  • 38. Kirane K. Dance/movement therapy: a unique response to the opioid crisis. Am J Dance Ther. 2018; 40:12-7.
  • 39. Fisher B. Dance/movement therapy: Its use in a 28-day substance abuse program. Arts Psychother. 1990; 17:325-331.
  • 40. Gönen T, Yakut Y. The effect of individual exercise and group exercise training on physical performance in healthy women. BSJ Health Sci. 2022; 5(3):526-532.
  • 41. Muller AE, Clausen T. Group exercise to improve quality of life among substance use disorder patients. Scand J Public Health. 2015; 43(2):146-52.
Toplam 41 adet kaynakça vardır.

Ayrıntılar

Birincil Dil Türkçe
Konular Sağlık Kurumları Yönetimi
Bölüm Makaleler
Yazarlar

İdil Esin Ünlü 0000-0001-7750-5363

Oğuzhan Doğan 0000-0003-4946-1281

İlke Keser 0000-0001-6999-4056

Yayımlanma Tarihi 24 Mart 2023
Gönderilme Tarihi 21 Ekim 2022
Kabul Tarihi 21 Aralık 2022
Yayımlandığı Sayı Yıl 2023 Cilt: 8 Sayı: 1

Kaynak Göster

APA Ünlü, İ. E., Doğan, O., & Keser, İ. (2023). EGZERSİZİN NİKOTİN, KOKAİN, METAMFETAMİN, OPİOİDLER VE ALKOL GİBİ MADDE BAĞIMLILIKLARINDAKİ YERİ. Gazi Sağlık Bilimleri Dergisi, 8(1), 70-78. https://doi.org/10.52881/gsbdergi.1190904
AMA Ünlü İE, Doğan O, Keser İ. EGZERSİZİN NİKOTİN, KOKAİN, METAMFETAMİN, OPİOİDLER VE ALKOL GİBİ MADDE BAĞIMLILIKLARINDAKİ YERİ. Gazi Sağlık Bil. Mart 2023;8(1):70-78. doi:10.52881/gsbdergi.1190904
Chicago Ünlü, İdil Esin, Oğuzhan Doğan, ve İlke Keser. “EGZERSİZİN NİKOTİN, KOKAİN, METAMFETAMİN, OPİOİDLER VE ALKOL GİBİ MADDE BAĞIMLILIKLARINDAKİ YERİ”. Gazi Sağlık Bilimleri Dergisi 8, sy. 1 (Mart 2023): 70-78. https://doi.org/10.52881/gsbdergi.1190904.
EndNote Ünlü İE, Doğan O, Keser İ (01 Mart 2023) EGZERSİZİN NİKOTİN, KOKAİN, METAMFETAMİN, OPİOİDLER VE ALKOL GİBİ MADDE BAĞIMLILIKLARINDAKİ YERİ. Gazi Sağlık Bilimleri Dergisi 8 1 70–78.
IEEE İ. E. Ünlü, O. Doğan, ve İ. Keser, “EGZERSİZİN NİKOTİN, KOKAİN, METAMFETAMİN, OPİOİDLER VE ALKOL GİBİ MADDE BAĞIMLILIKLARINDAKİ YERİ”, Gazi Sağlık Bil, c. 8, sy. 1, ss. 70–78, 2023, doi: 10.52881/gsbdergi.1190904.
ISNAD Ünlü, İdil Esin vd. “EGZERSİZİN NİKOTİN, KOKAİN, METAMFETAMİN, OPİOİDLER VE ALKOL GİBİ MADDE BAĞIMLILIKLARINDAKİ YERİ”. Gazi Sağlık Bilimleri Dergisi 8/1 (Mart 2023), 70-78. https://doi.org/10.52881/gsbdergi.1190904.
JAMA Ünlü İE, Doğan O, Keser İ. EGZERSİZİN NİKOTİN, KOKAİN, METAMFETAMİN, OPİOİDLER VE ALKOL GİBİ MADDE BAĞIMLILIKLARINDAKİ YERİ. Gazi Sağlık Bil. 2023;8:70–78.
MLA Ünlü, İdil Esin vd. “EGZERSİZİN NİKOTİN, KOKAİN, METAMFETAMİN, OPİOİDLER VE ALKOL GİBİ MADDE BAĞIMLILIKLARINDAKİ YERİ”. Gazi Sağlık Bilimleri Dergisi, c. 8, sy. 1, 2023, ss. 70-78, doi:10.52881/gsbdergi.1190904.
Vancouver Ünlü İE, Doğan O, Keser İ. EGZERSİZİN NİKOTİN, KOKAİN, METAMFETAMİN, OPİOİDLER VE ALKOL GİBİ MADDE BAĞIMLILIKLARINDAKİ YERİ. Gazi Sağlık Bil. 2023;8(1):70-8.