Terapia Laser de Baixa Intensidade para a redução da dor em artrite reumatoide e osteoatrite: uma revisão sistemática

Fangel, Renan; Vendrusculo-Fangel, Leticia Meda; Albuquerque, Cleandro Pires de; Parizotto, Nivaldo Antônio; Paz, Clarissa Cardoso dos Santos C.; Matheus, João Paulo Chieregato

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Sumário

REVIEW ARTICLE • Fisioter. mov. 32 • 2019 • https://doi.org/10.1590/1980-5918.032.AO29 copiar

Terapia Laser de Baixa Intensidade para a redução da dor em artrite reumatoide e osteoatrite: uma revisão sistemática

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo

Introdução:

Os tratamentos para artrite reumatoide (AR) e osteoartrite (OA) devem diminuir dor, modular inflamação e diminuir deformidades. O LLLT é um biomodulador e pode auxiliar no quadro clínico destas.

Objetivo:

Analisar os parâmetros mais comumente utilizados para a diminuição das respostas de dor em pacientes com AR e OA em ensaios clínicos controlados e não controlados.

Método:

Trata-se de uma revisão sistemática com busca de artigos em inglês, português e espanhol na: PUBMED, SCOPUS, LILACS e Web of SCIENCE, entre 2006 a 2018. Foram utilizados os descritores MESH. Critérios de inclusão: avaliação da eficácia do LLLT nestas populações, verificação da dor antes e depois do tratamento, ensaios clínicos controlados e não controlados, publicados integralmente. Foi realizado o cálculo da dosimetria do laser e análise de média, mediana e moda da energia por ponto e energia por tratamento.

Resultados:

Incluídos neste estudo 3 artigos de AR e 16 de OA. Em relação à dosimetria, apenas um AR apresentou redução da dor, sendo este com a maior dose de energia. Já na OA, a maioria dos artigos apresentou diminuição da dor, e com variabilidade na dosagem aplicada. Alguns tiveram poucos parâmetros apresentados, tornando impossível calcular a dosimetria.

Conclusão:

há evidências científicas para reduzir a dor relatada em pacientes com OA de joelho, principalmente com doses de 6 J por ponto e 48 J aplicadas no tratamento diário. Para as outras articulações afetadas com OA e AR, seria importante a publicação de mais artigos científicos com melhor qualidade metodológica e descrição da dosimetria.

Palavras-chave:
Terapia com Luz de Baixa Intensidade; Dosimetria; Artrite Reumatoide; Osteoartrite; Dor

	Group	Pain´s evalution	Sessions	Application's form	Application´s site	N	PEDro
Rheumatoid arthritis
Ekim et al. ²¹21. Ekim A, Armagan O, Tascioglu F, Oner C, Colak M. Effect of low level laser therapy in rheumatoid arthritis patients with carpal tunnel syndrome. Swiss Med Wkly. 2007;137(23-24):347-52.	Group I - LLLT	VAS	10 sessions (2 weeks)	Skin contact	Region volar in the direction of median nerve	19 patients with carpal tunnel syndrome caused by RA	6
	Group II- placebo	VAS	10 sessions (2 weeks)	Skin contact	Region volar in the direction of median nerve	19 patients with carpal tunnel syndrome caused by RA	6
Silva, Noravett, Baldan ³¹31. Silva DP, Novaretti APOC, Baldan C. Efeito analgésico do laser de baixa intensidade (LILT) na artrite reumatóide aguda. Rev Inst Cienc Saude. 2009;27(1):35-8.	Study Group- LLLT	Br-MPQ Pain Questionnaire, Brazilian Version.	10 sessions (5 weeks)	Skin contact	Region of pain´s reported.	10 participants with RA	7
	Control Group	Br-MPQ Pain Questionnaire, Brazilian Version.	10 sessions (5 weeks)	Skin contact	Region of pain´s reported.	10 participants with RA	7
Meireles et al. ²⁷27. Meireles SM, Jones A, Jennings F, Suda AL, Parizotto NA, Natour J. Assessment of the effectiveness of low-level laser therapy on the hands of patients with rheumatoid arthritis: a randomized double-blind controlled trial. Clin Rheumatol. 2010;29(5):501-9.	Group I - LLLT	VAS	16 sessions (8weeks)	Skin contact	joint lines of wrist and fingers	82 patients with RA.	10
	Group II - Placebo	VAS	16 sessions (8weeks)	Skin contact
Hands´ osteoarthritis
Baltzer, Ostapczuk Stosch ²⁵25. Baltzer AW, Ostapczuk MS, Stosch D. Positive effects of low level laser therapy (LLLT) on Bouchard's and Heberden's osteoarthritis. Lasers Surg Med. 2016;48(5):498-504.	No group	VAS	5 a 10 sessions (2,5 a 5 weeks)	Skin contact				Several points in the intra-articular space.	34 patients with hand OA with Bouchard and Heberden signs.	3
Knee´s osteoarthritis
Yurtkuran et al. ¹⁴14. Yurtkuran M, Alp A, Konur S, Özçakir S, Bingol U. Laser acupuncture in knee osteoarthritis: a double-blind, randomized controlled study. Photomed Laser Surg. 2007;25(1):14-20.	Group Laser	VAS; WOMAC	10 sessions (2 weeks)	Skin contact	Lateral side of knee at acupuncture point Sp9	52 patients with knee OA.	8
	Group Placebo	VAS; WOMAC	10 sessions (2 weeks)	Skin contact	Lateral side of knee at acupuncture point Sp9	52 patients with knee OA.	8
Hegedús et al. ³²32. Hegedus B, Viharos L, Gervain M, Gálfi M. The effect of low-level laser in knee osteoarthritis: a double-blind, randomized, placebo-controlled trial. Photomed Laser Surg. 2009;27(4):577-84.	Group Laser	VAS	8 sessions (4 weeks)	Skin contact	femoral and tibial condyles, articular line and fibular head	27 patients with knee OA	6
	Group Placebo	VAS	8 sessions (4 weeks)	Skin contact		27 patients with knee OA	6
Zhao et al. ³³33. Zhao L, Shen X, Cheng K, Deng H, Ding G, Tan M, et al. Validating a nonacupoint sham control for laser treatment of knee osteoarthritis. Photomed Laser Surg. 2010;28(3):351-6.	Group Laser	WOMAC	12 sessions (4 weeks)	2 cm above skin	joint line at the acupuncture point ST35	40 patients with knee OA	8
	Group Placebo	WOMAC	12 sessions (4 weeks)	2 cm above skin	joint line at the acupuncture point ST35	40 patients with knee OA	8
Fukuda et al. ³⁴34. Fukuda VO, Fukuda TY, Guimarães M, Shiwa S, Lima B del C, Martins RA, et al. Short-term efficacy of low-level laser therapy in patients with knee osteoarthritis: a randomized placebo-controlled, double-blind clinical trial. Rev Bras Ortop. 2011;46(5):526-33.	Group Laser	VAS; Lequesne Scale	9 sessions (3 weeks)	Skin contact	femoral and tibial condyles, articular line and fibular head	47 patients with knee OA	10
	Group Placebo	VAS; Lequesne Scale	9 sessions (3 weeks)	Skin contact		47 patients with knee OA	10
Štiglić-Rogoznica et al. ³⁵35. Štiglić-Rogoznica N, Stamenković D, Frlan-Vrgoc L, Avancini-Dobrović V, Vrbanić TS. Analgesic effect of high intensity laser therapy in knee osteoarthritis. Coll Antropol. 2011;35(2):183-5.	No group	VAS	10 sessions (10 days)	Skin contact	not supplied	96 patients with knee OA	3
Gworys et al. ³⁶36. Gworys K, Gasztych J, Puzder A, Gworys P, Kujawa J. Influence of various laser therapy methods on knee joint pain and function in patients with knee osteoarthritis. Ortop Traumatol Rehabil. 2011;14(3):269-77.	Group 1 laser irradiation Group 2 (MSL irradiation) Group 3 (MSL irradiation) Group 4 placebo	Lequesne scale, VAS; Modified Laitinen questionnaire	10 sessions (2 weeks)	Skin contact	femoral and tibial condyles, articular line and fibular head	125 patients with knee OA	9
Kedzierski et al. ³⁷37. Kedzierski T, Stanczak K, Gworys K, Gasztych J, Sibinski M, Kujawa J. Comparative evaluation of the direct analgesic efficacy of selected physiotherapeutic methods in subjects with knee joint degenerative disease-preliminary report. Ortop Traumatol Rehabil. 2011;14(6):537-44.	Group A - MSL laser therapy Group B - low frequency TENS.	VAS; Modified Laitinen questionnaire.	10 sessions (2 weeks)	Skin contact	Joint space, popliteal fossa and base of patella	50 patients with knee OA	5
Rayegani et al. ³⁸38. Rayegani SM, Bahrami MH, Elyaspour D, Saeidi M, Sanjari H. Therapeutic effects of low level laser therapy (LLLT) in knee osteoarthritis, compared to therapeutic ultrasound. J Lasers Med Sci. 2012;3(2):71-4.	Group 1 LLLT, Group 2 LLLT placebo; Group 3 Ultrasound.	VAS; WOMAC	10 sessions (2 weeks)	Skin contact	femoral and tibial condyles, articular line and fibular head	37 patients with knee OA	7
Alghadir et al. ¹⁶16. Alghadir A, Omar MT, Al-Askar AB, Al-Muteri NK. Effect of low-level laser therapy in patients with chronic knee osteoarthritis: a single-blinded randomized clinical study. Lasers Med Sci. 2014;29(2):749-55.	Group Laser	VAS; WOMAC.	8 sessions (4 weeks)	Skin contact	femoral and tibial condyles, articular line and fibular head	40 patients with knee OA	10
	Group Placebo	VAS; WOMAC.	8 sessions (4 weeks)	Skin contact		40 patients with knee OA	10
Nakamura et al. ³⁹39. Nakamura T, Ebihara S, Ohkuni I, Izukura H, Harada T, Ushigome N, et al. Low Level Laser Therapy for chronic knee joint pain patients. Laser Ther. 2014;23(4):273-7.	No group	VAS	8 sessions (4 weeks)	Skin contact	Articular line	35 patients with knee OA	3
Soleimanpour et al. ⁴⁰40. Soleimanpour H, Gahramani K, Taheri R, Golzari SE, Safari S, Esfanjani RM, et al. The effect of low-level laser therapy on knee osteoarthritis: prospective, descriptive study. Lasers Med Sci. 2014;29(5):1695-700.	No group	VAS	12 sessions (4 weeks)	Skin contact	LASER I- around patella; LASER II- bellow patella.	18 patients with knee OA	3
Hinman et al. ²⁸28. Hinman RS, McCrory P, Pirotta M, Relf I, Forbes A, Crossley KM, et al. Acupuncture for chronic knee pain: a randomized clinical trial. Jama. 2014;312(13):1313-22.	Control group, Group Needle acupuncture, Group laser	VAS; WOMAC	12 sessions (4 weeks)	Skin contact	Various acupuncture points	282 patients with knee OA	7
	Group placebo laser .	VAS; WOMAC	12 sessions (4 weeks)	Skin contact	Various acupuncture points	282 patients with knee OA	7
Nambi et al. ⁴¹41. Nambi G, Kamal W, George J, Manssor, E. Radiological and biochemical effects (CTX-II, MMP-3, 8, and 13) of low-level laser therapy (LLLT) in chronic osteoarthritis in Al-Kharj, Saudi Arabia. Lasers Med Sci. 2017;32(2):297-303.	Group Laser	VAS, joint space width, collagen-II telopeptide and MMP-3, 8, and 13	12 sessions (4 weeks)	Skin contact	Medial and lateral epicondyle of tibia and femur, tendon of the biceps femoris muscle and semitendinosus muscle	34 patients with knee OA	9
	Group Placebo		12 sessions (4 weeks)	Skin contact		34 patients with knee OA	9
Nazari et al. ⁴²42. Nazari A, Moezy A, Nejati P, Mazaherinezhad A. Efficacy of high-intensity laser therapy in comparison with conventional physiotherapy and exercise therapy on pain and function of patients with knee osteoarthritis: a randomized controlled trial with 12-week follow up. Lasers Med Sci. 2019;34(3):505-16.	High-intensity laser therapy (HILT) group, conventional physical therapy (CPT) group, and exercise therapy (ET) group	VAS, knee flexion range of motion, timed up and go test,6-min walk test, WOMAC	12 sessions (4 weeks)	Skin contact	Articular line	93 patients with knee OA	7
Temporomandibular´s osteoarthritis
Madani et al. ⁴³43. Madani AS, Ahrari F, Nasiri F, Abtahi M, Tunér J. Low-level laser therapy for management of TMJ osteoarthritis. Cranio. 2014;32(1):38-44.	Group Laser	VAS	12 sessions (4 weeks)	Skin contact	Points around the temporomandibular joint, mandibular muscles and condyles.	20 patients with temporomandibular OA	8
	Group Placebo	VAS	12 sessions (4 weeks)	Skin contact		20 patients with temporomandibular OA	8

	Laser	P	T	A	NP	PD	ED	EP	ET	Effect
Rheumatoid arthritis
Ekim et al. ²¹21. Ekim A, Armagan O, Tascioglu F, Oner C, Colak M. Effect of low level laser therapy in rheumatoid arthritis patients with carpal tunnel syndrome. Swiss Med Wkly. 2007;137(23-24):347-52.	Ga-Al-As (780 nm)	50 mW continuous	120 s	0.0078 cm²	5	6410.25 mW/cm²	192.3 J/cm²	6 J	30 J	Yes
Silva, Noravett, Baldan ³¹31. Silva DP, Novaretti APOC, Baldan C. Efeito analgésico do laser de baixa intensidade (LILT) na artrite reumatóide aguda. Rev Inst Cienc Saude. 2009;27(1):35-8.	As-Ga (904 nm)	8mW (peak power of 45 W and pulsed emission at 1000 Hz)	194 s	not supplied	not supplied	Cannot be calculate	Cannot be calculate	1.55 J	Cannot be calculate	No
Meireles et al. ²⁷27. Meireles SM, Jones A, Jennings F, Suda AL, Parizotto NA, Natour J. Assessment of the effectiveness of low-level laser therapy on the hands of patients with rheumatoid arthritis: a randomized double-blind controlled trial. Clin Rheumatol. 2010;29(5):501-9.	Ga-Al-As (785 nm)	70 mW continuous	2.57 s	0.06 cm²	20	1166.66 mW/cm²	3 J/cm²	0.18 J	7.56 J	No
Hands´ osteoarthritis
Baltzer, Ostapczuk, Stosch ²⁵25. Baltzer AW, Ostapczuk MS, Stosch D. Positive effects of low level laser therapy (LLLT) on Bouchard's and Heberden's osteoarthritis. Lasers Surg Med. 2016;48(5):498-504.	Diode laser	400 mW continuous	1200 s	0.0016 cm²	several points at the same time	25000 mW/cm2	cannot be calculated	Cannot be calculate	480 J	Yes
	6-fiber 658 nm
	4-fiber 785 nm
Knee´S Osteoarthritis
Yurtkuran et al. ¹⁴14. Yurtkuran M, Alp A, Konur S, Özçakir S, Bingol U. Laser acupuncture in knee osteoarthritis: a double-blind, randomized controlled study. Photomed Laser Surg. 2007;25(1):14-20.	As-Ga (904 nm)	4 mW pulsed	120 s	0.4 cm²	1 (Sp9)	10 mW/cm²	1.2 J/cm²	0.48 J	0.48 J	No
Hegedús et al. ³²32. Hegedus B, Viharos L, Gervain M, Gálfi M. The effect of low-level laser in knee osteoarthritis: a double-blind, randomized, placebo-controlled trial. Photomed Laser Surg. 2009;27(4):577-84.	As-Ga-Al (830 nm)	50 mW continuous	120 s	0.005 cm²	8	10000 mW/cm²	1200 J/cm²	6 J	48 J	Yes Intergroup
Zhao et al. ³³33. Zhao L, Shen X, Cheng K, Deng H, Ding G, Tan M, et al. Validating a nonacupoint sham control for laser treatment of knee osteoarthritis. Photomed Laser Surg. 2010;28(3):351-6.	Laser (650 nm) + CO2 laser (10.6 µm)	36 mW + 200 mW (40 hz)	1200 s	0.0314 cm²	1 (ST35)	1146.5 mW/cm² + 6369.4 mW/cm²	1375,8 J/cm² + 3821,65 J/cm²	43.2 J + 120 J	43.2 J + 120 J	Yes With 2 weeks
Fukuda et al. ³⁴34. Fukuda VO, Fukuda TY, Guimarães M, Shiwa S, Lima B del C, Martins RA, et al. Short-term efficacy of low-level laser therapy in patients with knee osteoarthritis: a randomized placebo-controlled, double-blind clinical trial. Rev Bras Ortop. 2011;46(5):526-33.	As-Ga (904 nm)	60 mW pulsed	50 s	0.5 cm²	9	120 mW/cm²	6 J/cm²	3 J	27 J	Yes
Štiglić-Rogoznica et al. ³⁵35. Štiglić-Rogoznica N, Stamenković D, Frlan-Vrgoc L, Avancini-Dobrović V, Vrbanić TS. Analgesic effect of high intensity laser therapy in knee osteoarthritis. Coll Antropol. 2011;35(2):183-5.	YAG laser (1064 nm)	3 kW	1200 s total	not supplied	not supplied	Cannot be calculate	Cannot be calculate	Cannot be calculate	Cannot be calculate	Yes
Gworys et al. ³⁶36. Gworys K, Gasztych J, Puzder A, Gworys P, Kujawa J. Influence of various laser therapy methods on knee joint pain and function in patients with knee osteoarthritis. Ortop Traumatol Rehabil. 2011;14(3):269-77.	Laser (810 nm)	400 mW continuous	20 s	0.63 cm²	12	634.9 mW/cm²	12.7 J/cm²	8 J	96 J	Yes
Group I	Laser (810 nm)	400 mW continuous	20 s	0.63 cm²	12	634.9 mW/cm²	12.7 J/cm²	8 J	96 J	Yes
Gworys et al. ³⁶36. Gworys K, Gasztych J, Puzder A, Gworys P, Kujawa J. Influence of various laser therapy methods on knee joint pain and function in patients with knee osteoarthritis. Ortop Traumatol Rehabil. 2011;14(3):269-77.	Laser MSL	1100 mW (2000Hz)	11.27 s	2 cm²	12	550 mW/cm²	6.2 J/cm²	12.4 J	148.8 J	Yes
Group II	Laser MSL	1100 mW (2000Hz)	11.27 s	2 cm²	12	550 mW/cm²	6.2 J/cm²	12.4 J	148.8 J	Yes
Gworys et al. ³⁶36. Gworys K, Gasztych J, Puzder A, Gworys P, Kujawa J. Influence of various laser therapy methods on knee joint pain and function in patients with knee osteoarthritis. Ortop Traumatol Rehabil. 2011;14(3):269-77.	Laser MSL	1100 mW (2000Hz)	6 s	2 cm²	12	550 mW/cm²	3.28 J/cm²	6.6 J	79.2 J	Yes
Group III	Laser MSL	1100 mW (2000Hz)	6 s	2 cm²	12	550 mW/cm²	3.28 J/cm²	6.6 J	79.2 J	Yes
Kedzierski et al. ³⁷37. Kedzierski T, Stanczak K, Gworys K, Gasztych J, Sibinski M, Kujawa J. Comparative evaluation of the direct analgesic efficacy of selected physiotherapeutic methods in subjects with knee joint degenerative disease-preliminary report. Ortop Traumatol Rehabil. 2011;14(6):537-44.	Laser 10 MSL M1 (808 nm) + (905 nm)	1250 mW Continuous + Pulsed	600 s	not supplied	not supplied	Cannot be calculate	Cannot be calculate	36 J	Cannot be calculate	Yes
Rayegani et al. ³⁸38. Rayegani SM, Bahrami MH, Elyaspour D, Saeidi M, Sanjari H. Therapeutic effects of low level laser therapy (LLLT) in knee osteoarthritis, compared to therapeutic ultrasound. J Lasers Med Sci. 2012;3(2):71-4.	Laser (880 nm)	50 mW continuous	120 s	0.01 cm²	8	5000 mW/cm²	600 J/cm²	6 J	48 J	Yes
Alghadir et al. ¹⁶16. Alghadir A, Omar MT, Al-Askar AB, Al-Muteri NK. Effect of low-level laser therapy in patients with chronic knee osteoarthritis: a single-blinded randomized clinical study. Lasers Med Sci. 2014;29(2):749-55.	As-Ga (850 nm)	100 mW	60 s	0.00785 cm²	8	12738.8 mW/cm²	764.33 J/cm²	6 J	48 J	Yes
Nakamura et al. ³⁹39. Nakamura T, Ebihara S, Ohkuni I, Izukura H, Harada T, Ushigome N, et al. Low Level Laser Therapy for chronic knee joint pain patients. Laser Ther. 2014;23(4):273-7.	Ga-Al-AS (830 nm)	1000 mW	30 s	1.5 cm²	4	666.67 mW/cm²	20.1 J/cm²	30 J	120 J	Yes
Soleimanpour et al. ⁴⁰40. Soleimanpour H, Gahramani K, Taheri R, Golzari SE, Safari S, Esfanjani RM, et al. The effect of low-level laser therapy on knee osteoarthritis: prospective, descriptive study. Lasers Med Sci. 2014;29(5):1695-700.	Laser (810 nm)	50mW (F = 3,000, peak power = 80W, Δt =200 ns)	120 s	1 cm²	6	50 mW/cm²	6 J/cm²	6 J	36 J	Yes
Laser I	Laser (810 nm)	50mW (F = 3,000, peak power = 80W, Δt =200 ns)	120 s	1 cm²	6	50 mW/cm²	6 J/cm²	6 J	36 J	Yes
Soleimanpour et al. ⁴⁰40. Soleimanpour H, Gahramani K, Taheri R, Golzari SE, Safari S, Esfanjani RM, et al. The effect of low-level laser therapy on knee osteoarthritis: prospective, descriptive study. Lasers Med Sci. 2014;29(5):1695-700.	Laser (890 nm)	30mW (F = 3,000Hz, peak power = 50W, Δt = 200 ns	588 s	1.765 cm²	1	17 mW/cm²	10 J/cm²	17.6 J	53.6 J	Yes
Laser II	Laser (890 nm)	30mW (F = 3,000Hz, peak power = 50W, Δt = 200 ns	588 s	1.765 cm²	1	17 mW/cm²	10 J/cm²	17.6 J	53.6 J	Yes
Hinman et al. ²⁸28. Hinman RS, McCrory P, Pirotta M, Relf I, Forbes A, Crossley KM, et al. Acupuncture for chronic knee pain: a randomized clinical trial. Jama. 2014;312(13):1313-22.	Red Laser (not specify)	10 mW	not supplied	not supplied	Varied	Cannot be calculated	Cannot be calculated.	0.2 J	Cannot be calculated.	No
Nambi et al. ⁴¹41. Nambi G, Kamal W, George J, Manssor, E. Radiological and biochemical effects (CTX-II, MMP-3, 8, and 13) of low-level laser therapy (LLLT) in chronic osteoarthritis in Al-Kharj, Saudi Arabia. Lasers Med Sci. 2017;32(2):297-303.	AS-Ga (905 nm)	25 mW, (pulsed)	60 s	1 cm²	8	25 mW/cm²	1,5 J/cm²	1.5 J	12 J	Yes
Nazari et al. ⁴²42. Nazari A, Moezy A, Nejati P, Mazaherinezhad A. Efficacy of high-intensity laser therapy in comparison with conventional physiotherapy and exercise therapy on pain and function of patients with knee osteoarthritis: a randomized controlled trial with 12-week follow up. Lasers Med Sci. 2019;34(3):505-16.	YAG (1064 nm)	5 W, (30 Hz)	8 min	not supplied	not supplied	Cannot be calculate	60 J/cm2	Cannot be calculate	2400 J	Yes
Temporomandibular´s osteoarthritis
Madani et al. ⁴³43. Madani AS, Ahrari F, Nasiri F, Abtahi M, Tunér J. Low-level laser therapy for management of TMJ osteoarthritis. Cranio. 2014;32(1):38-44.	810 nm Laser	50 mW	120 s	1.76 cm²	variable	28.41 mW/cm²	3.4 J/cm²	6 J	Cannot be calculate	No

	EP	ET
Knee´s osteoarthritis
Mean	18.94 J	218.70 J
Median	6.3 J	48 J
Mode	6 J	48 J

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[1] *RF: Doctoral Student, e-mail: renanfangel@yahoo.com.br LMVF: PhD, e-mail: leticiamvfangel@unb.br CPA: Doctoral Student, e-mail: cleandropires@hotmail.com NAP: PhD, e-mail: naparizotto@uniara.com.br CCSCP: PhD, e-mail: clarissacardoso@yahoo.com.br JPCM: PhD, e-mail: jpcmatheus@unb.br