This editorial discusses the need for changes in how non-specific chronic low back pain (NSCLBP) is managed. It summarizes evidence that challenges the traditional view of LBP as a biomechanical problem and the focus on interventions aiming to increase spinal stability. While exercises targeting the deep spinal muscles were commonly prescribed, research shows these are not more effective than other treatments and do not predict better patient outcomes. The editorial calls for a biopsychosocial approach that addresses cognitive, behavioral, lifestyle and neurophysiological factors associated with NSCLBP.
Maladaptive movement and motor control impairments as underlying mechanismMeziat
Artigo (5) importante para a preparação para o curso de dor lombar crônica. "Diagnóstico e classificação da dor lombar crônica: Disfunções de movimento e de controle mal adaptativas como mecanismo principal." É antigo, algumas coisas mudaram, mas vale à pena ler.
Maladaptive movement and motor control impairments as underlying mechanismMeziat
Artigo (5) importante para a preparação para o curso de dor lombar crônica. "Diagnóstico e classificação da dor lombar crônica: Disfunções de movimento e de controle mal adaptativas como mecanismo principal." É antigo, algumas coisas mudaram, mas vale à pena ler.
Critical Appraisal of an RCT using GATE - SPORT Trial Kshitij Chaudhary
This is a presentation given at the research methodology workshop at IOACON 2016, Kochi, India. Critical appraisal of the SPORT RCT study is presented using the GATE framework developed by Prof Rod Jackson. SPORT was a large multicenter trial conducted in the USA that compared surgery versus nonoperative treatment for lumbar disc herniation
Memoryscapes, Archaeology, and the River Street Neighborhood, Boise, IdahoRiverStreetHistory
Prior to the Civil Rights movement, most cities in the United States had at least one racially segregated neighborhood--a place where the "others" lived. This was typically a geographic location designated by the Euroamerican community as the area non-Euroamericans could reside. In Boise, Idaho, non-Euroamericans lived in the River Street Neighborhood, a place where African Americans, Basque, Japanese, and Eastern Europeans established homes and businesses. While the boundaries of this neighborhood were known by all residents, they were never formally demarcated on the map. River Street existed as a segregated enclave in the memoryscapes of historical Boiseans of all races. Oral history interviews conducted in advance of an upcoming community archaeology project revealed the boundaries of the River Street Neighborhood as remembered by African American residents. The multi-disciplinary concept of memoryscapes was applied in order to provide an ‘emic’ perspective of the role the neighborhood played in the creation of whiteness for Boise’s Euroamericans.
Artigo (4) importante para a preparação para o curso de dor lombar crônica. "Características sensoriais da dor lombar crônica inespecífica: uma investigação de subgrupos."
Critical Appraisal of an RCT using GATE - SPORT Trial Kshitij Chaudhary
This is a presentation given at the research methodology workshop at IOACON 2016, Kochi, India. Critical appraisal of the SPORT RCT study is presented using the GATE framework developed by Prof Rod Jackson. SPORT was a large multicenter trial conducted in the USA that compared surgery versus nonoperative treatment for lumbar disc herniation
Memoryscapes, Archaeology, and the River Street Neighborhood, Boise, IdahoRiverStreetHistory
Prior to the Civil Rights movement, most cities in the United States had at least one racially segregated neighborhood--a place where the "others" lived. This was typically a geographic location designated by the Euroamerican community as the area non-Euroamericans could reside. In Boise, Idaho, non-Euroamericans lived in the River Street Neighborhood, a place where African Americans, Basque, Japanese, and Eastern Europeans established homes and businesses. While the boundaries of this neighborhood were known by all residents, they were never formally demarcated on the map. River Street existed as a segregated enclave in the memoryscapes of historical Boiseans of all races. Oral history interviews conducted in advance of an upcoming community archaeology project revealed the boundaries of the River Street Neighborhood as remembered by African American residents. The multi-disciplinary concept of memoryscapes was applied in order to provide an ‘emic’ perspective of the role the neighborhood played in the creation of whiteness for Boise’s Euroamericans.
Artigo (4) importante para a preparação para o curso de dor lombar crônica. "Características sensoriais da dor lombar crônica inespecífica: uma investigação de subgrupos."
Artigo (3) importante para a preparação para o curso de dor lombar crônica. "Dor lombar crônica incapacitante como um problema iatrogênico: estudo qualitativo com aborígines australianos."
Efficacy of classification-based_cft_in_nsclbpMeziat
Artigo (6) importante para a preparação para o curso de dor lombar crônica. "Eficácia da Terapia Cognitiva Funcional em pacientes com dor lombar crônica inespecífica: ensaio clínico randomizado controlado."
Manual and physical therapists use a postural-structural-biomechanical (PSB) model to ascertain the causes of various musculoskeletal conditions.
The most important question is consistently being ignored is can a person’s physical shape/posture/structure/biomechanics be the cause of pain in spine
Nutritional Interventional trials in muscle and cachexia PhD research directi...PhD Assistance
Trials were organized according to the kind of nutrition intervention, dietary guidance, food supplement, and multimodal therapies are given to participants in the experimental arm.
For #Enquiry:
Website: https://www.phdassistance.com/blog/nutritional-interventional-trials-in-muscle-and-cachexia/
India: +91 91769 66446
Email: info@phdassistance.com
Nutritional Interventional trials in muscle and cachexia PhD research directi...PhD Assistance
Trials were organized according to the kind of nutrition intervention, dietary guidance, food supplement, and multimodal therapies are given to participants in the experimental arm.
For #Enquiry:
Website: https://www.phdassistance.com/blog/nutritional-interventional-trials-in-muscle-and-cachexia/
India: +91 91769 66446
Email: info@phdassistance.com
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
How STIs Influence the Development of Pelvic Inflammatory Disease.pptx
Br j sports med 2011-o'sullivan-bjsm.2010.081638
1. Editorial
Downloaded from bjsm.bmj.com on August 7, 2011 - Published by group.bmj.com
BJSM Online First, published on August 4, 2011 as 10.1136/bjsm.2010.081638
It’s time for change with the
management of non-specifi c
chronic low back pain
Peter O’Sullivan
Low back pain (LBP) is the second great-est
cause of disability in the USA. 1 USA
data supports that in spite of an enormous
increase in the health resources spent on
LBP disorders, the disability relating to
them continues to increase. 2 The man-agement
of LBP is underpinned by the
exponential increase in the use of physi-cal
therapies, opiod medications, spinal
injections as well as disc replacement
and fusion surgery. 2 This is maintained
by the underlying belief that LBP is fun-damentally
a patho-anatomical disorder
and should be treated within a biomedical
model. 1 This is in spite of calls over a num-ber
of years to adopt a bio-psycho-social
approach, and evidence that only 8–15%
of patients with LBP have an identifi ed
patho-anatomical diagnosis, resulting in
the majority being diagnosed as having
non-specifi c LBP. 3 Of this population,
a small but signifi cant group becomes
chronic and disabled, labelled non-specifi c
chronic low back pain (NSCLBP), consum-ing
a disproportionate amount of health-care
resources. 4
1. Over the past decade, the traditional
biomedical view of LBP has been
greatly challenged. This is a result
of: the failure of simplistic single-dimensional
therapies to show large
effects in patients with NSCLBP 5 – 8 ;
2. the results of clinical trials testing
commonly prescribed interventions
demonstrating that no management
approaches are clearly superior 5 – 7 9 ;
3. the stories of NSCLBP patients relat-ing
their own ongoing pain experi-ences
of multiple failed treatments,
confl icting diagnoses, lost hope and
ongoing suffering 10 ;
4. the indisputable evidence support-ing
the multidimensional nature of
NSCLBP as a disorder, where dis-ability
levels are more closely associ-ated
with cognitive and behavioural
aspects of pain rather than sensory
and biomedical ones 11 12 ;
5. positive outcomes in randomised
controlled trials (RCTs) are best pre-dicted
by changes in psychological
distress, fear avoidance beliefs, self-effi
cacy in controlling pain and cop-ing
strategies 13 14 ;
6. the evidence supporting the broad
subgrouping of NSCLBP disorders on
the basis of neuro-physiological, 15 16
cognitive, 17 physical factors 18 and
lifestyle behaviours. 19 20
Underlying primary healthcare clinical
practice has been simplistic biomechani-cal
and structural models of LBP and pelvic
girdle pain (PGP), which focus on struc-tural
diagnoses such as spinal and pelvic
‘instability’. 21 22 These have been based
on a belief that LBP and PGP is a result of
structural (ie, degenerative), biomechani-cal
and motor control defi cits resulting in
segmental or regional ‘instability’ of the
lumbo-pelvic region. 21 – 24 It is now clear
that there is little evidence (basic sci-ence
and outcome studies) to support the
view that ‘instability’ underpins the basis
of disabling NSCLBP. There are no stud-ies
that demonstrate a clear relationship
between spinal or pelvic mobility, degen-erative
processes, pain and disability. 25 26
Similarly, common patho-anatomical
fi ndings such as degenerative disc disease,
annular tears, fi ssures, facet joint arthrosis
and disc bulges have been found not to be
predictive of future LBP. 26 This highlights
the limitation of radiological imaging and
spinal structure to provide clear meaning
to people’s experience of pain. Rather, fac-tors
such as depression, 26 27 stress, cogni-tive
and physical behaviours and lifestyle
factors are more predictive of future LBP
episodes. 11 20
Yet in spite of this evidence, patients
with disabling NSCLBP disorders continue
to be provided with biomedical diagnoses
and on the basis of these beliefs, people
are prescribed with stabilising exercises,
pelvic belts, supportive vests, spinal injec-tions
or even stabilisation surgery. 1 2 23 28
These ‘magic bullet’ approaches, for some,
may in fact have the potential to drive
fear, abnormal body focus and reinforce
pain-related movement and avoidance
behaviours, hypervigilance, catastrophis-ing,
pain and disability fuelling the vicious
cycle of pain. 29
Diagnostic labels such as ‘instability’
should be reserved solely for ‘unstable frac-tures’
and ‘unstable spondylolisthesis’. 30
The application of this diagnostic label to
NSCLBP and PGP disorders is both inac-curate
and potentially detrimental. 21 29 31
This ‘belief system’, which I once advo-cated,
has resulted in the development of
an educational and management industry
aimed at enhancing spinal stability for the
prevention and treatment of NSCLBP, infl u-encing
the practice of physiotherapy, allied
health as well as sports rehabilitation and
training industries across the world. 28 32
This approach commonly instructs
patients to contract their ‘stabilising’ mus-cles
(pelvic fl oor and transverse abdominal
wall and lumbar multifi dus) prior to spinal
loading and during movement. 6 9 23 33 In
sports and gym rehabilitation settings,
patients are frequently instructed to brace
their abdominal wall and back muscles,
to create more spinal ‘stability’ with the
belief that ‘more stability is better’.
Yet these management approaches
have not arrested the growing disabil-ity
associated with NSCLBP. 2 Although
there is evidence for the effi cacy of sta-bilising
exercise for NSCLBP, 34 a number
of high-quality RCTs have demonstrated
that specifi c spinal stabilising exercises for
NSCLBP are not superior to other conser-vative
approaches 6 9 35 36 , they have small
effect sizes 37 and they are only marginally
better than placebo treatment consisting
of detuned shortwave and ultrasound. 33
Yet the benefi ts of this approach continue
to be exclusively promoted, in spite of
mounting scientifi c evidence that ques-tions
the underlying basis of this clini-cal
belief system. This includes evidence
that the motor control characteristics of
non-specifi c low back pain (NSLBP) and
NSCLBP commonly lie in fi ndings of:
1. increased co-contraction (stability) of
trunk muscles 38 39 and guarded spinal
movement 40 ;
2. hyperactivity of trunk muscles
(including muscles such as erector
spinae, lumbar multifi dus, pelvic
fl oor and transverse abdominal wall)
in NSCLBP and PGP disorders 18 41 42 ;
3. an inability of the back muscles to
relax 18 40 ;
4. a tendency for earlier onsets of the
antero-lateral abdominal wall mus-cles
during rapid arm movements
rather than timing delays 43 ;
Correspondence to
Professor Peter O’Sullivan, Professor/Specialist
Musculoskeletal Physiotherapist, Curtin University,
GPO Box U1987, Perth, WA 6845, Australia;
p.osullivan@curtin.edu.au
Copyright Article author (or their employer) 2011. Produced by BMJ Publishing Group Ltd under licence.
O’Sullivan P. Br J Sports Med (2011). doi:10.1136/bjsm.2010.081638 1 of 4
2. Editorial
Downloaded from bjsm.bmj.com on August 7, 2011 - Published by group.bmj.com
5. in some cases, trunk muscle hypertro-phy
in muscles such as lumbar mul-tifi
dus 44 and quadratus lumborum 45
have been documented in LBP sport
populations.
Further to this, there is evidence for:
1. a lack of association between muscle
density (degeneration) of lumbar
multifudus and LBP in a recent large
population study 46 ;
2. a lack of association between changes
in transversus abdominus muscle tim-ing
47 and lumbar multifi dus cross-sec-tional
area 13 as a predictor of positive
outcomes (disability levels) in RCTs.
This body of research challenges current
practice and beliefs and is a counter view
to previous literature. Some of the appar-ent
confl ict within the literature appears
to have arisen where the results of stud-ies
with small sample sizes, investigating
subjects with recurrent LBP 48 49 , have been
extrapolated to the broad NSCLBP popu-lation
without the results of these studies
being reproduced in these populations or
in larger groups.
The physiotherapy, manual therapy and
medical professions have long focused
on trying to fi nd the magic ‘technique’,
‘muscle’, ‘injection’ or ‘surgical technique’
required to solve the problem of NSCLBP
and PGP disorders. This reductionist
approach to dealing with complex disor-ders
in a simplistic manner clearly hasn’t
delivered for our patients 50 and contradicts
current knowledge that NSCLBP should
be considered within a multidimensional
bio-psycho-social framework. In fact, it
has been proposed that single-dimen-sional
approaches may in fact exacerbate
chronic disorders reinforcing a cumulative
feedback loop. 29
In response to the calls to manage
NSCLBP from a bio-psycho-social per-spective,
a number of RCTs have tested
cognitive behavioural approaches to more
effectively manage the disorder. Yet sys-tematic
reviews of these approaches have
failed to demonstrate greater effi cacy than
other active conservative approaches in
managing NSCLBP. 51 Possible reasons
for this failure may relate to the lack of
patient-centred and targeted manage-ment
52 as well as a failure to address other
dimensions such as neuro-physiological
factors and maladaptive lifestyle and
movement behaviours known to be asso-ciated
with NSCLBP disorders. 18 20 30
There is strong evidence that NSCLBP
disorders are associated with a complex
combination of physical behavioural,
lifestyle, neuro-physiological (peripheral
and central nervous system changes),
psychological/cognitive and social fac-tors.
12 20 30 These factors together have the
potential to promote maladaptive cognitive
behaviours (negative beliefs, fear, avoid-ance,
catastrophising, hypervigilance), 53
pain behaviours (pain communicative and
avoidant behaviours) 54 and movement
behaviours, 30 setting up a vicious cycle
of pain sensitisation and reinforcing dis-ability.
Changes in immune and neuro-endocrine
function linked to altered stress
responsiveness coupled with activation of
the pain neuro-matrix in the brain may
result in tissue hyperalgesia and altered
neuro-muscular responses. 11 It is thought
that these processes are mediated by envi-ronmental/
genetic interactions. 55
The balance and contribution of these
different factors will likely vary for each
individual. For example, it is known that
not all NSCLBP disorders are associated
with signifi cant psychosocial factors. 17 56
However, there is strong evidence that
disability and factors such as sick leave are
best predicted by factors such as negative
back pain beliefs, fear and distress. 17 57
Futhermore, psychological factors such as
fear and catastrophising commonly asso-ciated
with disabling pain have lifestyle,
physical, neuro-muscular 40 as well as neu-ro-
biological consequences, highlighting
that the mind and the body are inextrica-bly
linked. 11
There is also growing evidence that
NSCLBP disorders can be broadly cat-egorised
or subgrouped based on different
psychosocial/coping behaviours, 17 58 59
neuro-physiological characteristics, 15 56
pain behaviours 54 and movement
behaviours, 18 30 providing greater poten-tial
for targeting of multidimensional
interventions. 60 These broad subgroups,
rather than being rigid entities which are
characterised by prediction rules, 61 may
provide a framework for the clinician to
tailor management to patients in a more
targeted person- centred multidimensional
manner. 30 58 59
There is emerging evidence to support
this view that patient-centred multidimen-sional
targeted behavioural approaches
have greater effi cacy than current practice
for the management of NSCLBP disorders
in primary care settings. Asenlöf et al 62 63
compared individually tailored treatment
targeting activity levels, motor behaviour
and cognitions, demonstrating superior
outcomes to exercise therapy. A patient-centred
multidimensional behavioural
approach called ‘classifi cation-based cog-nitive
functional therapy’ that targets
maladaptive cognitive, lifestyle, pain and
movement behaviours was more effective
(greater effect sizes) than manual therapy
and exercise for localised NSCLBP. 64 Hill
et al 65 employed a patient-centred strati-fi
cation approach to target physiotherapy
treatment based on psychosocial risk pro-fi
le, demonstrating superior outcomes and
cost saving over standard physiotherapy
care. Further research into this patient-centred
multidimensional approach is
clearly required but recent evidence is
encouraging for improved outcomes.
Other behavioural therapies such as
mindfulness meditation, 66 acceptance and
commitment therapy, 67 brain-directed
therapies 68 69 and targeted medical man-agement
70 hold hope for the multidisci-plinary
management of some of the highly
complex and disabling central nervous
system pain disorders.
In spite of this emerging evidence,
recent research highlights that health
professionals dealing with LBP disorders
have diffi culty accurately identifying
psycho-social risk in their patients, limit-ing
their capacity to target management. 71
It appears that specifi c training in behav-ioural
aspects of a patients presentation
is required to enable health professionals
to identify psycho-social risk factors and
maladaptive movement behaviours from
a clinical examination. 72 There is also
growing evidence to support the criti-cal
role that the quality of the therapeu-tic
relationship plays in the management
of pain disorders. 73 Practitioner-related
factors such as communication skills,
empathy, level of confi dence and beliefs
have an important infl uence on patient
outcomes and compliance to treatment. 74
Conversely, patient beliefs and expecta-tions
also have a profound infl uence on
health disorder outcomes. 75
With all this in mind, the challenges for
the future in more effectively dealing with
NSCLBP disorders are likely to involve
primary healthcare providers shifting rig-idly
held biomedical beliefs and develop-ing
greater skills and knowledge across a
number of domains. These skills are likely
to include:
1. Greater understanding of the complex
multidimensional nature of NSCLBP.
2. Developing diagnostic skills to clearly
differentiate specifi c pathology as a
driver of pain from NSLBP disorders.
3. Develop more effective communica-tion
skills utilising empathy, refl ec-tive
questioning and motivational
interviewing techniques in order
to listen to the patients’ story and
explore their pain beliefs, fears,
coping strategies, life stresses, psy-cho-
social factors, pain behaviour,
impairments and goals. This allows
2 of 4 O’Sullivan P. Br J Sports Med (2011). doi:10.1136/bjsm.2010.081638
3. Editorial
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for the development of an effective
therapeutic relationship and the accu-rate
interpretation of clinical infor-mation
within a bio-psycho-social
framework in order to identify the
primary drivers of pain and disability.
This in turn provides the capacity to
clearly outline the vicious cycle of the
disorder in a patient-centred way.
4. I dentifi cation of maladaptive cog-nitive
behaviours (negative beliefs,
stress responsiveness, provocative
coping strategies, hypervigilance,
fear, catastrophising, anxiety, depres-sion
etc).
5. Identifying neuro-physiological pro-cesses
such as central and peripheral
sensitisation.
6. The analysis and interpretation of pain
communicative and avoidant behav-iours
54 and movement and postural
behaviours 30 in order to determine
adaptive (protective) from maladap-tive
(provocative) behaviours. 30
7. Synthesising and interpreting clini-cal
information across multiple
domains.
8. Developing multidimensional and
fl exible interventions that target
maladaptive cognitive, lifestyle, pain
and movement behaviours in an inte-grated
manner.
9. Facilitation of behavioural change in
patients by enhancing clinical skills
such as empathy, motivation, sup-port,
creativity, goal setting, fl exible
person-centred functional rehabilita-tion
programmes and clear feedback.
10. Developing clear multidisciplinary
approaches to management where
indicated.
11. Developing a broad framework for
subgrouping of NSCLBP patients
from a multidimensional perspec-tive.
17 30 52 58 This will allow the
broad categorisation of LBP disorders
based on the presence of dominant
psycho-social, neuro-physiological,
lifestyle and movement behaviours
that act as drivers for the disorder.
12. Adopting the routine use of screening
tools in clinical practice in order to
identify risk and targets for change to
better direct management. 65 76
This approach will likely focus less on
treating the structure or signs and symp-toms
of a disorder in NSCLBP disorders
and more on targeting the different combi-nations
of beliefs, cognitive, pain, lifestyle
and movement behaviours that underlie
and drive disorders. Implementation of
this approach will require a paradigm
shift in ‘beliefs’ of health professionals
in terms of how we understand and deal
with NSCLBP disorders. This will involve
abandoning ineffective practices, learning
new skills, adopting and integrating new
approaches. This new knowledge and
skill needs to be trained at undergradu-ate
and graduate levels and promoted
actively within the professions that deal
with these disorders. 77 There is also a
mandate to educate the public in order to
reinforce more positive back pain beliefs
to reduce the burden for both individu-als
and society. 78 This will invariably lead
to health insurers abandoning the ongo-ing
funding of non-effi cacious treatment
approaches.
Further research is clearly needed to bet-ter
identify the underlying mechanisms
associated with disabling NSCLBP dis-orders
and their development across the
lifespan. This will likely involve a greater
understanding of genetic/environmental
interactions associated with the devel-opment
of the nervous system, tissue
sensitisation and associated maladaptive
behaviours, tracking from early life to ado-lescence
and into adulthood. Developing
a greater understanding of those people
resilient to these disorders may also be
illuminating. Early screening and targeted
management of risk groups, based on
the identifi cation of the mechanisms that
drive them, may aid in the prevention of
pain chronicity and disability. Innovative
multidimensional, patient-centred and
targeted approaches to management for
these complex disorders need to be further
developed and adequately tested.
Characteristics such as hope, positive
help seeking and adaptability are traits
of resilience that we need to equip our
patients with, who suffer with disabling
NSCLBP. 12 Adopting a positive multi-dimensional
perspective of health that
is person focused may allow us to view
NSCLBP in a new light, providing hope
for our patients and an environment for
innovation, discovery and change.
Acknowledgements The author would like to
acknowledge the support of Joao Paulo Caneiro in the
preparation of this manuscript.
Competing interests None.
Provenance and peer review Not commissioned;
externally peer reviewed.
Accepted 29 June 2011
REFERENCES
1. Bagnall DL. Physiatry: what’s the end game? PM R
2010 ; 2 : 3 – 5 .
2. Deyo RA, Mirza SK, Turner JA, et al. Overtreating
chronic back pain: time to back off? J Am Board Fam
Med 2009 ; 22 : 62 – 8 .
3. Waddell G . The Back Pain Revolution . Edinburgh:
Churchill Livingstone 2004.
4. Croft PR, Macfarlane GJ, Papageorgiou AC, et al.
Outcome of low back pain in general practice: a
prospective study. BMJ 1998 ; 316 : 1356 – 9 .
5. Assendelft WJ, Morton SC, Yu EI, et al. Spinal
manipulative therapy for low back pain.
Cochrane Database Syst Rev 2004 ; 1 :CD000447.
6. Ferreira ML, Ferreira PH, Latimer J, et al. Comparison
of general exercise, motor control exercise and spinal
manipulative therapy for chronic low back pain: a
randomized trial. Pain 2007; 131 : 31– 7.
7. Hayden JA, van Tulder MW, Tomlinson G.
Systematic review: strategies for using exercise
therapy to improve outcomes in chronic low back
pain. Ann Intern Med 2005 ; 142 : 776 – 85 .
8. Ostelo RW, Van Tulder MW, Vlaeyen J, et al.
Behavioural treatment for chronic low back pain.
Cochrane Database Syst Rev 2005 ; 1 : CD002014 .
9. Unsgaard-Tøndel M, Fladmark AM, Salvesen Ø,
et al. Motor control exercises, sling exercises, and
general exercises for patients with chronic low
back pain: a randomized controlled trial with 1-year
follow-up. Phys Ther 2010 ; 90 : 1426 – 40 .
10. Holloway I , Sofaer-Bennet B, Walker J. The
transition from well person to ‘pain affl icted’ patient:
the career of people with chronic back pain.
Illness Crisis Loss 2000; 8 :373–87.
11. Campbell CM, Edwards RR. Mind-body interactions
in pain: the neurophysiology of anxious and
catastrophic pain-related thoughts. Transl Res
2009 ; 153 : 97 – 101 .
12. Gatchel RJ, Peng YB, Peters ML, et al. The
biopsychosocial approach to chronic pain: scientifi c
advances and future directions. Psychol Bull
2007 ; 133 : 581 – 624 .
13. Mannion AF, Junge A, Taimela S, et al. Active
therapy for chronic low back pain: part 3. Factors
infl uencing self-rated disability and its change
following therapy. Spine 2001 ; 26 : 920 – 9 .
14. Woby SR, Urmston M, Watson PJ. Self-effi cacy
mediates the relation between pain-related fear and
outcome in chronic low back pain patients. Eur J Pain
2007 ; 11 : 711 – 18 .
15. Woolf CJ, Bennett GJ, Doherty M, et al. Towards
a mechanism-based classifi cation of pain? Pain
1998 ; 77 : 227 – 9 .
16. Woolf CJ, Salter MW. Neuronal plasticity: increasing
the gain in pain. Science 2000 ; 288 : 1765 – 9 .
17. Boersma K, Linton SJ. Psychological processes
underlying the development of a chronic pain
problem: a prospective study of the relationship
between profi les of psychological variables in the
fear-avoidance model and disability. Clin J Pain
2006 ; 22 : 160 – 6 .
18. Dankaerts W, O’Sullivan P, Burnett A, et al.
Discriminating healthy controls and two clinical
subgroups of nonspecifi c chronic low back
pain patients using trunk muscle activation
and lumbosacral kinematics of postures and
movements: a statistical classifi cation model. Spine
2009 ; 34 : 1610 – 18 .
19. Björck-van Dijken C, Fjellman-Wiklund A,
Hildingsson C. Low back pain, lifestyle factors and
physical activity: a population based-study. J Rehabil
Med 2008 ; 40 : 864 – 9 .
20. Mitchell T, O’Sullivan PB, Burnett A, et al.
Identifi cation of modifi able personal factors that
predict new-onset low back pain: a prospective
study of female nursing students. Clin J Pain
2010 ; 26 : 275 – 83 .
21. Renckens CN. Between hysteria and quackery:
some refl ections on the Dutch epidemic of obstetric
‘pelvic instability’. J Psychosom Obstet Gynaecol
2000 ; 21 : 235 – 9 .
O’Sullivan P. Br J Sports Med (2011). doi:10.1136/bjsm.2010.081638 3 of 4
4. Editorial
from bjsm.bmj.com on August 7, 2011 - Published by group.bmj.com
most likely to benefi t from spinal manipulation: a
validation study. Ann Intern Med 2004 ; 141 : 920 – 8 .
62. Asenlöf P, Denison E, Lindberg P. Individually
tailored treatment targeting activity, motor behavior,
and cognition reduces pain-related disability:
a randomized controlled trial in patients with
musculoskeletal pain. J Pain 2005 ; 6 : 588 – 603 .
63. Asenlöf P, Denison E, Lindberg P. Long-term
follow-up of tailored behavioural treatment and
exercise based physical therapy in persistent
musculoskeletal pain: a randomized controlled trial in
primary care. Eur J Pain 2009 ; 13 : 1080 – 8 .
64. Fersum KV, O’Sullivan P, Kvale A, et al.
Classifi cation based cognitive functional therapy
for the management of non-specifi c low back pain
(NSLBP) – a randomized control trial. Melbourne
International Forum XI, Primary Care Research on
Low Back Pain, 15–18 March 2011, Melbourne,
Victoria, Australia.
65. Hill J, Dunn K, Lewis M, et al. A randomised trial of
targeted treatment for low back pain compared with
current best practice: the start back trial. Melbourne
International Forum XI, Primary Care Research on Low
Back Pain, 15–18 March 15–18 2011, Melbourne,
Victoria, Australia.
66. McCracken LM, Gauntlett-Gilbert J, Vowles KE.
The role of mindfulness in a contextual cognitive-behavioral
analysis of chronic pain-related suffering
and disability. Pain 2007 ; 131 : 63 – 9 .
67. Meredith P, Ownsworth T, Strong J. A review of the
evidence linking adult attachment theory and chronic
pain: presenting a conceptual model. Clin Psychol Rev
2008 ; 28 : 407 – 29 .
68. Moseley GL. Pain, brain imaging and
physiotherapy – opportunity is knocking. Man Ther
2008 ; 13 : 475 – 7 .
69. Wand BM, Parkitny L, O’Connell NE, et al. Cortical
changes in chronic low back pain: current state of the
art and implications for clinical practice. Man Ther
2011 ; 16 : 15 – 20 .
70. Reichling DB, Levine JD. Critical role of nociceptor
plasticity in chronic pain. Trends Neurosci
2009 ; 32 : 611 – 18 .
71. Hill JC, Vohora K, Dunn KM, et al. Comparing the
STarT back screening tool’s subgroup allocation of
individual patients with that of independent clinical
experts. Clin J Pain 2010 ; 26 : 783 – 7 .
72. Fersum KV, Kvale A, O’Sullivan P, et al. Inter-examiner
reliability of a classifi cation system for
patients with non-specifi c low back pain. Man Ther
2009 ; 14 : 555 – 61 .
73. Slade SC, Molloy E, Keating JL. People with
non-specifi c chronic low back pain who have
participated in exercise programs have preferences
about exercise: a qualitative study. Aust J Physiother
2009 ; 55 : 115 – 21 .
74. Hartman SE. Why do ineffective treatments
seem helpful? A brief review. Chiropr Osteopat
2009 ; 17 : 10 .
75. Goubert L, Craig KD, Vervoort T, et al. Facing
others in pain: the effects of empathy. Pain
2005 ; 118 : 285 – 8 .
76. Linton SJ, Boersma K. Early identifi cation of patients
at risk of developing a persistent back problem: the
predictive validity of the Orebro Musculoskeletal Pain
Questionnaire. Clin J Pain 2003 ; 19 : 80 – 6 .
77. Foster NE, Delitto A. Embedding psychosocial
perspectives within clinical management of low
back pain: integration of psychosocially informed
management principles into physical therapist
practice – challenges and opportunities. Phys Ther
2011 ; 91 : 790 – 803 .
78. Buchbinder R, Pransky G, Hayden J. Recent
advances in the evaluation and management of
nonspecifi c low back pain and related disorders.
Best Pract Res Clin Rheumatol 2010 ; 24 : 147 – 53 .
related low back pain, pelvic fl oor activity and pelvic
fl oor dysfunction. Int Urogynecol J Pelvic Floor
Dysfunct 2005 ; 16 : 468 – 74 .
42. Dankaerts W, O’Sullivan P, Burnett A, et al.
Altered patterns of superfi cial trunk muscle
activation in non-specifi c chronic low back pain
patients: the importance of sub-classifcation. Spine
2006 ; 31 : 2017 – 23 .
43. Gubler D, Mannion AF, Schenk P, et al. Ultrasound
tissue Doppler imaging reveals no delay in abdominal
muscle feed-forward activity during rapid arm
movements in patients with chronic low back pain.
Spine 2010 ; 35 : 1506 – 13 .
44. McGregor AH, Anderton L, Gedroyc WM. The
trunk muscles of elite oarsmen. Br J Sports Med
2002 ; 36 : 214 – 7 .
45. Hides J, Stanton W, Freke M, et al. MRI study of
the size, symmetry and function of the trunk muscles
among elite cricketers with and without low back
pain. Br J Sports Med 2008 ; 42 : 809 – 13 .
46. Kalichman L, Hodges P, Li L, et al. Changes in
paraspinal muscles and their association with low
back pain and spinal degeneration: CT study.
Eur Spine J 2010 ; 19 : 1136 – 44 .
47. Oestergaard LG . Abdominal muscle onset
after specifi ed general exercises: a randomised
controlled trial. Proceedings of 7th Interdisciplinary
World Congress on Low Back and Pelvic Pain,
9–12 November, 2010, Los Angeles, CA, USA.
48. Hodges PW, Richardson CA. Ineffi cient muscular
stabilization of the lumbar spine associated with low
back pain. A motor control evaluation of transversus
abdominis. Spine 1996 ; 21 : 2640 – 50 .
49. Hides JA, Jull GA, Richardson CA. Long-term effects
of specifi c stabilizing exercises for fi rst-episode low
back pain. Spine 2001 ; 26 : E243 – 8 .
50. Wand BM, O’Connell NE. Chronic non-specifi c low
back pain – sub-groups or a single mechanism? BMC
Musculoskelet Disord 2008 ; 9 : 11 .
51. Henschke N, Ostelo RWJG, van Tulder MW, et al.
Behavioural treatment for chronic low-back pain.
Cochrane Database Syst Rev 2010 ; 7 : CD002014 .
52. Hill JC, Foster NE, Main CJ, et al. In response to:
‘a randomized trial of behavioural physical therapy
interventions for acute and sub-acute low back pain’,
by George SZ. Pain 2009 ; 140 : 145 – 57 .
53. Vlaeyen JW, Morley S. Cognitive-behavioral
treatments for chronic pain: what works for whom?
Clin J Pain 2005 ; 21 : 1 – 8 .
54. Martel MO, Thibault P, Sullivan MJ. The persistence
of pain behaviors in patients with chronic back pain is
independent of pain and psychological factors. Pain
2010 ; 151 : 330 – 6 .
55. Reichborn-Kjennerud T, Stoltenberg C, Tambs K,
et al. Back-neck pain and symptoms of anxiety and
depression: a population-based twin study. Psychol
Med 2002 ; 32 : 1009 – 20 .
56. Dunn KM, Croft PR. Classifi cation of low back pain in
primary care: using ‘bothersomeness’ to identify the
most severe cases. Spine 2005 ; 30 : 1887 – 92 .
57. Briggs AM, Jordan JE, Buchbinder R, et al. Health
literacy and beliefs among a community cohort
with and without chronic low back pain. Pain
2010 ; 150 : 275 – 83 .
58. Turk DC. The potential of treatment matching for
subgroups of patients with chronic pain: lumping
versus splitting. Clin J Pain 2005 ; 21 : 44 – 55 .
59. Hill JC, Dunn KM, Lewis M, et al. A primary care
back pain screening tool: identifying patient subgroups
for initial treatment. Arthritis Rheum 2008; 59 : 632– 41.
60. Simmonds MJ, Smeets RJ, Degenhardt B. Pain,
mind, and movement: towards a sophisticated
understanding and a tailored clinical approach.
Clin J Pain 2010 ; 26 : 737 – 8 .
61. Childs JD, Fritz JM, Flynn TW, et al. A clinical
prediction rule to identify patients with low back pain
22. O’Sullivan PB. Lumbar segmental ‘instability’:
clinical presentation and specifi c stabilizing exercise
management. Man Ther 2000 ; 5 : 2 – 12 .
23. Richardson C , Hodges P, Hides J. Therapeutic
Exercise for Lumbopelvic Stabilization – A Motor
Control Approach for the Treatment and Prevention
of Low Back Pain . 2nd edition. Churchill Livingstone,
Edinburgh 2004.
24. Sahrmann S . Diagnosis and Treatment of Movement
Impairment Syndromes . Mosby St Louis, Mo; London
2001.
25. Damen L, Buyruk HM, Güler-Uysal F, et al. Pelvic
pain during pregnancy is associated with asymmetric
laxity of the sacroiliac joints. Acta Obstet Gynecol
Scand 2001 ; 80 : 1019 – 24 .
26. Jarvik JG, Hollingworth W, Heagerty PJ, et al.
Three-year incidence of low back pain in an initially
asymptomatic cohort: clinical and imaging risk
factors. Spine 2005 ; 30 : 1541 – 8 .
27. Carroll LJ, Cassidy JD, Côté P. Depression as a risk
factor for onset of an episode of troublesome neck
and low back pain. Pain 2004 ; 107 : 134 – 9 .
28. Comerford MJ . Core stability – priorities in
the management of the athlete. Sport Ex Med
2004; 22 :15–22.
29. Brown CA. Mazes, confl ict, and paradox:
tools for understanding chronic pain. Pain Pract
2009 ; 9 : 235 – 43 .
30. O’Sullivan P. Diagnosis and classifi cation of chronic
low back pain disorders: maladaptive movement and
motor control impairments as underlying mechanism.
Man Ther 2005 ; 10 : 242 – 55 .
31. O’Sullivan PB, Beales DJ. Diagnosis and
classifi cation of pelvic girdle pain disorders – part 1: a
mechanism based approach within a biopsychosocial
framework. Man Ther 2007 ; 12 : 86 – 97 .
32. Cook J . Jumping on bandwagons: taking the right
clinical message from research. Br J Sports Med
2008; 4 :941–4.
33. Costa LO, Maher CG, Latimer J, et al. Motor
control exercise for chronic low back pain: a
randomized placebo-controlled trial. Phys Ther
2009 ; 89 : 1275 – 86 .
34. Ferreira PH, Ferreira ML, Maher CG, et al. Specifi c
stabilisation exercise for spinal and pelvic pain: a
systematic review. Aust J Physiother 2006 ; 52 : 79 – 88 .
35. Critchley DJ, Ratcliffe J, Noonan S, et al.
Effectiveness and cost-effectiveness of three types of
physiotherapy used to reduce chronic low back pain
disability: a pragmatic randomized trial with economic
evaluation. Spine 2007 ; 32 : 1474 – 81 .
36. Koumantakis GA, Watson PJ, Oldham JA.
Supplementation of general endurance exercise
with stabilisation training versus general exercise
only. Physiological and functional outcomes of
a randomised controlled trial of patients with
recurrent low back pain. Clin Biomech (Bristol, Avon)
2005 ; 20 : 474 – 82 .
37. Dworkin RH, Turk DC, McDermott MP, et al.
Interpreting the clinical importance of group
differences in chronic pain clinical trials: IMMPACT
recommendations. Pain 2009 ; 146 : 238 – 44 .
38. Hodges P, van den Hoorn W, Dawson A, et al.
Changes in the mechanical properties of the trunk in
low back pain may be associated with recurrence.
J Biomech 2009 ; 42 : 61 – 6 .
39. van Dieën JH, Selen LP, Cholewicki J. Trunk
muscle activation in low-back pain patients, an
analysis of the literature. J Electromyogr Kinesiol
2003 ; 13 : 333 – 51 .
40. Geisser ME, Haig AJ, Wallbom AS, et al. Pain-related
fear, lumbar fl exion, and dynamic EMG among
persons with chronic musculoskeletal low back pain.
Clin J Pain 2004 ; 20 : 61 – 9 .
41. Pool-Goudzwaard AL, Slieker ten Hove MC,
Vierhout ME, et al. Relations between pregnancy-Downloaded
4 of 4 O’Sullivan P. Br J Sports Med (2011). doi:10.1136/bjsm.2010.081638
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It's time for change with the management of
non-specific chronic low back pain
Peter O'Sullivan
Br J Sports Med published online August 4, 2011
doi: 10.1136/bjsm.2010.081638
Updated information and services can be found at:
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