3/28/2016
Disclosure
• There are no conflicts of interest regarding relevant financial interests in making this presentation and I have indicated that my presentation does not include discussion of an unlabeled use of a commercial product or an investigational use not yet approved for any purpose. How to Talk to Patients
about Self-Managing
Pain
Murray J. McAllister
Courage Kenny Rehabilitation Institute
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Self-management…
What are we referring to?
Objectives
• Acute, post‐surgical and/or terminal pain
• Identify and review the main obstacle for effective pain self‐management for pain
• Review the competing paradigms for conceptualizing & understanding pain
• Review common self‐management interventions
• Review 4 strategies for communicating information about self‐management to patients
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– Can stay cognitively & emotionally grounded (not overly alarmed or avoidant of pain); knows what it is, knows its normal given the circumstances
– Can stay active, within reason, despite pain; maybe even sees value in staying active or productive, given its capacity to distract attention away from pain
– Engages the relaxation response: breathing, etc
– Engages in gentle exercises, beyond stretching, such as walking or pool exercises (or another aerobic exercise)
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Self-management…
What are we referring to?
How do we get patients to engage in selfmanagement?
• Chronic pain
• Some people just naturally do it.
– Stays cognitively & emotionally grounded (not alarmed or avoidant of pain); knows what it is; accepts it
– Stays active, within reason, despite pain; doesn’t stop & rest with bad pain day, but gets up and goes, gets out of the house or to work
– Understands relationship between pain & stress; sees fluctuating pain as a stress barometer
– Engages in mild aerobic exercise: walking, pool, etc
– Engages in regular relaxation therapies: mindfulness, meditation, yoga, tai chi
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How do we get patients to engage in selfmanagement?
• Some people just naturally do it.
– High health literacy
– Invested in their health, take ownership of it
– Have a history of engaging in health behavior change
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How do we get patients to engage in selfmanagement?
• Some people just naturally do it.
• Others, not so much…
– And it’s not just because they may have a low health literacy or low motivation for health behavior change
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How do we get patients to engage in selfmanagement?
• Some people just naturally do it.
• Others, not so much…
– And it’s not just because they may have a low health literacy or low motivation for health behavior change
– Maybe it’s also because of how society and certain parts of the healthcare system conceptualize and treat pain itself
What’s the problem?
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The problem
• We routinely see patients in pain
• Neck
• Low back
• Leg
• Hips, knees, shoulders
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The problem…
• We routinely see patients in pain
• As providers and patients, we routinely conceptualize their presentation of pain in terms of an orthopedic condition
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The problem…
• We routinely see patients in pain
• As providers and patients, we routinely conceptualize their presentation of pain in terms of an orthopedic condition
– Disc herniation
– Degenerative changes of the spine
– Osteoarthritis of the hip, knee or shoulder joints
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The problem…
• We routinely see patients in pain
• We conceptualize pain as orthopedic in nature
• As such, our patients expect to pursue an acute medical model course of care that’s indicative of an orthopedic injury
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The problem…
• We routinely see patients in pain
• We routinely conceptualize pain as an orthopedic condition
• As such, our patients expect to pursue an acute medical model course of care that’s indicative of an orthopedic injury
– Scan it
– Fix it (injections, spine surgeries, arthroscopic joint surgeries)
– Stop using it (immobilize it, brace it, guard it, rest it)
– Ice it, heat it
– Wait for it to heal (stay home from work & other activities, expect disability paperwork completed)
– Keep it comfortable (take opioid pain medications)
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The problem…
• We routinely see patients in pain
• We routinely conceptualize pain as an orthopedic condition
• As such, our patients tend to pursue an acute medical model course of care that’s indicative of an orthopedic injury
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–
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• In other words, engage in passive coping strategies while waiting for active agency of the healthcare provider to do something
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The problem…
• In still other words, this conceptualization of pain as an orthopedic condition with its subsequent reliance on the acute medical model fosters:
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Scan it
Fix it (injections, spine surgeries, arthroscopic surgeries of the joint)
Stop using it (immobilize it, brace it, guard it, rest it)
Ice it, heat it
Wait for it to heal (stay home from work & other activities)
Keep it comfortable (take opioid pain medications)
The problem…
• This conceptualization of pain as an orthopedic condition with its subsequent reliance on the acute medical model fosters:
– A disempowering shift in power from an internal locus of control to an external locus of control when patients come to rely on scans and procedural fixes
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The problem…
• This conceptualization of pain as an orthopedic condition with its subsequent reliance on the acute medical model fosters:
The problem…
• This conceptualization of pain as an orthopedic condition with its subsequent reliance on the acute medical model fosters:
– A disempowering shift in power
– Passive behavioral coping strategies of stop, guard, stay home, rest and medicate
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– A disempowering shift in power
– Passive behavioral coping strategies
– Dependency on the healthcare system
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The problem…
• This conceptualization of pain as an orthopedic condition with its subsequent reliance on the acute medical model fosters:
– A shift in power – Passive behavioral coping strategies
– Dependency on the healthcare system
– Squashes the possibility of self‐management: for what does self‐management have to do with the bony structures of the spine or joints?
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On top of it all…
• The course of care that patients expect to pursue, as a result of conceptualizing pain as solely the result of an orthopedic condition, runs counter to empirical‐based treatment guidelines!
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On top of it all…
Empirically‐unsupported
Empirically‐supported
Scan it
No scans, unless red flags, which are rare
Fix it
No procedures or surgeries, unless red flags, which are rare
Rest it
Keep moving
Ice it, heat it
No ice or heat, again keep moving
Medicate it
No opioids; not indicated
Stay home from work as a result of it
Keep working; modify if patient insists
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The problem of communicating what’s most
helpful to patients
• If everyone involved conceptualizes pain as the result of an orthopedic condition, how do we communicate to patients:
– Why a scan isn’t needed? (Why don’t we want to know about the condition in my spine? patients might ask)
– Why they don’t need to see a surgeon or interventional pain provider (What can I do to help a bone problem? Isn’t that the orthopedic surgeon’s job?)
– Why they should see a PT (How will making my muscles stronger help fix a problem in the bones of my spine?)
– How remaining active, mild aerobic exercise, and remaining at work help? (Shouldn’t I brace and rest a bone‐related condition? Shouldn’t I wait til it heals?)
– Why they should manage stress? (Stress doesn’t affect bones!)
– Why they shouldn’t take opioids (Why shouldn’t I feel comfortable while I wait for it to heal?)
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What’s the real problem here?
• We have a paradigm for understanding pain that involves conceptualizing it as solely an orthopedic or spinal condition that leads to:
What’s the real problem
here?
– A scan it, fix it, rest it, medicate it ‐ treatment protocol that isn’t supported by empirical research
– Established, empirically supported treatment guidelines that don’t make sense
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So, again, what’s the real
problem here?
What if it’s our conceptual
model of pain?
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Competing paradigms for understanding
pain
• Cartesian/orthopedic model: – Pain is a function of tissue damage; severity is commensurate with severity of injury
– Pain without identifiable tissue damage is either presumed to have such damage (until it can be found) or presumed to be psychogenic (w/out plausible psychophysiological explanation)
• Nervous system (neuromatrix) model:
– Pain is a function of the nervous system, particularly the CNS (brain and spinal cord)
– Can plausibly explain all pain, with or without tissue damage
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Which paradigm is empirically-supported?
• The last 50 years of basic & applied pain science leads to the conclusion that pain is a function of the nervous system in response to any number of different stimuli that might elicit a danger response within the CNS, the latter of which is sometimes an injury (e.g., an orthopedic injury in the spine).
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Outline of the neuromatrix model
• Pain is produced by multiple parts of the brain (neuromatrix) as it processes information (nociception)
• This info processing must involve activation of the danger/stress response (likely in the frontal lobe & limbic system)
• Information (nociception) is delivered to the CNS by the peripheral nervous system (PNS)
• Numerous biopsychosocial factors can alter the CNS’ threshold for processing nociception as dangerous, making the PNS more or less sensitive to stimuli
• As the nervous system becomes more sensitive:
– Less tactile stimuli is required to elicit pain
– A wider variety of stimuli becomes capable of producing pain: motoric, emotional, cognitive, environmental
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Example
• Head pain with and without tissue damage
– Bumping head on way to basement
– Tension headache
• Same outcome due to the up‐regulation of the nervous system, with the brain processing different nociception as equally dangerous or threatening
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From here, we can see clear
Self-management in a nutshell
• How cognitive‐behavioral or self‐management therapies work:
– Cognitive/emotional interventions change how the brain processes nociception
– Behavioral interventions reduce (or down‐
regulate) the sensitivity of the nervous system
– (Incidentally, we can now see why a scan it, fix it, guard it, medicate it approach isn’t empirically‐
supported & is often counter‐productive)
• Cognitive interventions: to reduce threat or sense of alarm/dangerousness
• Behavioral interventions: reduce sensitivity or “irritability” of the nervous system
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In other words…
• You must teach patients a scientifically accurate way of understanding their pain
• By doing so, it becomes clear as to why self‐
management is effective
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What you need
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An empirically‐based understanding of pain
A note pad and pen
5 or more minutes
Practice
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Lesson #0: Prep patient
Lesson #1: What is the nervous system?
• Validate pain, demonstrate empathy: patients need to understand that you see it as important and that you get it.
• But don’t do it by – Colluding with their experience of adversity – watch tone of voice!
– Emphasizing the severity of their condition
– Emphasizing that it’s impossible or nearly impossible to cope with
• Assess their openness to learning and their health literacy: ask permission to teach them; phrase in hypothetical
– “We’ll certainly want to take your pain seriously. Now, there are likely things that you might do for your pain… Would you ever be interested in learning about them?”
• Tell them what you are going to do
– “It would take learning some things about the nervous system…”
• Don’t jump to pain self‐management strategies, unless the patient has demonstrated a high health literacy, because they won’t understand their relationship to the orthopedic condition that they perceive as the cause of pain
• We have nerves throughout our ourselves & its what we feel things with
– Demonstrate touch: “When we touch something, we can feel that it is smooth or rough because of the nerves in our finger tips and hands.”
– “Now, we also feel feelings like fear and anger because we have nerves. When we say we are ‘nervous’ it’s literally true. It’s our nerves that have become reactive.”
– “We also feel sensations because of nerves… sensations like itches, tickles, and pain.”
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Lesson #1: Contd
Lesson #2:
Injury + the nervous system = Pain
• “All the nerves in our body make up the nervous system.”
– “Have you ever heard of the nervous system?” – Use examples of other systems: cardiovascular or intestinal systems
– “We also have an immune system and a hormonal system, called the endocrine system.”
• We can divide our nervous system into two parts
– Draw diagram
– Central and peripheral
• When feeling something, the peripheral nervous system sends messages to the brain, the brain processes that information, & produces the sensation
• “Oftentimes, when it comes to pain and our healthcare system, we focus only on the injury or condition that is painful.”
• “Find & fix the injury and the pain should go away.”
• “It can come to seem that the injury or condition that started it all is the only thing we should focus on.”
• “But we need more than an injury (or tumor, birthing process, etc.) to have pain. We also need a nervous system.”
• “Were it not for the nerves in the area of the injury, as well as the spinal cord and brain, we wouldn’t be able to feel the injury.”
• While drawing or tracing the nervous system
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Lesson #2: Contd
• “It’s nerves that detect the injury and send a message to the brain via the spinal cord, and it’s the brain that processes those messages and sounds the alarm of pain.”
• “The nervous system is like the fire alarm of this building, detecting a fire and sounding an alarm, alerting us to a problem.
• “Now it’s here where you can have an effect. By learning how to gain more and more control of the nervous system, you can affect your pain level.”
• Write out: “Injury (surgical scar, tumor, birthing process) + nervous system = pain”
• “Now, us healthcare providers will work on this variable in the equation (circling the word ‘injury’) in order to reduce pain, but you can work on this variable in the equation (circling ‘nervous system’) to reduce pain.”
• “if you are open to learning how.”
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Lesson #3: The nervous system can become
irritable
• “Now when the brain processes the information sent from those nerves in the area of injury, the brain sounds the alarm of pain.”
• “In doing so, the brain also tells the hormonal system to release some stress hormones, adrenaline and cortisol. You probably have heard of adrenaline.”
• “Now cortisol tells the immune system to get into the act and the immune system gets sent down to the point of injury.”
• “The immune system are white blood cells & other chemicals which fight infection, fight cancer, and repair damaged tissues of injuries. We also call it inflammation.”
• “In the process of doing its job, inflammation makes the nerves in the area around the injury very sensitive or irritable.”
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Lesson #3: Irritable nerves (contd)
Lesson #3: Irritable nerves (contd)
• “You’ve probably experienced that sensitivity before. Have you ever had a sprained ankle or broken finger? It got inflamed, right? Red or bruised, puffy and swollen. Any little movement hurt.” • “When your provider examined it, and asked, ‘Does this hurt?’ it might have sent you through the roof, but she was probably just barely pressing on it.”
• “Now, the simple movement or light pressure normally shouldn’t be painful, but it is when we have a lot of inflammation because the inflammation has made those nerves highly sensitive. Anything little thing sets them off, sending signals back up to the brain for processing into pain.”
• While drawing or tracing your nervous system figure:
• “We commonly think of pain as a bottoms‐up process, an injury being detected by nerves which send signals up to the brain where there the signal register as pain”
• “But it’s also a top‐down process: the brain produces pain and sends inflammation to the nerves making them irritable, which leads them to send more signals up to the brain for processing into pain, and thereby creating a feedback loop that makes for the experience of pain in the area of the injury.”
• Once the inflammation heals the injury, the brain stops sending it; the nerves return to their normal level of sensitivity and we no longer have pain.”
• “Chronic pain occurs when this feedback loop remains in a vicious cycle long past the point of healing.”
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Lesson #3: Irritable nerves (contd)
Lesson #3: Irritable nerves (contd)
• “Now you can wait for the injury to heal or wait for your healthcare providers to fix you, but we know from a lot of experience and science that people who do that tend to take longer to get better and are at higher risk of developing chronic pain.”
• “However, you could also learn how to exercise some control over your nervous system, calming it down, so you have less pain now.”
• Cognitive interventions which reduce the sense of alarm and inhibit the pain response:
– Learning about pain; knowing what pain is
– Staying grounded (catching yourself catastrophize the sense of dangerousness or doom associated with pain)
– Recognizing that the pain is largely due to the sensitivity of the nerves, and not because you are producing further injury; safe to remain active, move and exercise
– Re‐directing attention elsewhere to work, which further reduces sense of alarm in the brain
– Manage your internal and external stressors, which further fan the flames of an already inflamed & irritable nervous system
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Lesson #4: Pain & the brain (or How you
think & feel matters)
Lesson #3: Irritable nerves (contd)
• Behavioral or lifestyle interventions which reduce sensitivity of the nervous system:
– Mild aerobic exercise, which produces a ‘runner’s high’ that reduces the sensitivity of nerves
– Relaxation therapies, which elicit the relaxation response (and helps to become grounded) which reduces irritability of nerves
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• Teach patients about the neuromatrix: “When the brain processes the signals that are sent to it from the peripheral nerves, the processing occurs simultaneously in multiple areas of the brain.”
• Draw an outline of the brain. Draw in each of the different parts as you go over it:
– Somatosensory cortex: responsible for where in the body the pain is felt and the quality of its sensation (i.e., whether it’s sharp, stabbing, burning, etc)
– Limbic system: responsible for the emotional sense of alarm that is felt with pain; borrows from the architecture of the stress response (‘fight‐or‐flight’)
– Frontal lobe: responsible for one’s attention on pain, it’s meaning in relation to other aspects of life, it’s threat value or sense of dangerousness
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Lesson #4: Pain & the brain (or How you
think & feel matters)
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“Through learning and practice, you can change how your brain processes pain.”
Use everyday examples to demonstrate how attention and how one conceptualizes an experience determines pain levels:
– Upon completing a day of yard work, you come to see that you had tissue damage of a cut or bruise on your leg, but had no pain and hadn’t noticed the injury
– Immunizing children: how nurses reduce threat and distract attention
– Child birth: rather than the healthcare system & society disempowering & frightening expecting mothers, what if we conceptualized childbirth as a moving, miraculous, even spiritual, event that women have been successfully doing for tens of thousands of years
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While discussing the example, trace on your illustration of the brain how the frontal lobe overrides the limbic system to reduce threat and sense of alarm, and thereby reduces the overall experience of pain.
“What if you set out to learn how to use your frontal lobe to override your limbic system, reduce the sense of threat and alarm, and thereby reduce pain?”
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Lesson #4: Pain & the brain (or How you
think & feel matters)
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Help your patient conceptualize the experience so that pain is experienced as:
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Safe and not dangerous (e.g., it’s safe to move when in pain)
Expected (e.g., with post‐surgical pain)
Has a purpose (e.g., in childbirth)
Is tolerable if the patient is willing to learn how to make sense of it, stay grounded, and re‐direct attention elsewhere
Use metaphors:
– With practice, you could stay at your work station and continue working even if the fire alarm was stuck on all afternoon, as long as you knew it wasn’t signaling a fire
– With practice, you could learn to drive with your check‐engine light on, knowing that you don’t have to pull over and stop, if you knew that it was basically safe to drive even though the light was on
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Introduce the concept that you have to prove it to yourself: if you only avoid pain through medications and inactivity, you’ll never learn that you can safely move with pain, which in turn inhibits pain
– The gradually increasing exercises of physical therapy are really an exposure based treatment designed to show patients that it is safe to move, thereby demonstrating to the limbic system that there’s no need for alarm, which subsequently inhibits the production of pain, inflammation and sensitivity of the peripheral nerves
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Recap
• Injury (or other health condition) + the nervous system (particularly the brain) = pain
• If patients only rely on providers to fix their injury, they remain disempowered and alarmed in the presence of pain
• If patients learn to use CBT‐based self‐management to affect their nervous system (particularly how their brain processes information to produce pain), they become empowered and grounded in the presence of pain, thereby reducing pain
• To learn how they can affect their nervous system and thereby reduce pain, you need to teach them a scientifically accurate conceptualization of how pain works – you need to stop understanding pain as solely the result of an orthopedic condition
• To reduce pain, patients need to re‐conceptualize pain as less threatening and reduce the sensitivity of their nervous system
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Selected bibliography
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Apkerian, A. V., Bushnell, M. C., Treede, R. D., & Zubleta, J. K. (2005). Human brain mechanisms of pain perception and regulation in health and disease. European Journal of Pain. 9(4), 463‐484.
Chapman, C. R., Tuckett, R. P., & Song, C. W. (2008). Pain and stress in a systems perspective: Reciprocal neural, endocrine and immune interactions. Journal of Pain, 9(2), 122‐145. doi: 10.1016/j.jpain.2007.09.006.
Melzack, R. (1999). From the gate to the neuromatrix. Pain, S6, S121‐S126.
Melzack, R. & Loeser, J. D. (1978). Phantom body parts in paraplegics: Evidence for a central ‘pattern generating mechanism’ for pain. Pain, 4, 195‐210.
Melzack, R. & Wall, P. D. (1965). Pain mechanisms: A new theory. Science, 150, 971‐979.
Melzack, R., Coderre, T. J., Kat, J., & Vaccarino, A. L. (2001). Central neuroplasticity and pathological pain. Annals of the New York Academy of Sciences, 933, 157‐174.
Rivat, C., Becker, C., Blugeot, A., Zeau, B., Mauborgne, A., Pohl, M., & Benoliel, J. (2010). Chronic stress induces transient spinal neuroinflammation, triggering sensory hypersensitivity and long‐
lasting anxiety‐induced hyperalgesia. Pain, 150, 358‐368.
Woolf, C. J. (2011). Central sensitization: Implication for diagnosis and treatment of pain. Pain, 152(3), S2‐S15.
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Contact
Contact
Murray J. McAllister
Clinical Director of Pain Services
Courage Kenny Rehabilitation Institute
651‐241‐3820
[email protected]
Murray J. McAllister
Clinical Director of Pain Services
Courage Kenny Rehabilitation Institute
651‐241‐3820
[email protected]
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