The effectiveness of exercise-based telemedicine on pain, physical activity and quality of life in the treatment of chronic pain: A systematic review

Introduction The aim of this study was to systematically review the evidence on the effectiveness of exercise-based telemedicine in chronic pain. Methods We searched the Cochrane, PubMed, MEDLINE, EMBASE, CINAHL and PEDRO databases from 2000 to 2015 for randomised controlled trials, comparing exercise-based telemedicine intervention to no intervention or usual care in adults with chronic pain. Primary outcome data were pooled using random effect meta-analysis. Primary outcomes were pain, physical activity (PA), limitations in activities of daily living (ADL) and quality of life (QoL). Secondary outcomes were barriers, facilitators and usability of telemedicine. Results Sixteen studies were included. Meta-analyses were performed in three subgroups of studies with comparable control conditions. Telemedicine versus no intervention showed significantly lower pain scores (MD −0.57, 95% CI −0.81; −0.34), but not for telemedicine versus usual care (MD −0.08, 95% CI −0.41; 0.26) or in addition to usual care (MD −0.25, 95% CI −1.50; 1.00). Telemedicine compared to no intervention showed non-significant effects for PA (MD 19.93 min/week, 95% CI −5.20; 45.06) and significantly diminished ADL limitations (SMD −0.20, 95% CI −0.29; −0.12). No differences were found for telemedicine in addition to usual care for PA or for ADL (SMD 0.16, 95% CI −0.66; 0.34). Telemedicine versus usual care showed no differences for ADL (SMD 0.08, 95% CI −0.37; 0.53). No differences were found for telemedicine compared to the three control groups for QoL. Limited information was found on the secondary outcomes. Conclusions Exercise-based telemedicine interventions do not seem to have added value to usual care. As substitution of usual care, telemedicine might be applicable but due to limited quality of the evidence, further exploration is needed for the rapidly developing field of telemedicine.

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A physical activity program versus usual care in the management of quality of life for pre-frail older adults with chronic pain in primary care: randomized controlled trial.

10.21203/rs.3.rs-33919/v1 ◽

2020 ◽

Author(s):

Pedro Otones ◽

Eva García ◽

Teresa Sanz ◽

Azucena Pedraz

Keyword(s):

Quality Of Life ◽

Physical Activity ◽

Older Adults ◽

Chronic Pain ◽

Usual Care ◽

Pain Intensity ◽

Physical Performance ◽

Frail Older Adults

Abstract Background Exercise have shown being effective for managing chronic pain and preventing frailty status in older adults but the effect of an exercise program in the quality of life of pre-frail older adults with chronic pain remains unclear. Our objective was to evaluate the effectiveness of multicomponent structured physical exercise program for pre-frail adults aged 65 years or more with chronic pain to improve their perceived health related quality of life, compared with usual care. Methods Open label randomized controlled trial. Participants were community-dwelling pre-frail older adults aged 65 years or older with chronic pain and non-dependent for basic activities of daily living attending a Primary Healthcare Centre. Forty-four participants were randomly allocated to a control group (n = 20) that received usual care or an intervention group (n = 24) that received an 8-week physical activity and education program. Frailty status (SHARE Frailty Index), quality of life (EuroQol-5D-5L), pain intensity (Visual Analogue Scale), physical performance (Short Physical Performance Battery) and depression (Yessavage) were assessed at baseline, after the intervention and after 3 months follow-up. The effect of the intervention was analysed by mean differences between the intervention and control groups. Results The follow-up period (3 months) was completed by 32 patients (73%), 17 in the control group and 15 in the intervention group. Most participants were women (78.1%) with a mean age (standard deviation) of 77.2 (5.9) years and a mean pain intensity of 48.1 (24.4) mm. No relevant differences were found between groups at baseline. After the intervention, mean differences in the EuroQol Index Value between control and intervention groups were significant (-0.19 95%CI(-0.33- -0.04)) and remained after three months follow-up (-0.21 95%CI(-0.37- -0.05)). Participants in the exercise group showed better results in pain intensity and frailty after the intervention, and an improvement in physical performance after the intervention and after three months. Conclusions An eight-week physical activity and education program for pre-frail older adults with chronic pain, compared with usual care, could be effective to improve quality of life after the intervention and after three-months follow-up. Study registration details: This study was retrospectively registered in ClinicalTrials.gov with the identifier NCT04045535.

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A physical activity program versus usual care in the management of quality of life for pre-frail older adults with chronic pain: randomized controlled trial

BMC Geriatrics ◽

10.1186/s12877-020-01805-3 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Pedro Otones ◽

Eva García ◽

Teresa Sanz ◽

Azucena Pedraz

Keyword(s):

Quality Of Life ◽

Physical Activity ◽

Older Adults ◽

Chronic Pain ◽

Usual Care ◽

Pain Intensity ◽

Physical Performance ◽

Frail Older Adults

Abstract Background Exercise has shown being effective for managing chronic pain and preventing frailty status in older adults but the effect of an exercise program in the quality of life of pre-frail older adults with chronic pain remains unclear. Our objective was to evaluate the effectiveness of multicomponent structured physical exercise program for pre-frail adults aged 65 years or more with chronic pain to improve their perceived health related quality of life, compared with usual care. Methods Open label randomized controlled trial. Participants were community-dwelling pre-frail older adults aged 65 years or older with chronic pain and non-dependent for basic activities of daily living attending a Primary Healthcare Centre. Forty-four participants were randomly allocated to a control group (n = 20) that received usual care or an intervention group (n = 24) that received an 8-week physical activity and education program. Frailty status (SHARE Frailty Index), quality of life (EuroQol-5D-5L), pain intensity (Visual Analogue Scale), physical performance (Short Physical Performance Battery) and depression (Yessavage) were assessed at baseline, after the intervention and after 3 months follow-up. The effect of the intervention was analysed by mean differences between the intervention and control groups. Results The follow-up period (3 months) was completed by 32 patients (73%), 17 in the control group and 15 in the intervention group. Most participants were women (78.1%) with a mean age (standard deviation) of 77.2 (5.9) years and a mean pain intensity of 48.1 (24.4) mm. No relevant differences were found between groups at baseline. After the intervention, mean differences in the EuroQol Index Value between control and intervention groups were significant (− 0.19 95% CI(− 0.33- -0.04)) and remained after 3 months follow-up (− 0.21 95% CI(− 0.37- -0.05)). Participants in the exercise group showed better results in pain intensity and frailty after the intervention, and an improvement in physical performance after the intervention and after 3 months. Conclusions An eight-week physical activity and education program for pre-frail older adults with chronic pain, compared with usual care, could be effective to improve quality of life after the intervention and after three-months follow-up. Study registration details This study was retrospectively registered in ClinicalTrials.gov with the identifier NCT04045535.

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Improving Rehabilitation for Patients with Intermittent Claudication: A Randomized Controlled Trial with a Mixed-Methods Evaluation (The CIPIC Rehab Study)

10.31487/j.jicoa.2021.04.01.sup ◽

2021 ◽

Author(s):

Maj Siercke ◽

Sanne Pagh Moller ◽

Lau Caspar Thygesen ◽

Henrik Sillesen ◽

Dorthe Overgaard

Keyword(s):

Quality Of Life ◽

Physical Activity ◽

Clinical Trial ◽

Mixed Methods ◽

Usual Care ◽

Randomized Clinical Trial ◽

Intermittent Claudication ◽

Walking Distance ◽

Significant Difference

Aim: This study aimed to explore how qualitative data about rehabilitation for patients with intermittent claudication do provide an enhanced understanding of the quantitative experimental results. Background: The study was a randomized clinical trial comparing a rehabilitation intervention with usual care. A statistically significant difference between rehabilitation and usual care was found in walking distance, physical activity, quality of life and diet. The findings from the quantitative and qualitative analyses were analysed separately on their own tradition. In this study, mixed methods address whether the qualitative results could help explain the quantitative results and bring forward additional information. Design: Complex mixed-method intervention design with a convergent questionnaire variant. Methods: From April 2017- May 2019, patients diagnosed with intermittent claudication were included in a randomized clinical trial (N=118). In addition, qualitative interview informants from the intervention group were sampled from the quantitative study population for a survey (N=43) and focus group interviews (N=10). Interviews were conducted from April 2018-August 2019. Results: Integrated analyses identified how improvement in walking distance, physical activity, diet and quality of life was affected by team spirit, pedometer, education and fun exercise in a local setting. Quantitative and qualitative findings primarily confirmed and expanded each other; however, two discordant results were also evident. Conclusion: Our study adds empirical evidence regarding how a mixed-methods study can be used to obtain a more nuanced understanding of complex healthcare problems. The study provides new knowledge concerning how to set up a rehabilitation programme for patients with intermittent claudication.

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Role of the intelligent exercise rehabilitation management system on adherence of cardiac rehabilitation in patients with coronary heart disease: a randomised controlled crossover study protocol

BMJ Open ◽

10.1136/bmjopen-2019-036720 ◽

2020 ◽

Vol 10 (6) ◽

pp. e036720

Author(s):

Linqi Xu ◽

Wenji Xiong ◽

Jinwei Li ◽

Hongyu Shi ◽

Meidi Shen ◽

...

Keyword(s):

Quality Of Life ◽

Risk Factors ◽

Coronary Heart Disease ◽

Usual Care ◽

Rehabilitation Management ◽

Exercise Rehabilitation ◽

Related Risk ◽

Secondary Outcomes ◽

Randomised Controlled

IntroductionThe benefits of cardiac rehabilitation (CR) on the reduction of cardiac and all-cause mortality are well documented. However, adherence remains suboptimal in China. It is clear that traditional CR does not meet the needs of many eligible patients and innovation is required to improve its application. Home-based CR (HBCR) is a cost-effective method that may be a valuable alternative for many individuals in China. In HBCR, it is often difficult to maintain an exercise intensity that is both effective and within safe limits, factors that are essential for patient safety. Mobile health interventions have the potential to overcome these obstacles and may be efficacious in improving adherence. The purpose of this study is to evaluate whether an Intelligent Exercise Rehabilitation Management System (IERMS)-based HBCR could improve adherence to CR and to assess the effects on exercise capacity, mental health, self-efficacy, quality of life and lifestyle-related risk factors.Methods and analysisWe propose a single-blinded, two-arm, randomised controlled crossover study of 70 patients with coronary heart disease (CHD). Participants will be randomly assigned in a 1:1 ratio to one of the two groups. Patients in group 1 will receive the IERMS intervention together with usual care for the first 6 weeks and usual care for the last 6 weeks, while patients assigned to group 2 will receive usual care for the first 6 weeks and will use IERMS in the last 6 weeks. The primary outcome is adherence to the programme and secondary outcomes include exercise capacity, psychological well-being, quality of life, self-efficacy and lifestyle-related risk factors. All secondary outcomes will be measured at baseline, 6 weeks and 12 weeks.Ethics and disseminationThis study has been approved by the Human Research Ethics Committee of the School of Nursing, Jilin University (HREC 2019120901). The results will be published in peer-reviewed journals and at conferences.Trial registration numberChiCTR1900028182; Pre-results.

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Diet, physical activity, and health-related outcomes of endometrial cancer survivors in a behavioral lifestyle program: the Diet and Exercise in Uterine Cancer Survivors (DEUS) parallel randomized controlled pilot trial

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2018-000039 ◽

2019 ◽

Vol 29 (3) ◽

pp. 531-540 ◽

Cited By ~ 2

Author(s):

Dimitrios A Koutoukidis ◽

Rebecca J Beeken ◽

Ranjit Manchanda ◽

Matthew Burnell ◽

Nida Ziauddeen ◽

...

Keyword(s):

Quality Of Life ◽

Physical Activity ◽

Endometrial Cancer ◽

Cancer Survivors ◽

Usual Care ◽

Healthy Eating ◽

Pilot Trial ◽

Healthy Eating Index ◽

Global Quality Of Life

ObjectivesTo explore the effectiveness of a theory-based behavioral lifestyle intervention on health behaviors and quality of life in endometrial cancer survivors.’MethodsThis was a secondary analysis of a randomized controlled pilot trial conducted in two UK hospitals enrolling disease-free stage I-IVA endometrial cancer survivors. Participants were allocated to an 8-week group-based healthy eating and physical activity intervention or usual care using 1:1 minimization. Participants were followed up at 8 and 24 weeks, with the 8-week assessment being blinded. Diet, physical activity, and quality of life were measured with the Alternative Healthy Eating Index 2010, Stanford 7-Day Physical Activity Recall, and the EORTC Quality of life Questionnaire Core 30, respectively. We analyzed all eligible participants using the intention-to-treat approach in complete cases, adjusting for baseline values, body mass index, and age.ResultsWe enrolled 60 of the 296 potentially eligible endometrial cancer survivors (May - December 2015). Fifty-four eligible participants were randomized to the intervention (n=29) or usual care (n=31), and 49 had complete follow-up data (n=24 in the intervention and n= 25 in usual care). Intervention adherence was 77%. At 8 weeks, participants in the intervention improved their diet compared to usual care (difference in Alternative Healthy Eating Index 2010 score 7.5 (95% CI: 0.1 to 14.9), P=0.046) but not their physical activity (0.1 metabolic equivalent-h/day 95% CI: (-1.6 to 1.8), P=0.879), or global quality of life score (5.0 (95% CI: -3.4 to 13.3), P=0.236). Global quality of life improved in intervention participants at 24 weeks (difference 8.9 (95% CI: 0.9 to 16.8), P=0.029). No intervention-related adverse events were reported.ConclusionsThe potential effectiveness of the intervention appeared promising. A future fully-powered study is needed to confirm these findings.Trial registration numberNCT02433080.

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Efficacy of task-specific circuit training on physical activity levels and mobility of stroke patients: A randomized controlled trial

Neurorehabilitation ◽

10.3233/nre-203207 ◽

2020 ◽

Vol 47 (4) ◽

pp. 451-462

Author(s):

Júlia Caetano Martins ◽

Sylvie Nadeau ◽

Larissa Tavares Aguiar ◽

Aline Alvim Scianni ◽

Luci Fuscaldi Teixeira-Salmela ◽

...

Keyword(s):

Quality Of Life ◽

Physical Activity ◽

Randomized Controlled Trial ◽

Controlled Trial ◽

Post Intervention ◽

Randomized Controlled ◽

Secondary Outcomes ◽

Experimental Group

BACKGROUND: Impaired mobility is related to low physical activity (PA) levels observed after stroke. Therapeutic approaches, such as task-specific circuit training (TSCT), used to improve mobility in individuals with stroke, could also improve PA levels. OBJECTIVE: To investigate the efficacy of TSCT, focused on both upper (UL) and lower (LL) limbs, in improving PA levels and mobility (primary outcomes), as well as muscle strength, exercise capacity, and quality of life (secondary outcomes) in subjects with stroke. METHODS: A randomized controlled trial with 36 subjects with chronic stroke was conducted. Experimental group: TSCT, involving both UL and LL. Control group: global stretching, memory exercises, and education sessions. Both groups received 60 minute sessions/week over 12 weeks. Outcomes were measured at baseline, post-intervention and 16 week follow-up. RESULTS: No changes were found for primary and secondary outcomes (0.11≤p≤0.99), except for quality of life, which improved in the experimental group post-intervention and 16 week follow-up (p = 0.02). CONCLUSION: TSCT focused on both UL and LL was not effective on PA levels and mobility of individuals with chronic stroke, however, improvements in quality of life were observed. Since this is the first study to investigate this combined training aimed at improving PA levels, future studies are necessary to better understand the impact of this type of intervention.

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TIRED: A randomised controlled trial evaluating efficacy of cognitive behavior therapy and graded exercise therapy in severely fatigue patients with advanced cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.34_suppl.183 ◽

2018 ◽

Vol 36 (34_suppl) ◽

pp. 183-183

Author(s):

Hanneke Poort ◽

Marlies Peters ◽

Winette T.A. Van Der Graaf ◽

Pythia Nieuwkerk ◽

Agnes W Van de Wouw ◽

...

Keyword(s):

Quality Of Life ◽

Usual Care ◽

Advanced Cancer ◽

Severe Fatigue ◽

Graded Exercise Therapy ◽

Significant Difference ◽

Eortc Qlq C30 ◽

Secondary Outcomes ◽

Eortc Qlq

183 Background: Patients with advanced, metastatic cancer frequently suffer from severe fatigue. We assessed the effect of cognitive behavioral therapy (CBT) and graded exercise therapy (GET) on fatigue during cancer treatment with palliative intent. Methods: This randomized study took place between Jan 1, 2013 and Sep 1, 2017 at Radboud University Medical Center (Nijmegen, Netherlands). We enrolled adult patients from nine medical oncology clinics. Eligible patients had advanced cancer and reported severe fatigue (Checklist Individual Strength, subscale fatigue severity [CIS fatigue] ≥ 35) during cancer treatment. Participants were randomized to CBT, GET, or usual care (1:1:1 ratio, using a computer-generated sequence, stratified by study site and minimized for sex). We measured fatigue (CIS fatigue and European Organisation for Research and Treatment of Cancer-Quality of Life Questionnaire-Core 30 [EORTC-QLQ-C30] fatigue), quality of life, emotional functioning, physical functioning (all by EORTC-QLQ-C30), and functional impairments (Sickness Impact Profile [SIP8]) at baseline, 14, 18, and 26 weeks. The primary outcome was CIS fatigue at 14 weeks; secondary outcomes included scores for the aforementioned scales. We registered the trial with TrialRegister.nl (NTR3812). Results: 134 participants completed baseline measures (46 CBT, 42 GET, 46 usual care); 126 completed assessment at 14 weeks. There was a significant difference in CIS fatigue scores between CBT and usual care (-7.22, 97.5% CI -12.73 to -1.72; p = .003, d= 0.72), but no significant difference between GET and usual care (-4.70, -10.24 to 0.85, p = .057, d= 0.44). Secondary outcomes showed significant differences for EORTC-QLQ-C30 fatigue (-13.05 [95% CI -22.12 to -3.97]; p = 0.005), quality of life (10.15 [2.37 to 17.93]; p = 0.11), and physical functioning (7.10 [0.48 to 13.72]; p = 0.036), but not for emotional functioning or SIP8 functional impairments (p's > 0.05). There were no significant differences in secondary outcomes between GET and usual care. Conclusions: The findings support CBT for severe fatigue in patients with advanced cancer during treatment. Clinical trial information: NTR3812.

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Exercise Management Using a Mobile App in Patients with Parkinsonism: A Prospective, Open-label, Single-arm, Pilot Study (Preprint)

10.2196/preprints.27662 ◽

2021 ◽

Author(s):

Aram Kim ◽

Seo Jung Yun ◽

Kwan Sik Sung ◽

Yeonju Kim ◽

Ju Young Jo ◽

...

Keyword(s):

Quality Of Life ◽

Physical Activity ◽

Pilot Study ◽

Management Strategy ◽

Exercise Program ◽

Mobile App ◽

Open Label ◽

Home Based ◽

Secondary Outcomes

BACKGROUND Although exercise has benefits for motor function and quality of life in patients with parkinsonism, these patients have many barriers to exercise participation. Recently, the use of mobile apps has been highlighted as a remotely supervised exercise management strategy. OBJECTIVE This study aimed to evaluate the effects of home-based exercise management with a customized mobile app on exercise amount, physical activity, and quality of life in patients with parkinsonism. METHODS This was a prospective, open-label, single-arm, pilot study. Participants were encouraged to engage in an 8-week home-based exercise program delivered through a customized app. The primary outcome was the exercise amount. The secondary outcomes were International Physical Activity Questionnaire (IPAQ), Parkinson’s Disease Questionnaire-39 (PDQ-39), and Geriatric Depression Scale (GDS). RESULTS A total of 21 participants completed the intervention and assessment (mean age: 72 years; women: 17/21, 81%; men: 4/21, 19%). The participants reported a significant increase in the total amount of exercise (baseline: 343.33±206.70 min/week; 8-week follow up: 693.10±373.45 min/week; P<.001) and in the amount of each exercise component including stretching, strengthening, balance and cooperation, and oral-motor and vocal exercise after 8 weeks. The analysis of secondary outcomes revealed significant improvements in the IPAQ (P=.006), PDQ-39 (P=.02), and GDS (P=.04) scores. The usability of the program with the mobile app was verified based on the positive responses such as “intention to use” and “role expectation for rehabilitation.” CONCLUSIONS Exercise management with a customized mobile app may have benefits for improving exercise adherence, physical activity, depression, and quality of life in patients with parkinsonism. This supervised home-based, technology-based, reinforcing, and multimodal exercise management strategy should be recommend to patients with parkinsonism. In addition, this program may be useful as an alternative exercise management strategy during the COVID-19 pandemic. Additional clinical trials are needed to evaluate the efficacy of this exercise program in a large population and to confirm its disease-modifying effects.

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The influence of the HEART Camp intervention on physical function, health-related quality of life, depression, anxiety and fatigue in patients with heart failure

European Journal of Cardiovascular Nursing ◽

10.1177/1474515119867444 ◽

2019 ◽

Vol 19 (1) ◽

pp. 64-73 ◽

Cited By ~ 1

Author(s):

Joseph F Norman ◽

Kevin A Kupzyk ◽

Nancy T Artinian ◽

Steven J Keteyian ◽

Windy S Alonso ◽

...

Keyword(s):

Quality Of Life ◽

Heart Failure ◽

Usual Care ◽

Physical Function ◽

Clinical Outcomes ◽

Health Related Quality ◽

Related Quality ◽

Health Related ◽

Secondary Outcomes

Background: Regular exercise training has beneficial effects on quality of life, physical function, depression and anxiety in individuals with heart failure. Unfortunately, individuals with heart failure have low levels of adherence to exercise. Thus, studies are needed to assess intervention strategies which may enhance clinical outcomes. Aim: The aim of this study was to identify the components of the HEART Camp intervention, which contributed to optimizing clinical outcomes. Methods: The Heart Failure Exercise and Resistance Training Camp (HEART Camp) was a randomized controlled trial to evaluate the effect of a multicomponent intervention on adherence to exercise (6, 12 and 18 months) compared to an enhanced usual care group. This study assessed various components of the intervention on the secondary outcomes of physical function, health-related quality of life, depression, anxiety, and fatigue. Results: Individuals participating ( n=204) in this study were 55.4% men and the average age was 60.4 (11.5) years. A combination of individualized and group-based strategies demonstrated clinical improvements, HEART Camp versus enhanced usual care groups, in physical function, positive trends in health-related quality of life and positive changes in the minimally important differences for depression, anxiety, and fatigue. Conclusions: Individualized coaching by an exercise professional and group-based educational sessions were identified as important components of patient management contributing to improvements in the secondary outcomes of physical function, health-related quality of life, depression, anxiety and fatigue.

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Wool-derived keratin dressings versus usual care dressings for treatment of slow-healing venous leg ulceration: study protocol for a randomised controlled trial (Keratin4VLU)

BMJ Open ◽

10.1136/bmjopen-2017-020319 ◽

2018 ◽

Vol 8 (2) ◽

pp. e020319 ◽

Cited By ~ 6

Author(s):

Andrew Jull ◽

Angela Wadham ◽

Chris Bullen ◽

Varsha Parag ◽

Jill Waters

Keyword(s):

Quality Of Life ◽

Randomised Controlled Trial ◽

Usual Care ◽

Controlled Trial ◽

Health Related Quality ◽

Related Quality ◽

Health Related ◽

Secondary Outcomes ◽

Randomised Controlled

IntroductionKeratins, filament-forming proteins found in vertebrate epithelium, are downregulated in slow-healing venous leg ulcers (VLU) compared with normal-healing VLU. Laboratory and animal model research has suggested exogenous keratins increase expression of endogenous keratins. A non-randomised controlled trial of an exogenous keratin dressing reported increased healing in slow-healing VLU. To date, no randomised controlled trial has been done to verify these promising findings.Methods and analysisThe Keratin4VLU trial is a single-blind, pragmatic, parallel group, randomised controlled trial of keratin dressings compared with usual care non-medicated dressings in patients with VLU where either (1) the ulcer area is greater than 5 cm2, (2) the ulcer has been present for more than 26 weeks or (3) both. All patients will receive compression therapy. The primary outcome is the proportion of patients with healed VLU at 24 weeks after randomisation as adjudicated by blinded review of an ulcer photograph. Secondary outcomes are time to healing, estimated change in ulcer area, change in health-related quality of life, agreement between blinded and unblinded assessors and adverse events. The analysis will be intention-to-treat on the primary and secondary outcomes (excepting health-related quality of life).Ethics and disseminationThe Keratin4VLU trial received ethical approval from the Northern A Health and Disability Ethics Committee. We plan to publish the results within 1 year of trial completion and will include the results on the trial registration page.Trial registration numberNCT02896725; Pre-results.

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