Cited by 2,280Musculoskeletal pain and rehabilitationPain Mechanisms and TreatmentsPain Management and Treatment

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pain DETECT : a new screening questionnaire to identify neuropathic components in patients with back pain

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Freynhagen, Rainer, Baron, Ralf, Gockel, Ulrich, Tölle, Thomas R.·2006·Current Medical Research and Opinion

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Abstract

OBJECTIVE: Nociceptive and neuropathic components both contribute to pain. Since these components require different pain management strategies, correct pain diagnosis before and during treatment is highly desirable. As low back pain (LBP) patients constitute an important subgroup of chronic pain patients, we addressed the following issues: (i) to establish a simple, validated screening tool to detect neuropathic pain (NeP) components in chronic LBP patients, (ii) to determine the prevalence of neuropathic pain components in LBP in a large-scale survey, and (iii) to determine whether LBP patients with an NeP component suffer from worse, or different, co-morbidities. METHODS: In co-operation with the German Research Network on Neuropathic Pain we developed and validated the painDETECT questionnaire (PD-Q) in a prospective, multicentre study and subsequently applied it to approximately 8000 LBP patients. RESULTS: The PD-Q is a reliable screening tool with high sensitivity, specificity and positive predictive accuracy; these were 84% in a palm-top computerised version and 85%, 80% and 83%, respectively, in a corresponding pencil-and-paper questionnaire. In an unselected cohort of chronic LBP patients, 37% were found to have predominantly neuropathic pain. Patients with NeP showed higher ratings of pain intensity, with more (and more severe) co-morbidities such as depression, panic/anxiety and sleep disorders. This also affected functionality and use of health-care resources. On the basis of given prevalence of LBP in the general population, we calculated that 14.5% of all female and 11.4% of all male Germans suffer from LBP with a predominant neuropathic pain component. CONCLUSION: Simple, patient-based, easy-to-use screening questionnaires can determine the prevalence of neuropathic pain components both in individual LBP patients and in heterogeneous cohorts of such patients. Since NeP correlates with more intense pain, more severe co-morbidity and poorer quality of life, accurate diagnosis is a milestone in choosing appropriate therapy.

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Diagnostic accuracy of standardised qualitative sensory test in the detection of lumbar lateral stenosis involving the L5 nerve root
Lin, J.-H., Hsieh, Y., Chen, Y., Wang, Y., Chen, C., & Chiang, Y. H. (2017) · Scientific Reports · doi:10.1038/s41598-017-10641-2 · Cited by 15
Translation and cultural adaptation of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale into Arabic for use with patients with diabetes in Libya
Garoushi, S., Johnson, M. I., & Tashani, O. A. (2017) · Libyan Journal of Medicine · doi:10.1080/19932820.2017.1384288 · Cited by 15
“Tools used to screen for the presence of neuropathic pain have been developed in English, French and German for use in European countries and the USA, and include the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) [2], the self-reported version of the LANSS (S-LANSS) [3], the Neuropathic Pain Questionnaire…”
Validity of the Dutch modified painDETECT questionnaire for patients with hip or knee osteoarthritis
Rienstra, W., Blikman, T., Dijkstra, B., van Raay, J., Slager, G. E. C., Bulstra, S. K., Stevens, M. J., & van den Akker‐Scheek, I. (2017) · Disability and Rehabilitation · doi:10.1080/09638288.2017.1413429 · Cited by 15
A Biopsychosocial Approach to Managing HIV-Related Pain and Associated Substance Abuse in Older Adults: a Review
Miller, T. R., Halkitis, P. N., & Durvasula, R. (2018) · Ageing International · doi:10.1007/s12126-018-9333-y · Cited by 18
Loxapine for Treatment of Patients With Refractory, Chemotherapy-Induced Neuropathic Pain: A Prematurely Terminated Pilot Study Showing Efficacy But Limited Tolerability
Schmiedl, S., Peters, D., Schmalz, O., Mielke, A., Roßmanith, T., Diop, S., Piefke, M., Thürmann, P., & Schmidtko, A. (2019) · Frontiers in Pharmacology · doi:10.3389/fphar.2019.00838 · Cited by 15
KARAOKE: Krill oil versus placebo in the treatment of knee osteoarthritis: protocol for a randomised controlled trial
Laslett, L. L., Antony, B., Wluka, A. E., Hill, C. L., MARCH, L. M., Keen, H. I., Otáhal, P., Cicuttini, F., & Jones, G. (2020) · Trials · doi:10.1186/s13063-019-3915-1 · Cited by 15
Development of Postoperative Pain in Patients with End-Stage Knee Osteoarthritis Is Associated with Upregulation of Genes Related to Extracellular Matrix Degradation, Inflammation, and Apoptosis Measured in the Peripheral Blood before Knee Surgery
Tchetina, E. V., Glemba, K. E., Markova, G. A., Naryshkin, E. A., Александровна, Т. Е., Макаров, М. А., & Lila, A. M. (2020) · Life · doi:10.3390/life10100224 · Cited by 15
“IL-1β gene expression also positively correlated with PainDETECT scores (r = 0.313, p = 0.04).”
MethodInfluential
Altered Resting-State Connectivity with Pain-Related Expectation Regions in Female Patients with Severe Knee Osteoarthritis.
Ushio, K., Nakanishi, K., Mikami, Y., Yoshino, A., Takamura, M., Hirata, K., Akiyama, Y., Kimura, H., Okamoto, Y., & Adachi, N. (2020) · PubMed Central · doi:10.2147/jpr.s268529 · Cited by 14
Diagnostik und Therapie neuropathischer Schmerzen
Goßrau, G., & Sabatowski, R. (2021) · Der Anaesthesist · doi:10.1007/s00101-021-01039-x · Cited by 15
Association of Neuropathic Pain Symptoms with Sensitization Related Symptomatology in Women with Fibromyalgia
Úbeda-D’Ocasar, E., Valera‐Calero, J. A., Gallego‐Sendarrubias, G. M., Fernández‐de‐las‐Peñas, C., Arias‐Buría, J. L., Morales-Cabezas, M., Arendt‐Nielsen, L., & Cigarán‐Méndez, M. (2022) · Biomedicines · doi:10.3390/biomedicines10030612 · Cited by 16
“Two of the most commonly used questionnaires are the Self-Report Leeds Assessment of Neuropathic Symptoms (S-LANSS) [14] and PainDETECT [15].”
BackgroundMethod
Does Pain Score in Response to a Standardized Subcutaneous Local Anesthetic Injection Predict Epidural Steroid Injection Outcomes in Patients with Lumbosacral Radiculopathy? A Prospective Correlational Study
Cohen, S. P., Mao, J., Vu, T.-N., Strassels, S. A., Gupta, A., Erdek, M. A., Christo, P. J., Kurihara, C., Griffith, S. R., Buckenmaier, C. C., et al. (2013) · Pain Medicine · doi:10.1111/pme.12027 · Cited by 15
Catastrophising, pain self‐efficacy and acceptance in patients with Burning Mouth Syndrome
Chana, P., Smith, J. G., Karamat, A., Simpson, A., & Renton, T. F. (2020) · Journal of Oral Rehabilitation · doi:10.1111/joor.13136 · Cited by 14
User-Centered Development of a Mobile App for Biopsychosocial Pain Assessment in Adults: Usability, Reliability, and Validity Study
Lopes, F., Rodrigues, M. J. F., & Silva, A. G. (2021) · JMIR mhealth and uhealth · doi:10.2196/25316 · Cited by 14
“Then, validated instruments that covered most of the defined domains were identified and adapted to be included in the app: the Brief Pain Inventory-Short Form [25,26], covering pain intensity, disability, and sleep; and the painDETECT questionnaire [27], covering the phenotype of pain.”
BackgroundMethod
Developments in the assessment of non-motor disease progression in amyotrophic lateral sclerosis
Chiò, A., Canosa, A., Calvo, A., Moglia, C., Cicolin, A., & Mora, G. (2021) · Expert Review of Neurotherapeutics · doi:10.1080/14737175.2021.1984883 · Cited by 14
“Pain Detect Questionnaire (PDQ) Self-administered 7 items, scored 0 (never) to 5 (very strongly), evaluates gradation of pain 1 item, scored −1, 0 or +1, evaluates pain course pattern 1 item is a yes/no question related to the radiation of pain to other body regions PD-Q evaluates intensity and time course of pain [11…”
Background
Effects of adding aerobic physical activity to strengthening exercise on hip osteoarthritis symptoms: protocol for the PHOENIX randomised controlled trial
Hall, M., Allison, K., Hinman, R. S., Bennell, K. L., Spiers, L., Knox, G., Plinsinga, M. L., Klyne, D. M., McManus, F. J., Lamb, K. E., et al. (2022) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-022-05282-0 · Cited by 16
“Scores of < 12 indicate pain is unlikely to be neuropathic and scores of > 19 suggest pain is likely to have neuropathic components [48].”
Background
Pain measurement in painful skin conditions and rheumatoid arthritis randomized controlled trials: a scoping review to inform pain measurement in hidradenitis suppurativa
Hasan, S. B., Gendra, R., James, J. F., Morris, D., Orenstein, L. A. V., & Ingram, J. R. (2022) · British Journal of Dermatology · doi:10.1111/bjd.21821 · Cited by 14
“41,42 The goal of HISTORIC is to generate the minimum set of outcomes that should be measured in HS clinical trials.”
Pain Sensitization and Neuropathic Pain-like Symptoms Associated with Effectiveness of Exercise Therapy in Patients with Hip and Knee Osteoarthritis
Hattori, T., Shimo, K., Niwa, Y., Katsura, Y., Tokiwa, Y., Ohga, S., & Matsubara, T. (2022) · Pain Research and Management · doi:10.1155/2022/4323045 · Cited by 14
“,e PDQ is a self-report questionnaire with nine items [32] and comprises seven sensory descriptor items and two items related to the spatial and temporal characteristics.”
BackgroundMethod
Chronic pain in adults with osteogenesis imperfecta and its relationship to appraisal, coping, and quality of life: A cross-sectional study
Rubén, M., Pastor, J. F., & Dolz, V. M. (2022) · Medicine · doi:10.1097/md.0000000000030256 · Cited by 17
“The intensity, location and type of pain was assessed through the questionnaire PainDETECT (PD-Q)[41] in its original version in English and its adaptation to the Spanish language.[42] This questionnaire assesses the neuropathic component of conditions accompanied by chronic pain by means of a user-friendly self-admin…”
Method
Systemic neuroimmune responses in people with non-specific neck pain and cervical radiculopathy, and associations with clinical, psychological, and lifestyle factors
Schipholt, I. J. L., Scholten-Peeters, G. G. M., Koop, M. A., Bonnet, P., Bontkes, H. J., & Coppieters, M. W. (2022) · Frontiers in Molecular Neuroscience · doi:10.3389/fnmol.2022.1003821 · Cited by 15
“The PD-Q is a reliable screening tool with high specificity (Freynhagen et al., 2006).”
Method
Berlin Registry of Neuroimmunological entities (BERLimmun): protocol of a prospective observational study
Sperber, P. S., Brandt, A. U., Zimmermann, H. G., Bahr, L. S., Chien, C., Rekers, S., Mähler, A., Böttcher, C., Asseyer, S., Duchow, A. S., et al. (2022) · BMC Neurology · doi:10.1186/s12883-022-02986-7 · Cited by 16
“Next to a brief pain anamnesis we use the brief pain inventory (BPI) [49] and the painDETECT questionnaire, which has been proposed to be more sensitive to neuropathic pain [50].”
Assessing the potential anti-neuroinflammatory effect of minocycline in chronic low back pain: Protocol for a randomized, double-blind, placebo-controlled trial
Morrissey, E. J., Alshelh, Z., Knight, P. C., Saha, A., Kim, M., Torrado-Carvajal, Á., Zhang, Y., Edwards, R. R., Pike, C., Locascio, J. J., et al. (2023) · Contemporary Clinical Trials · doi:10.1016/j.cct.2023.107087 · Cited by 14
Frontiers in diagnostic and therapeutic approaches in diabetic sensorimotor neuropathy (DSPN)
Sharma, S., & Rayman, G. A. (2023) · Frontiers in Endocrinology · doi:10.3389/fendo.2023.1165505 · Cited by 18
Serum levels of endocannabinoids and related lipids in painful vs painless diabetic neuropathy: results from the Pain in Neuropathy Study
Bäckryd, E., Themistocleous, A. C., Stensson, N., Rice, A. S. C., Tesfaye, S. H., Bennett, D., Gerdle, B. U. C., & Ghafouri, B. (2023) · Pain · doi:10.1097/j.pain.0000000000003015 · Cited by 14
Quantitative Sensory Testing to Characterize Sensory Changes in Hidradenitis Suppurativa Skin Lesions
Alsouhibani, A., Speck, P. J., Cole, E. F., Mustin, D. E., Li, Y., Barron, J., Orenstein, L. A. V., & Harper, D. (2023) · JAMA Dermatology · doi:10.1001/jamadermatol.2023.3243 · Cited by 14
Quantitative sensory testing, psychological profiles and clinical pain in patients with psoriatic arthritis and hand osteoarthritis experiencing pain of at least moderate intensity
Vela, J., Dreyer, L., Petersen, K. K., Arendt‐Nielsen, L., Duch, K. S., Amris, K., & Kristensen, S. (2023) · European Journal of Pain · doi:10.1002/ejp.2183 · Cited by 15
Phenotyping Pain in Patients With Fibrous Dysplasia/McCune-Albright Syndrome
Golden, E., van der Heijden, H. C., Ren, B., Randall, E. T., Drubach, L. A., Shah, N. A., Cay, M., Ebb, D. H., Kaban, L. B., Peacock, Z. S., et al. (2023) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/clinem/dgad589 · Cited by 14
Tetraspanin profiles of serum extracellular vesicles reflect functional limitations and pain perception in knee osteoarthritis
Mustonen, A.-M., Palviainen, M., Säisänen, L., Karttunen, L., Tollis, S., Esrafilian, A., Reijonen, J., Julkunen, P., Siljander, P., Kröger, H., et al. (2024) · Arthritis Research & Therapy · doi:10.1186/s13075-023-03234-0 · Cited by 15
In subjects with chronic low back pain, does neuropathia exclusively correlated to neuronal compression? A correlation study of PainDETECT questionnaire and corresponding MRI and X-ray findings
Sima, S., Lapkin, S., & Diwan, A. D. (2024) · European Spine Journal · doi:10.1007/s00586-024-08156-2 · Cited by 14
“The PainDETECT questionnaire (supplementary 1) is a screening tool to discriminate between NeP and NoP on a 38 point scale, with 0–12 being negative of NeP, 12–18 being an ambiguous result and 19–38 being positive of NeP [9].”
PATTERNS OF PRESCRIPTION AND ADR MONITORING OF DRUGS IN THE MANAGEMENT OF NEUROPATHIC PAIN IN A TERTIARY CARE TEACHING HOSPITAL
Jena, S. S., Jena, M., Patro, N., Mishra, S. D., Panda, M., & Dash, M. (2021) · International Journal of Pharmacy and Pharmaceutical Sciences · doi:10.22159/ijpps.2021v13i3.41308 · Cited by 14
“It was described in some studies that the incidence of post herpetic neuralgia, painful diabetic neuropathy, phantom limb pain increased with age & also depend on severity of the underlying condition [19, 20].”
Background
Designing a reliable pain drawing tool: avoiding interaction flaws by better tailoring to patients’ impairments
Jaatun, E. A. A., Haugen, D. F., Dahl, Y., & Kofod‐Petersen, A. (2015) · Personal and Ubiquitous Computing · doi:10.1007/s00779-015-0850-3 · Cited by 14
“A large number of different pain assessment tools have been developed for different patient groups with the aim to capture the multidimensional nature of pain [4, 7, 12, 32].”
Background
Epidural analgesia is not superior to systemic postoperative analgesia with regard to preventing chronic or neuropathic pain after thoracotomy
Kampe, S., Lohmer, J., Weinreich, G., Hahn, M., Stamatis, G., & Welter, S. (2013) · Journal of Cardiothoracic Surgery · doi:10.1186/1749-8090-8-127 · Cited by 14
“The painDETECT questionnaire is classified as validated tool for assessing neuropathic pain [8,13].”
Method
Brain morphological alternation in chronic pain patients with neuropathic characteristics
Sugimine, S., Ogino, Y., Kawamichi, H., Obata, H., & Saito, S. (2016) · Molecular Pain · doi:10.1177/1744806916652408 · Cited by 14
“A score5 19 indicates a high possibility of neuropathic characteristics and4 12 indicates their unlikelihood.(10)”
BackgroundInfluential
Altered neural responses to heat pain in drug-naive patients with Parkinson disease
Forkmann, K., Grashorn, W., Schmidt, K., Fründt, O., Buhmann, C., & Bingel, U. (2017) · Pain · doi:10.1097/j.pain.0000000000000923 · Cited by 14
“We assessed PD-related symptoms using the Parkinson’s disease questionnaire, PDQ39,(6) clinical pain and related disability using the German Pain Questionnaire, DSF(33) and painDETECT.(22) Pain-related psychological processing was evaluated using the Pain Catastrophizing Scale, PCS(31) and the Pain Sensitivity Questio…”
Method
A one-year follow-up study of chronic pain in community-dwelling older adults with and without neuropathic pain
Rapo-Pylkkö, S., Haanpää, M. L., & Liira, H. (2017) · BMC Geriatrics · doi:10.1186/s12877-017-0537-x · Cited by 14
“Depression and anxiety appear to be more common in patients with neuropathic pain compared to those without [9].”
Background
Prevalence of Neuropathic Pain Symptoms in Foot and Ankle Patients
Sidon, E., Rogero, R. G., McDonald, E., Daecher, A., Shakked, R. J., Pedowitz, D. I., Fuchs, D. J., Daniel, J. N., & Raikin, S. M. (2019) · Foot & Ankle International · doi:10.1177/1071100719838302 · Cited by 14
Measures of central sensitisation and their measurement properties in the adult musculoskeletal trauma population: a protocol for a systematic review and data synthesis
Middlebrook, N., Rushton, A., Heneghan, N. R., & Falla, D. (2019) · BMJ Open · doi:10.1136/bmjopen-2018-023204 · Cited by 14
Field testing of the revised neuropathic pain grading system in a cohort of patients with neck and upper limb pain
Tampin, B., Broe, R. E., Seow, L. L., George, S. G., Tan, J.-J., Menon, R., Jacques, A., & Slater, H. (2019) · Scandinavian Journal of Pain · doi:10.1515/sjpain-2018-0348 · Cited by 14
One‐year follow‐up study of neuropathic pain in chronic inflammatory demyelinating polyradiculoneuropathy
Bjelica, B., Perić, S., Božović, I., Kačar, A., Cobeljic, M., Dejanović, I., Stević, Z., & Basta, I. Z. (2019) · Journal of the Peripheral Nervous System · doi:10.1111/jns.12318 · Cited by 14
“Patients with NeP had worse INCAT sensory score (P .01), INCAT disability score (P .05) and MRC sum score (P .05) at time of testing than patients without NeP.”
BackgroundMethodInfluential
Muscle function assessed by the non-invasive method acoustic myography (AMG) in a Danish group of healthy adults
Bartels, E. M., Olsen, J. K., Andersen, E. L., Danneskiold‐Samsøe, B., Bliddal, H., Kristensen, L. E., & Harrison, A. P. (2020) · Current Research in Physiology · doi:10.1016/j.crphys.2020.02.002 · Cited by 15
Pain reduction by inducing sensory-motor adaptation in Complex Regional Pain Syndrome (CRPS PRISMA): protocol for a double-blind randomized controlled trial
Halicka, M., Vittersø, A. D., Proulx, M. J., & Bultitude, J. H. (2020) · BMC Neurology · doi:10.1186/s12883-020-1604-z · Cited by 14
Empowering the woman: a comprehensive model of sexual anti-ageing
Sofra, X., & Lampe, N. (2020) · Journal of Aesthetic Nursing · doi:10.12968/joan.2020.9.3.118 · Cited by 14
Cervical Epidural and Subarachnoid Catheter Placement in Standing Adult Horses
Hurcombe, S. D. A., Morris, T. B., VanderBroek, A. R., Habecker, P. L., Wulster, K. B., & Hopster, K. (2020) · Frontiers in Veterinary Science · doi:10.3389/fvets.2020.00232 · Cited by 14
The Use of Oral Analgesics and Pain Self-Efficacy Are Independent Predictors of the Quality of Life of Individuals with Rheumatoid Arthritis
Hashimoto, A., Sonohata, M., & Mawatari, M. (2020) · Pain Research and Management · doi:10.1155/2020/7409396 · Cited by 14
Recovery of Impaired Endogenous Pain Modulation by Dopaminergic Medication in Parkinson's Disease
Florin, E., Koschmieder, K. C., Schnitzler, A., & Becker, S. (2020) · Movement Disorders · doi:10.1002/mds.28241 · Cited by 14
The eEgg: Evaluation of a New Device to Measure Pain
Böing-Meßing, D. M., Tomschi, F., Cegla, T. H., & Hilberg, T. (2022) · Frontiers in Physiology · doi:10.3389/fphys.2022.832172 · Cited by 14
“In- and exclusion criteria regarding pain were assessed by the German PainDETECT questionnaire (Freynhagen et al., 2006).”
Method
The influence of exercise on clinical pain and pain mechanisms in patients with subacromial pain syndrome
Lyng, K. D., Andersen, J. S., Jensen, S. L., Olesen, J. L., Arendt‐Nielsen, L., Madsen, N. K., & Petersen, K. K. (2022) · European Journal of Pain · doi:10.1002/ejp.2010 · Cited by 13
“The PainDETECT questionnaire is a selfreported questionnaire, which contains three 11point numerical rating scales (Freynhagen et al., 2006).”
BackgroundInfluential
Outcomes and reflections on a consensus-building workshop for developing a spinal cord injury-related chronic pain research agenda
Hitzig, S. L., Hunter, J. P., Ballantyne, E. C., Katz, J. D., Rapson, L. M., Craven, B. C., & Boschen, K. A. (2016) · Journal of Spinal Cord Medicine · doi:10.1080/10790268.2015.1136115 · Cited by 14
Biobehavioral Assessments in BACPAC: Recommendations, Rationale, and Methods
Greco, C. M., Wasan, A. D., Schneider, M. J., Mehling, W., Williams, D. A., Darwin, J., & Harte, S. E. (2023) · Pain Medicine · doi:10.1093/pm/pnac175 · Cited by 13
“For assessing whether pain is of neuropathic origin, we recommend the PainDETECT questionnaire [31].”
Method

Authors: Freynhagen, R., Baron, R., Gockel, U., & Tölle, T. R.
Affiliations: Düsseldorf University Hospital (DE)
University Hospital Schleswig-Holstein (DE)
Pfizer (Germany) (DE)
Technical University of Munich (DE)
Corresponding author: Freynhagen, Rainer
ORCID: Freynhagen, Rainer
Baron, Ralf
Tölle, Thomas R.
Venue: Current Medical Research and Opinion
Publisher: Informa UK Limited
Published: 2006-08-29
Volume: 22
Issue: 10
Pages: 1911-1920
ISSN: 0300-7995 (ISSN-L)
1473-4877
DOI: 10.1185/030079906x132488
OpenAlex: W2154693681
Cited by: 2,280
References: 25
Citations by year: 2026: 158 · 2025: 182 · 2024: 187 · 2023: 177 · 2022: 172 · 2021: 179 · 2020: 149 · 2019: 121 · 2018: 161 · 2017: 128 · 2016: 130 · 2015: 99 · 2014: 99 · 2013: 102 · 2012: 68
FWCI: 12.54
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: Current Medical Research and Opinion (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
Health Sciences › Medicine › Physiology (medical) › Pain Mechanisms and Treatments
Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
Keywords: neuropathic pain, low back pain, chronic pain, painDETECT questionnaire, screening questionnaire, prevalence, comorbidities, depression, anxiety, sleep disorders, pain intensity, quality of life, health care utilization, pain diagnosis
MeSH terms: Adult, Aged, Chronic Disease, Female, Humans, Male, Middle Aged, Prospective Studies, Surveys and Questionnaires, Sensitivity and Specificity, Comorbidity, Low Back Pain

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pain DETECT : a new screening questionnaire to identify neuropathic components in patients with back pain

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