Prolotherapy

Sports Medicine & General Practice Dr. Jason E. Barker: Optimizing Your Fitness and Health, Naturally

What is Prolotherapy?
FAQ’s About Prolotherapy
Injury, Pain & Healing
Return to Activity after Prolotherapy
Common Conditions Treated with Prolotherapy
Historical Research
Modern Research Abstracts

What is Prolotherapy?
Prolotherapy involves precision injections of a solution directly into areas where tendons and ligaments attach to bone, and in places where cartilage is worn or damaged for the purpose of repairing and strengthening tendons, ligaments and cartilage. This process creates a localized, controlled inflammatory process that stimulates the body’s own repair mechanisms to heal the damaged tissue. This leads to repair at the exact site of injury. The reason why phototherapy works is because it addresses the root cause of chronic pain, which is ligament and tendon weakness.

Normally, the body will attempt to heal damaged connective tissues. However, tendons, ligament and cartilage have a poor blood supply by nature. Low blood supply actually impedes optimal healing; this often leads to incompletely healed/chronically injured tissues that become a source of pain and disability.

Compared to the costs and dangers of surgery and a lifetime of pain medications, prolotherapy is a highly cost effective solution, not to mention it preserves bodily tissues through healing and repair. Surgery removes important pieces of tissue (such as protective cartilage) and many pain medications actually inhibit tissue from repairing itself.

Prolotherapy heals tissue by stimulating repair and regeneration. The solutions used in prolotherapy create inflammation, which is the body’s way of healing damaged tissue. This leads to the creation of new collagen, the protein that makes up ligaments, tendons and cartilage. By doing this, the structures are made stronger. A commonly used analogy is that prolotherapy is similar to spot-welding; ligament and tendon attachments to bone are made much stronger, just as spot welding can strongly attach two pieces of steel together with great strength.

Prolotherapy is useful for treating pain throughout all the joints of the body; the majority of muscle/skeletal pain is thought to originate from weakened ligaments and tendons. This is because when these tissues are weak, they are not fully supporting the muscles of the body and therefore the muscles are forced to contract and tighten as a way to take over the job of the connective tissues. After being continually tight, pain, spasm, and disability are the results.

Prolotherapy works based on a simple mechanism. The injected solution creates localized inflammation, during which the body produces new collagen at the site of injection. The new collagen makes the weak or damaged tendons and ligaments stronger and thicker, thereby resolving pain and joint dysfunction resulting from injury.

Prolotherapy works on the premise that the majority of pain in the muscle and skeletal system is caused by weak or damaged connective tissue (tendons, ligaments, cartilage), most of which is found in and around joints. Connective tissue can become weakened or damaged in a variety of ways, whether through repetitive movement (sports) or through degeneration associated with aging, or just suboptimal health.

FAQ’s About Prolotherapy

1. What is Prolotherapy?
Prolotherapy involves the precision injection of an irritating solution that creates a localized inflammatory reaction where tendons and ligaments attach to bone (cartilage can also be treated). This causes the attachment areas to become much stronger, thereby reducing pain and improving joint function, allowing a return to pain-free activity.

2. How long does it take to heal?
Depending on one’s individual health, the healing and regeneration process typically may take anywhere from 4 to 6 weeks to a few months. This is a relatively short time period compared to a lifetime of pain and disability. As the tissue grows stronger, pain is resolved and function improves.

3. How many Treatments does it take?
This depends on the exact nature of the injury. Some people experience a quick resolution of symptoms after one or two treatments, but on average it requires 3 to 5 sessions separated by 3-week intervals.

4. How does Prolotherapy differ from cortisone injections?
Injecting cortisone for any injury has fallen out of favor, mainly because cortisone was found to actually weaken and lead to further damage in the affected area. Prolotherapy strengthens the damaged tissue and assists with healing.

5. Who is an ideal candidate for Prolotherapy?
A person who has localized joint pain or who has recently suffered an injury will typically benefit from prolotherapy. Prolotherapy works by activating the body’s healing mechanisms at the site of injection. Because of this, it is important for a person to be in good health so the body is able to begin the healing process. Prolotherapy is not a quick fix; the body must be given time (weeks to months) to complete the healing process, therefore one must be patient and committed to allowing the healing to take place and for pain to resolve.

5. Why haven’t I heard of Prolotherapy?
Prolotherapy has been around since the 1940s when George S. Hackett, MD, pioneered it. It is not currently taught in medical schools, for a variety of reasons -mainly because medical education focuses primarily on symptom-based treatments such as drugs and surgery. Prolotherapy is a form of preventive medicine and doctors must seek out continuing education opportunities to become proficient in it. There are roughly 400 doctors in the United States that practice prolotherapy. Interest in prolotherapy continues to grow rapidly; more and more doctors are learning this valuable technique because it is highly effective and is relatively low in cost in comparison to surgery. Dr. Barker is one of the few doctors in the Portland area that offers this service.

Injury, Pain & Healing
Standard medical care for the majority of sports injuries involves either cortisone injections or lots of NSAIDs (non-steroidal antiinflammatory drugs) such as ibuprofen and aspirin. The problem is that these methods only treat the symptoms (pain)…they do nothing to address the actual cause of the pain, which is often a weakened ligament or tendon. In fact, cortisone and NSAIDs are losing popularity because of their many side effects and lack of effectiveness at treating the injury; several medical organizations caution against their chronic use.

In an ironic twist of medical treatment, the highly prescribed NSAIDs actually inhibit the repair and regeneration of cartilage! This does not make any sense to take a drug that actually contributes to further degeneration of the cartilage tissue! They are also notorious for causing bleeding in the gut and raising blood pressure.

Pain is of course not caused by a deficiency of ibuprofen, yet this is the most often prescribed treatment for injuries.

Proper healing occurs when the correct healing environment is provided for the body. This involves prolotherapy to stimulate joint repair, nutritional support to provide the body with the necessary raw materials to do its job, and hormone balancing to ensure proper functioning and support of all the bodily tissues.

Return to Activity after Prolotherapy
Typically, one will be sore in the days after receiving prolotherapy. This is because we have created spots of inflammation in the tissue that leads to a transient increase in pain. There are several ways of addressing this pain; gentle massage, ultrasound and natural pain relievers are all effective. If one is in considerable pain that prevents them from going about daily activities, stronger pain medications (not anti-inflammatories!) may be used. It is important to remember that we do not want you to take any anti-inflammatory medications; this will antagonize the healing process!

Many people want to know when they can return to their activity; this depends on the severity of the injury and the extent of treatment. In general however, we do want people to get on their feet and get their body moving. As a rule, one should not exercise vigorously in the few days after receiving prolotherapy, but light exercise is encouraged as the patient feels ready. Follow-ups are recommended to ensure that proper healing is taking place, and to monitor the progression of recovery.

Common Conditions Treated with Prolotherapy*

Tendon injuries (strains)
Ligament injuries (sprains)
Chronic low back pain
Rotator cuff injuries (shoulder pain)
Knee pain/injuries
Tennis elbow
Chronic ankle sprains
Hip pointers (pain on the side of the hip)

*This is not an inclusive list; call the clinic to find out if prolotherapy is a solution for you

Historical Research:

In a review article written by John R. Merriman, M.D In 1964, he estimated that prolotherapy was successful in roughly 80% to 90% of the 15,000 patients he treated with a diagnosis of tendon and ligament relaxation.

George S. Hackett, MD postulated in 1939 that the major cause of back pain was tendon and ligament relaxation. In his initial animal experiments he demonstrated a 30-40% increase in tendon size after prolotherapy injections in animal subjects.

During 19 years of practice, Dr. Hackett treated 656 patients with prolotherapy, ranging in age from 15 to 88 years old and delivering a total of 18,000 prolotherapy injections. At follow up, he noted an incredible 82% of the patients had no reportable pain in the treated areas.

In another large-scale, whole-practice study, Dr. Gustav A. Hemwall treated 1,871 patients with 6,000 injections, 75.5% percent reported complete recovery from pain, 24% reported general improvement, and .02% reported no improvements at time of the follow up study in 1974.

In a clinical paper from 1937, Dr. Earl Gedney reported successful treatment of painful joint conditions by injecting ligaments around the knee, sacroiliac joint, shoulder and sternum. The Osteopathic Profession, 30-31, 1937, June.

Modern Research Abstracts:

“Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity ”

CONCLUSION: Prolotherapy injection with 10% dextrose resulted in clinically and statistically significant improvements in knee osteoarthritis. Preliminary blinded radiographic readings (1-year films, with 3-year total follow-up period planned) demonstrated improvement in several measures of osteoarthritis severity. ACL laxity, when present in these osteoarthritic patients, improved.

Reeves KD, Hassanein KM. Altern Ther Health Med 2000 Mar;6(2):68-74, 77-80

_________________________________________________________________________

“Long-term effects of dextrose prolotherapy for anterior cruciate ligament laxity”.

CONCLUSION: In patients with symptomatic anterior cruciate ligament laxity, intermittent dextrose injection resulted in clinically and statistically significant improvement in ACL laxity, pain, swelling, and knee range of motion.

Reeves KD, Hassanein KM. Altern Ther Health Med. 2003 May-Jun;9(3):58-62.

__________________________________________________________________________

“Randomized, prospective, placebo-controlled double-blind study of dextrose prolotherapy for osteoarthritic thumb and finger (DIP, PIP, and trapeziometacarpal) joints: evidence of clinical efficacy”

CONCLUSION: Dextrose prolotherapy was clinically effective and safe in the treatment of pain with joint movement and range limitation in osteoarthritic finger joints.

Reeves KD, Hassanein KM. J Altern Complement Med 2000 Aug;6(4):311-20

__________________________________________________________________________

“Intraligamentous injection of sclerosing solutions (prolotherapy) for spinal pain: a critical review of the literature”

CONCLUSION: Prolotherapy describes a variety of treatment approaches rather than a specific protocol. Results from clinical studies published to date indicate that it may be effective at reducing spinal pain. Great variation was found in the injection and treatment protocols used in these studies that preclude definite conclusions. Future research should focus on those solutions and protocols that are most commonly used in clinical practice and have been used in trials reporting effectiveness to help determine which patients, if any, are most likely to benefit from this treatment.

Dagenais S, Haldeman S, Wooley JR. Spine J. 2005 May-Jun;5(3):310-28.

__________________________________________________________________________

“Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain”

CONCLUSIONS: Dextrose prolotherapy showed marked efficacy for chronic groin pain in this group of elite rugby and soccer athletes.

Topol GA, Reeves KD, Hassanein KM. Arch Phys Med Rehabil. 2005 Apr;86(4):697-702.

___________________________________________________________________________

“Prolotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized trial”

CONCLUSIONS: In chronic nonspecific low-back pain, significant and sustained reductions in pain and disability occur with ligament injections, irrespective of the solution injected or the concurrent use of exercises.

Spine. 2004 Jan 1;29(1):9-16

___________________________________________________________________________

“Injection therapy for enthesopathies causing axial spine pain and the "failed back syndrome": a single blinded, randomized and cross-over study.”

RESULTS: By clinical assessment patients obtained excellent to good relief of pain and tenderness after 80% of prolotherapy injections, but only 47% after anesthetics alone. By questionnaire, 66% reported excellent to good relief after prolotherapy vs. 34% after anesthetics alone. Patients reported improvement in work capacity and social functioning following both types of injections, but a greater reduction in focal pain intensity following prolotherapy injections. In the crossover portion of the study, patients reported that prolotherapy injections following initial anesthetic-only injections provided much better relief than that achieved after their anesthetic-only injections, and that anesthetic-only injections following initial prolotherapy injections failed to provide relief as good as that achieved after their prolotherapy. Subsequent to this study, only four of 35 patients required additional spine surgery, but 29 of the 35 patients requested additional injections.

CONCLUSIONS : Injection therapy of painful enthesopathies can provide significant relief of axial pain and tenderness combined with functional improvement, even in "failed back syndrome" patients. Phenol-glycerol prolotherapy provides better and longer lasting relief than injection with anesthetics alone. However, most patients described good to excellent relief, felt that the injections had been beneficial, and requested additional injections for recurrent or residual focal pain.

Wilkinson HA. Pain Physician. 2005 Apr;8(2):167-73.

_________________________________________________________________


Home Integrative Medicine Treatment & Services About Contact Articles Newsletter Archives Resources	Prolotherapy Sports Medicine & General Practice Dr. Jason E. Barker Optimizing Your Fitness and Health, Naturally *What is Prolotherapy?* *FAQ’s About Prolotherapy* *Injury, Pain & Healing* *Return to Activity after Prolotherapy* *Common Conditions Treated with Prolotherapy* *Historical Research* *Modern Research Abstracts* *What is Prolotherapy?* Prolotherapy involves precision injections of a solution directly into areas where tendons and ligaments attach to bone, and in places where cartilage is worn or damaged for the purpose of repairing and strengthening tendons, ligaments and cartilage. This process creates a localized, controlled inflammatory process that stimulates the body’s own repair mechanisms to heal the damaged tissue. This leads to repair at the exact site of injury. The reason why phototherapy works is because it addresses the root cause of chronic pain, which is ligament and tendon weakness. Normally, the body will attempt to heal damaged connective tissues. However, tendons, ligament and cartilage have a poor blood supply by nature. Low blood supply actually impedes optimal healing; this often leads to incompletely healed/chronically injured tissues that become a source of pain and disability. Compared to the costs and dangers of surgery and a lifetime of pain medications, prolotherapy is a highly cost effective solution, not to mention it preserves bodily tissues through healing and repair. Surgery removes important pieces of tissue (such as protective cartilage) and many pain medications actually inhibit tissue from repairing itself. Prolotherapy heals tissue by stimulating repair and regeneration. The solutions used in prolotherapy create inflammation, which is the body’s way of healing damaged tissue. This leads to the creation of new collagen, the protein that makes up ligaments, tendons and cartilage. By doing this, the structures are made stronger. A commonly used analogy is that prolotherapy is similar to spot-welding; ligament and tendon attachments to bone are made much stronger, just as spot welding can strongly attach two pieces of steel together with great strength. Prolotherapy is useful for treating pain throughout all the joints of the body; the majority of muscle/skeletal pain is thought to originate from weakened ligaments and tendons. This is because when these tissues are weak, they are not fully supporting the muscles of the body and therefore the muscles are forced to contract and tighten as a way to take over the job of the connective tissues. After being continually tight, pain, spasm, and disability are the results. Prolotherapy works based on a simple mechanism. The injected solution creates localized inflammation, during which the body produces new collagen at the site of injection. The new collagen makes the weak or damaged tendons and ligaments stronger and thicker, thereby resolving pain and joint dysfunction resulting from injury. Prolotherapy works on the premise that the majority of pain in the muscle and skeletal system is caused by weak or damaged connective tissue (tendons, ligaments, cartilage), most of which is found in and around joints. Connective tissue can become weakened or damaged in a variety of ways, whether through repetitive movement (sports) or through degeneration associated with aging, or just suboptimal health. <Return to Top> *FAQ’s About Prolotherapy* 1. What is Prolotherapy? Prolotherapy involves the precision injection of an irritating solution that creates a localized inflammatory reaction where tendons and ligaments attach to bone (cartilage can also be treated). This causes the attachment areas to become much stronger, thereby reducing pain and improving joint function, allowing a return to pain-free activity. 2. How long does it take to heal? Depending on one’s individual health, the healing and regeneration process typically may take anywhere from 4 to 6 weeks to a few months. This is a relatively short time period compared to a lifetime of pain and disability. As the tissue grows stronger, pain is resolved and function improves. 3. How many Treatments does it take? This depends on the exact nature of the injury. Some people experience a quick resolution of symptoms after one or two treatments, but on average it requires 3 to 5 sessions separated by 3-week intervals. 4. How does Prolotherapy differ from cortisone injections? Injecting cortisone for any injury has fallen out of favor, mainly because cortisone was found to actually weaken and lead to further damage in the affected area. Prolotherapy strengthens the damaged tissue and assists with healing. 5. Who is an ideal candidate for Prolotherapy? A person who has localized joint pain or who has recently suffered an injury will typically benefit from prolotherapy. Prolotherapy works by activating the body’s healing mechanisms at the site of injection. Because of this, it is important for a person to be in good health so the body is able to begin the healing process. Prolotherapy is not a quick fix; the body must be given time (weeks to months) to complete the healing process, therefore one must be patient and committed to allowing the healing to take place and for pain to resolve. 5. Why haven’t I heard of Prolotherapy? Prolotherapy has been around since the 1940s when George S. Hackett, MD, pioneered it. It is not currently taught in medical schools, for a variety of reasons -mainly because medical education focuses primarily on symptom-based treatments such as drugs and surgery. Prolotherapy is a form of preventive medicine and doctors must seek out continuing education opportunities to become proficient in it. There are roughly 400 doctors in the United States that practice prolotherapy. Interest in prolotherapy continues to grow rapidly; more and more doctors are learning this valuable technique because it is highly effective and is relatively low in cost in comparison to surgery. Dr. Barker is one of the few doctors in the Portland area that offers this service. <Return to Top> *Injury, Pain & Healing* Standard medical care for the majority of sports injuries involves either cortisone injections or lots of NSAIDs (non-steroidal antiinflammatory drugs) such as ibuprofen and aspirin. The problem is that these methods only treat the symptoms (pain)…they do nothing to address the actual cause of the pain, which is often a weakened ligament or tendon. In fact, cortisone and NSAIDs are losing popularity because of their many side effects and lack of effectiveness at treating the injury; several medical organizations caution against their chronic use. In an ironic twist of medical treatment, the highly prescribed NSAIDs actually inhibit the repair and regeneration of cartilage! This does not make any sense to take a drug that actually contributes to further degeneration of the cartilage tissue! They are also notorious for causing bleeding in the gut and raising blood pressure. Pain is of course not caused by a deficiency of ibuprofen, yet this is the most often prescribed treatment for injuries. Proper healing occurs when the correct healing environment is provided for the body. This involves prolotherapy to stimulate joint repair, nutritional support to provide the body with the necessary raw materials to do its job, and hormone balancing to ensure proper functioning and support of all the bodily tissues. <Return to Top> *Return to Activity after Prolotherapy* Typically, one will be sore in the days after receiving prolotherapy. This is because we have created spots of inflammation in the tissue that leads to a transient increase in pain. There are several ways of addressing this pain; gentle massage, ultrasound and natural pain relievers are all effective. If one is in considerable pain that prevents them from going about daily activities, stronger pain medications (not anti-inflammatories!) may be used. It is important to remember that we do not want you to take any anti-inflammatory medications; this will antagonize the healing process! Many people want to know when they can return to their activity; this depends on the severity of the injury and the extent of treatment. In general however, we do want people to get on their feet and get their body moving. As a rule, one should not exercise vigorously in the few days after receiving prolotherapy, but light exercise is encouraged as the patient feels ready. Follow-ups are recommended to ensure that proper healing is taking place, and to monitor the progression of recovery. <Return to Top> *Common Conditions Treated with Prolotherapy** Tendon injuries (strains) Ligament injuries (sprains) Chronic low back pain Rotator cuff injuries (shoulder pain) Knee pain/injuries Tennis elbow Chronic ankle sprains Hip pointers (pain on the side of the hip) This is not an inclusive list; call the clinic to find out if prolotherapy is a solution for you <Return to Top> Historical Research:* In a review article written by John R. Merriman, M.D In 1964, he estimated that prolotherapy was successful in roughly 80% to 90% of the 15,000 patients he treated with a diagnosis of tendon and ligament relaxation. George S. Hackett, MD postulated in 1939 that the major cause of back pain was tendon and ligament relaxation. In his initial animal experiments he demonstrated a 30-40% increase in tendon size after prolotherapy injections in animal subjects. During 19 years of practice, Dr. Hackett treated 656 patients with prolotherapy, ranging in age from 15 to 88 years old and delivering a total of 18,000 prolotherapy injections. At follow up, he noted an incredible 82% of the patients had no reportable pain in the treated areas. In another large-scale, whole-practice study, Dr. Gustav A. Hemwall treated 1,871 patients with 6,000 injections, 75.5% percent reported complete recovery from pain, 24% reported general improvement, and .02% reported no improvements at time of the follow up study in 1974. In a clinical paper from 1937, Dr. Earl Gedney reported successful treatment of painful joint conditions by injecting ligaments around the knee, sacroiliac joint, shoulder and sternum. The Osteopathic Profession, 30-31, 1937, June. <Return to Top> *Modern Research Abstracts:* “Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity ” CONCLUSION: Prolotherapy injection with 10% dextrose resulted in clinically and statistically significant improvements in knee osteoarthritis. Preliminary blinded radiographic readings (1-year films, with 3-year total follow-up period planned) demonstrated improvement in several measures of osteoarthritis severity. ACL laxity, when present in these osteoarthritic patients, improved. Reeves KD, Hassanein KM. Altern Ther Health Med 2000 Mar;6(2):68-74, 77-80 _________________________________________________________________________ “*Long-term effects of dextrose prolotherapy for anterior cruciate ligament laxity”.* CONCLUSION: In patients with symptomatic anterior cruciate ligament laxity, intermittent dextrose injection resulted in clinically and statistically significant improvement in ACL laxity, pain, swelling, and knee range of motion. Reeves KD, Hassanein KM. Altern Ther Health Med. 2003 May-Jun;9(3):58-62. __________________________________________________________________________ “Randomized, prospective, placebo-controlled double-blind study of dextrose prolotherapy for osteoarthritic thumb and finger (DIP, PIP, and trapeziometacarpal) joints: evidence of clinical efficacy” CONCLUSION: Dextrose prolotherapy was clinically effective and safe in the treatment of pain with joint movement and range limitation in osteoarthritic finger joints. Reeves KD, Hassanein KM. J Altern Complement Med 2000 Aug;6(4):311-20 __________________________________________________________________________ “Intraligamentous injection of sclerosing solutions (prolotherapy) for spinal pain: a critical review of the literature” CONCLUSION: Prolotherapy describes a variety of treatment approaches rather than a specific protocol. Results from clinical studies published to date indicate that it may be effective at reducing spinal pain. Great variation was found in the injection and treatment protocols used in these studies that preclude definite conclusions. Future research should focus on those solutions and protocols that are most commonly used in clinical practice and have been used in trials reporting effectiveness to help determine which patients, if any, are most likely to benefit from this treatment. Dagenais S, Haldeman S, Wooley JR. Spine J. 2005 May-Jun;5(3):310-28. __________________________________________________________________________ “Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain” CONCLUSIONS: Dextrose prolotherapy showed marked efficacy for chronic groin pain in this group of elite rugby and soccer athletes. Topol GA, Reeves KD, Hassanein KM. Arch Phys Med Rehabil. 2005 Apr;86(4):697-702. ___________________________________________________________________________ “Prolotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized trial” CONCLUSIONS: In chronic nonspecific low-back pain, significant and sustained reductions in pain and disability occur with ligament injections, irrespective of the solution injected or the concurrent use of exercises. Spine. 2004 Jan 1;29(1):9-16 ___________________________________________________________________________ *“Injection therapy for enthesopathies causing axial spine pain and the "failed back syndrome": a single blinded, randomized and cross-over study.”* RESULTS: By clinical assessment patients obtained excellent to good relief of pain and tenderness after 80% of prolotherapy injections, but only 47% after anesthetics alone. By questionnaire, 66% reported excellent to good relief after prolotherapy vs. 34% after anesthetics alone. Patients reported improvement in work capacity and social functioning following both types of injections, but a greater reduction in focal pain intensity following prolotherapy injections. In the crossover portion of the study, patients reported that prolotherapy injections following initial anesthetic-only injections provided much better relief than that achieved after their anesthetic-only injections, and that anesthetic-only injections following initial prolotherapy injections failed to provide relief as good as that achieved after their prolotherapy. Subsequent to this study, only four of 35 patients required additional spine surgery, but 29 of the 35 patients requested additional injections. CONCLUSIONS : Injection therapy of painful enthesopathies can provide significant relief of axial pain and tenderness combined with functional improvement, even in "failed back syndrome" patients. Phenol-glycerol prolotherapy provides better and longer lasting relief than injection with anesthetics alone. However, most patients described good to excellent relief, felt that the injections had been beneficial, and requested additional injections for recurrent or residual focal pain. Wilkinson HA. Pain Physician. 2005 Apr;8(2):167-73. _________________________________________________________________ <Return to Top>

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