پژوهشگاه تربیت بدنی و علوم ورزشی مطالعات طب ورزشی 2322-1658 17 44 2025 06 22 Effects of Reactive Neuromuscular Exercise on Balance, Mobility, Fear of Fall and Muscle Strength in Older People with Sarcopenia تأثیر تمرینات عصبی‌عضلانی‌ واکنشی بر تعادل، جنبش‌پذیری، ترس از سقوط و آمادگی عضلانی سالمندان مبتلا به سارکوپنی 111 128 4908 10.22089/smj.2025.18082.1813 FA کمیل Dashti Rostami گروه بیومکانیک و رفتار حرکتی، دانشکده علوم ورزشی، دانشگاه مازندران، بابلسر، ایران 0000-0002-3467-2660 راحله غفاری چراتی دانشکده علوم ورزشی، دانشگاه شمال، آمل، ایران 0000-0002-0760-3117 دنیا کارگران دانشکده علوم ورزشی، دانشگاه شمال، آمل، ایران 0009-0002-0089-0974 Journal Article 2025 06 02 <strong><span style="font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">Background and Purpose</span></strong> <span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">Sarcopenia, or reduction of muscle mass, has been reported to occur in 50% of people over 80 years of age and is an important risk factor for functional disability and poor physical performance. Elderly people with sarcopenia experience problems such as balance, fear of falling, mobility, and decreased muscle strength. Previous studies have shown that reactive neuromuscular training (RNT) can lead to improved mobility and functional balance. RNT improves proprioception and dynamic stability, which can result in postural awareness, adaptations in balance, and improved position sense. RNT emphasizes precise body position to enhance dynamic stabilization of the muscular system, thus can improve functional activities. The purpose of this study was to investigate the effect of RNT exercises on functional mobility, balance, fear of falling, and muscle fitness of elderly people with sarcopenia.</span> <strong><span style="font-size: 10.0pt; font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;"> </span></strong> <strong><span style="font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">Materials and Methods</span></strong> <span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">In this semi-experimental study, 30 elderly people with the age range of 60 to 75 years (15 experimental group, N = 15; control group, N = 15) suffering from sarcopenia in Amol</span><span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;"> city were recruited as samples with the confirmation of a physician. The sampling method was purposeful in which participants were chosen according to inclusion and exclusion criteria. G-Power software was used to determine the sample size with a statistical power of 80%, a confidence interval of 95%, and an effect size of 0.7. Sarcopenia was assessed according to the criteria of the European Working Group on Sarcopenia in Older People (EWGSOP). Berg Balance Scale (BBS) was used to evaluate balance. Fear of falling was assessed using the FES-I (International Fall Efficiency Scale) questionnaire, which has 16 items related to 16 activities of daily living. Timed Up and Go test (TUG) was used to evaluate functional mobility. For performing the TUG test, the subject sits on a standard chair with a height of 46 cm, and the time required for the participant to get up from the chair, walk a distance of three meters, go around a specified place, and return to sit on the chair is recorded by a digital timer.</span> <span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">For assessing upper and lower extremity muscle fitness, the 30-second bicep curl test and 30-second sit-to-stand test were used respectively. The muscular fitness of the upper limb was evaluated using the biceps curl with a dumbbell in 30 seconds. The weight of the dumbbell for men was 3.63 kg and for women 2.27 kg.</span> <span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">The experimental group performed eight weeks of reactive neuromuscular exercises, three sessions a week, a total of 24 sessions, each session lasting 45–60 minutes. The control group did not perform any activity during this period. The intensity of the exercises increased by manipulating the time of execution of the movement or the level and type of movement. In the final weeks, the maximum possible amount of pressure was considered according to the condition of the people. It should be noted that the intensity of the exercises used in the present study was recommended by the American College of Sports Medicine (ACSM).</span> <span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">SPSS software version 26 was utilized for data analysis. The normality of the data distribution was checked by the Shapiro-Wilk test. Analysis of covariance and Bonferroni’s post hoc test were used to compare research variables in two experimental and control groups at a significance level of p = 0.05.</span> <strong><span style="font-size: 10.0pt; font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;"> </span></strong> <strong><span style="font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">Findings</span></strong> <span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">The two groups included 30 elderly people with an average age of 64.93 ± 4.11 years, height 169.23 ± 7.88 cm, weight 73.70 ± 8.14 kg, and body mass index 25.55 ± 1.85 kg/m². There was no significant difference in demographic characteristics between the two groups.</span> <span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">ANCOVA results showed a significant difference between the experimental and control groups (F = 48.82, p = 0.001, η² = 0.64) in Berg Balance Scale. Specifically, the scores of the balance test in the experimental group increased significantly after the intervention. The results of the ANCOVA test showed a significant effect of RNT exercises on the functional mobility of the older people with sarcopenia (F = 64.26, p = 0.001, η² = 0.51). In fact, the time of the Timed Up and Go test was significantly reduced in the experimental group.</span> <span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">There was no significant difference between the experimental and control groups in the fear of falling variable (F = 2.86, p = 1.02, η² = 0.11). Also, RNT exercises significantly improved the muscle fitness of the upper limb (η² = 0.59, p = 0.001, F = 29) and lower limb (η² = 0.53, p = 0.001, F = 30.06) in the experimental group compared to the control group.</span> <strong><span style="font-size: 10.0pt; font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;"> </span></strong> <strong><span style="font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">Conclusion<br></span></strong><span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">It seems that RNT is effective in improving balance, mobility, and muscle fitness. RNT could improve the sense of proprioception and movement control pattern. These exercises affect balance and functional mobility and, by improving muscle fitness, help older people to cope better in activities of daily living. The strength of the upper and lower limbs is one of the important factors in maintaining the balance of older people with sarcopenia. Additionally, maintaining functional independence and performing daily necessary tasks by older people should be achieved by improving the level of mobility and functional balance. Considering the lack of effect of RNT on the fear of falling, it is suggested to consider more time for exercises in future research.</span> <strong><span style="font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">Article Message</span></strong> <span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">Reactive neuromuscular training can be considered an effective training modality for improving balance, joint mobility, and lower and upper limb strength in older adults with sarcopenia.</span> <strong><span style="font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">Ethical Considerations</span></strong> <span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">The research ethics code was obtained from the ethics committee of Shahroud University of Technology</span><span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;"> with the number IR.SHAROODUT.REC.1404.003.</span> <strong><span style="font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">Authors’ Contributions</span></strong> <span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">Conceptualization: Komeil Dashti Rostami, Raheleh Ghaffari<br>Data Collection: Donya Kargaran<br>Data Analysis: Komeil Dashti Rostami<br>Manuscript Writing: Komeil Dashti Rostami, Raheleh Ghaffari, Donya Kargaran<br>Review and Editing: Raheleh Ghaffari, Donya Kargaran<br>Project Manager: Komeil Dashti Rostami, Raheleh Ghaffari</span> <strong><span style="font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">Conflict of Interest</span></strong> <span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">The authors of the article declare that they have no conflicts of interest related to the present research.</span> <strong><span style="font-size: 10.0pt; font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;"> </span></strong> <strong><span style="font-size: 12.0pt; font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">Acknowledgments</span></strong> <span style="font-family: 'Times New Roman',serif; color: black; mso-themecolor: text1;">The authors express their gratitude and appreciation to all the dear elderly individuals who collaborated in this research project.</span> <span style="font-size: 10.0pt; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;"><span style="text-decoration: none;"> </span></span> <strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; color: black; mso-themecolor: text1;">سا</span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;">رکوپنی کاهش توده عضلانی است که بر بسیاری از سالمندان تأثیر می‌گذارد؛ ازاین‌رو هدف پژوهش حاضر، بررسی تأثیر هشت هفته تمرینات عصبی</span></strong><strong><span dir="LTR" style="font-size: 10.0pt; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra';">‌</span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;">عضلانی </span></strong><strong><span dir="LTR" style="font-size: 10.0pt; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra';">‌</span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;">واکنشی (</span></strong><strong><span dir="LTR" style="font-size: 10.0pt; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra';">RNT</span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;">) بر تعادل، جنبش‌پذیری، ترس از سقوط و قدرت اندام فوقانی و تحتانی سالمندان مبتلا به سارکوپنی بود. تعداد 30 سالمند مبتلا به سارکوپنی به صورت هدفمند به</span></strong><strong><span dir="LTR" style="font-size: 10.0pt; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra';">‌</span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;">عنوان نمونه تحقیق حاضر انتخاب شدند. آزمودنی‌ها به صورت تصادفی در دو گروه تمرین (15=</span></strong><strong><span dir="LTR" style="font-size: 10.0pt; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra';">N</span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;">) و کنترل (15=</span></strong><strong><span dir="LTR" style="font-size: 10.0pt; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra';">N</span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;">) قرار گرفتند. گروه تمرینی سه بار در هفته و به مدت هشت هفته </span></strong><strong><span dir="LTR" style="font-size: 10.0pt; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra';">RNT</span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;"> را انجام دادند. مقیاس تعادل برگ، آزمون زمانی برخاستن و راه رفتن، مقیاس بین‌المللی کارآمدی سقوط</span></strong><strong><span lang="FA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-language: FA;">، </span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;">آزمون 30 ثانیه‌ای جلو بازو و آزمون 30 ثانیه‌ای نشستن و برخاستن، قبل و بعد از پروتکل تمرین ارزیابی شدند. برای تحلیل داده‌ها از آزمون آنکووا استفاده شد. تمام تحلیل‌های آماری در نرم</span></strong><strong><span dir="LTR" style="font-size: 10.0pt; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra';">‌</span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;">افزار </span></strong><strong><span dir="LTR" style="font-size: 10.0pt; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra';">SPSS</span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;"> نسخه 26 انجام شد. نتایج نشان داد،</span></strong><strong><span dir="LTR" style="font-size: 10.0pt; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra';">RNT </span></strong><strong><span style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;"><span style="mso-spacerun: yes;"> </span><span lang="AR-SA">به طور معناداری تعادل <span class="MsoPlaceholderText">(</span></span></span></strong><strong><span lang="FA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-language: FA;">001/0</span></strong><strong><span dir="LTR" style="font-size: 10.0pt; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra'; mso-bidi-language: FA;">P= </span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;">)،</span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;"> <span class="MsoPlaceholderText">تحرک عملکردی (</span></span></strong><strong><span lang="FA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-language: FA;">001/0</span></strong><strong><span dir="LTR" style="font-size: 10.0pt; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra'; mso-bidi-language: FA;">P= </span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;">)، قدرت اندام فوقانی (</span></strong><strong><span lang="FA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-language: FA;">001/0</span></strong><strong><span dir="LTR" style="font-size: 10.0pt; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra'; mso-bidi-language: FA;">P= </span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;">) و اندام تحتانی (</span></strong><strong><span lang="FA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-language: FA;">001/0</span></strong><strong><span dir="LTR" style="font-size: 10.0pt; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra'; mso-bidi-language: FA;">P= </span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;">) را در گروه تمرین نسبت به گروه کنترل افزایش داد؛ با وجود این، تفاوت معناداری در متغیر ترس از سقوط بین دو گروه وجود نداشت (</span></strong><strong><span lang="FA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-language: FA;">102/0</span></strong><strong><span dir="LTR" style="font-size: 10.0pt; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra'; mso-bidi-language: FA;">P= </span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;">). براساس نتایج،<span style="mso-spacerun: yes;">  </span></span></strong><strong><span dir="LTR" style="font-size: 10.0pt; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra';">RNT</span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;"> را می‌توان به</span></strong><strong><span dir="LTR" style="font-size: 10.0pt; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-font-family: 'B Mitra';">‌</span></strong><strong><span lang="AR-SA" style="font-size: 10.0pt; font-family: 'B Mitra'; mso-ascii-font-family: 'Times New Roman'; mso-ascii-theme-font: major-bidi; mso-hansi-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi;">عنوان یک مدالیته تمرینی برای بهبود تعادل، تحرک و قدرت اندم فوقانی و تحتانی در سالمندان مدنظر قرار داد.</span></strong> https://smj.ssrc.ac.ir/article_4908_1b33d16fc562464579b7199ca3114982.pdf