उਵखघॊऒध➨10ᅇCSP-HORᖺ఍ 0,'धम

0,'भ೾৒ध42/௬੼षभણ৷
ূਨপ৾ୢ৾௺ଢ଼஢ఐ௽૩ఐ৾௧వ࿔৬ਂঽ૓৾ী৙

 0,'௺ଁ৓ঞঅগ‫ش‬भ਄ॉੌा
$‫ۂ‬,'भ৒ଝ%0,'॑৷ःञଢ଼஢ऋ੗ः୩ୠ

&0,'भ௓৒্১

' ॔क़ॺढ़঒ੰ๸भ੦૆धखथभઞ৷্১൝࿾ेखा ऽधीফা঩

Tohoku University Graduate School of Medicine㻌㻌 142/352५॥॔भਔ௡

0,'धम
 0LQLPDOLPSRUWDQWGLIIHUHQFH

$औ॒भ42/५॥॔௓୎੘௜৏भ42/५॥॔ૻຎ೩঻ऋ‫ؚ‬੎ਏ‫ؚ‬થஇ‫ँؚ‬ॊःमથ૩ध૎ग‫ؚ‬ಏ෫ੇऋ೩঻ଵ৶भ૗ಌ॑અൟघॊ‫ؚ‬ঢ়ੱ୩ୠभ੭ਡभਈ৵भ୷

*50454035302520151050‫ہۄۆ‬५॥॔ 605040¾ 7KHVPDOOHVWGLIIHUHQFHLQVFRUHLQWKHGRPDLQRILQWHUHVWWKDWSDWLHQWVSHUFHLYHDVLPSRUWDQWHLWKHUEHQHILFLDORUKDUPIXODQGWKDWZRXOGOHDGWKHFOLQLFLDQWRFRQVLGHUDFKDQJHLQWKHSDWLHQWbVPDQDJHPHQW
*X\DWWHWDO0D\R&OLQ3URF 

30
20100A἞⒪⩌B἞⒪⩌*: p < 0.05

㻌2

㻌3

㻌40,'௺ଁ৓ঞঅগ‫ش‬भ৯৓0,'पঢ়घॊব৔ਗभଢ଼஢৿਱धୖ਻
॑‫ؚ‬ীෲॸ‫ش‬ঐ॑ਝ৒खथ৥ैऊपख‫ؚ‬ଢ଼஢धੰ๸भञीभफ़ॖॻছॖথ॑੿ਛ
घॊऒध0,'௺ଁ৓ঞঅগ‫ش‬पणःथ೩঻ਾઔ॔क़ॺढ़঒‫؞‬42/भఐ৾৓௬੼ু১भનয়‫ش‬ଢ଼஢धੰ๸भफ़ॖॻছॖথ੿ਛ ଢ଼஢ྉ
㻌50,'௺ଁ৓ঞঅগ‫਻ୖ؟ش‬ਝ৒㻌6ધ൴ྴল

 0,'भ৒ଝ 0,'ऋਝ৒औोथःॊჃ২भྴল
 0,'ऋઞ৷औोथःॊী৙
 0,'ৠ৒্১ ॔क़ॺढ़঒ੰ๸भ੦૆धखथभઞ৷্১ ෆฐ৓ऩ42/ध્৒भඪ૾प્৲खञ352੐ఏ
भ0,'भਹ৷্১‫ق‬ಏ෫૥ୡभ॔क़ॺढ़঒धखथभਹ৷‫ك‬ਫ਼ดग़থ४থ‫؟‬3XE0HGਫ਼ด঩‫؟‬ফা঩ਫ਼ด৷ୁ
¾0LQLPDOLPSRUWDQWGLIIHUHQFH
• 0LQLPDOPLQLPDOO\PLQLPXP
• 'LIIHUHQFHFKDQJH
• &OLQLFDOO\ँॉ‫ط‬ऩखધ൴ྴল㻌7㻌8nPLQLPDOFOLQLFDOO\LPSRUWDQWGLIIHUHQFH| ੂল૛ધ
*X\DWW*:DOWHU61RUPDQ*0HDVXULQJFKDQJH
RYHUWLPHDVVHVVLQJWKHXVHIXOQHVVRIHYDOXDWLYHLQVWUXPHQWV-&KURQLF'LV  ਰৣभ௾ਗ੦૆पेॉધ൴௾ਗ‫ڀ‬¾ୖ਻धखथ੉఺भा¾$EVWUDFWऩख¾ওॱ॔ॼজ३५¾ওॱ॔ॼজ३५ਰਗभঞঅগ‫ش‬૛ધ¾352दऩः੐ఏ
¾ઃଢ଼஢दऩः‫ق‬উটॺ॥ঝ૛ધ‫ؚ‬फ़ॖॻছॖথ‫ ؚ‬ॣ‫ش‬५ঞএ‫ؚॺش‬ऩन‫ك‬¾0,'ঢ়৴৷ୁऩख
¾जभ౎‫ق‬ஶୁ‫؞‬঩মୁਰਗ‫ؚ‬੥ટभ੶ൗऩख‫ؚ‬ऩन‫ك‬㻌9㻌 10㻷㼕㼚㼓㻌㻹㼀㻚㻌㻱㼤㼜㼑㼞㼠㻌㻾㼑㼢㻌㻼㼔㼍㼞㼙㼍㼏㼛㼑㼏㼛㼚㻌㻻㼡㼠㼏㼛㼙㼑㼟㻌㻾㼑㼟㻚㻌㻝㻝㻔㻞㻕㻘㻌㻝㻣㻝䇵㻝㻤㻠㻘㻌㻞㻜㻝㻝$ 0,'भ৒ଝ㻌 11㻌 120,'भঢ়৴৷ୁ⋇0LQLPDOFOLQLFDOO\LPSRUWDQWGLIIHUHQFH 0&,'   
⋈6XEMHFWLYHO\VLJQLILFDQWGLIIHUHQFH 66' ⋉0LQLPDOLPSRUWDQWGLIIHUHQFH 0,' ⋊&OLQLFDOVLJQLILFDQFH

⋋&OLQLFDOO\LPSRUWDQWGLIIHUHQFHV &,' ⋌&OLQLFDOO\VLJQLILFDQWFKDQJH

⋍0LQLPDOO\LPSRUWDQWFKDQJH 0,& ⋎0LQLPDOO\GHWHFWDEOHGLIIHUHQFH 0'' ⋏0LQLPXPGHWHFWDEOHFKDQJH 0'& ⋐6PDOOHVWUHDOGLIIHUHQFH 65' ⋑6PDOOHVWVWDWLVWLFDOO\GHWHFWDEOHGLIIHUHQFH 6''  ⋒5HVSRQGHUGHILQLWLRQಏ෫৓पਔ௡भँॊ૗৲)'$फ़ॖॲথ५भൃံदम‫ؼ‬ 0LQLPXPLPSRUWDQWGLIIHUHQFH‫؟‬ಏ෫૥ୡपउःथ‫ँؚ‬ॊ੘௜ऋથ஍दँॊधੰ๸दऌॊ‫ؚ‬೩঻ਾઔૄ॔क़ॺढ़঒Ⴣ২पेॉ௴௄औोञ‫ؚ‬੘௜ණ৑भ୷ृ૗৲୤¾ 0LQLPXPLPSRUWDQWGLIIHUHQFH 0,' 7KHDPRXQWRIGLIIHUHQFHRUFKDQJHREVHUYHGLQD3523DWLHQW5HSRUWHG
2XWFRPH!PHDVXUHEHWZHHQWUHDWPHQWJURXSVLQD
FOLQLFDOWULDOWKDWZLOOEHLQWHUSUHWHGDVDWUHDWPHQWEHQHILW)'$*XLGDQFHIRU,QGXVWU\3DWLHQW5HSRUWHG2XWFRPH0HDVXUHV8VHLQ0HGLFDO
3URGXFW'HYHORSPHQWWR6XSSRUW/DEHOLQJ&ODLPV 㻔㻷㼕㼚㼓㻌㻹㼀㻚㻌㻞㻜㻝㻝㻘㻌㻱㼤㼜㼑㼞㼠㻌㻾㼑㼢㻌㻼㼔㼍㼞㼙㼍㼏㼛㼑㼏㼛㼚㻌㻻㼡㼠㼏㼛㼙㼑㼟㻌㻾㼑㼟㻚㻕㻌 13ಏ෫৓पਔ௡भँॊ૗৲㻌 14&260,1पउऐॊ0,'&260,1 5HVSRQGHUGHILQLWLRQ‫؟‬ས஍୻भ৒ଝৌ଴धऩॊૐ੮पउःथ‫ؚ‬হ৐प৒ीैोञ਋৑রप೩঻ऋ৽ୡघॊ‫ؚ‬ਔ௡भँॊ੘௜ঋॿইॕॵॺ॑਀घ‫ؚ‬Ⴣ২भ५॥॔૗৲୤¾ &2QVHQVXVEDVHG6WDQGDUGVIRUWKHVHOHFWLRQRIKHDOWK0HDVXUHPHQW,1VWUXPHQWV ௏೨ঢ়৴Ⴣ২भ৭උपঢ়घॊ়ਔप੦तऎ੐ଉ

¾ 5HVSRQGHUGHILQLWLRQٕ$VFRUHFKDQJHLQDPHDVXUHH[SHULHQFHGE\DQLQGLYLGXDOSDWLHQWRYHUD
SUHGHWHUPLQHGWLPHSHULRGWKDWKDVEHHQ
GHPRQVWUDWHGLQWKHWDUJHWSRSXODWLRQWRKDYHDVLJQLILFDQWWUHDWPHQWEHQHILW)'$*XLGDQFHIRU,QGXVWU\3DWLHQW5HSRUWHG2XWFRPH0HDVXUHV8VH
LQ0HGLFDO3URGXFW'HYHORSPHQWWR6XSSRUW/DEHOLQJ&ODLPV 㻌 15

㻌 16

&260,1पउऐॊ0,'

&260,1पउऐॊੰ๸૭ચਙn୤৓Ⴣ২५॥॔ुखऎम૗৲५॥॔॑ସ৓ऩਔ௡‫ق‬ಏ෫৓ुखऎम঳ಹ৓प৶ੰदऌॊਔ௡‫ك‬पસॉਊथॊऒधऋदऌॊங২|PROᑻᗘ䛾㉁ಙ㢗ᛶ㻌ෆⓗᩚྜᛶ㻌ጇᙜᛶ㻌ಙ㢗ᛶ㻌ෆᐜⓗ㻌ጇᙜᛶ㻌⾲㠃ⓗ㻌ጇᙜᛶ㻌ᐃㄗᕪ㻌ᇶ‽㛵㐃㻌ጇᙜᛶ㻌཯ᛂᛶ㻌ᵓ㐀ⓗ㻌ጇᙜᛶ㻌ੰ๸૭ચਙभଡਛਏಞᵓᡂᴫᛕ㻌ጇᙜᛶ㻌⋇ ଢ଼஢ఏমपउऐॊ੭ਡীഘऋંऔोथःॊऊ⋈ ෫஍ટधଠ੩஍ટभੲਾऋંऔोथःॊऊ⋉ ঢ়৴घॊૐ੮भ५॥॔ध૗৲५॥॔ऋਹ৷૭ચऊ‫ق‬੦૆ૐ੮‫ؚ‬೩঻ॢঝ‫ش‬উ‫ؚ‬঳ಹಟૐ੮ऩन‫ك‬⋊ ਈ৵੎ਏ૗৲‫ق‬0,&‫ुك‬खऎमਈ৵੎ਏ୷‫ق‬0,'‫ك‬ऋંऔोथःॊऊ௬ㄝ㻌᳨ド㻌␗ᩥ໬㛫㻌ጇᙜᛶ㻌཯ᛂᛶ㻌ゎ㔘㻌ྍ⬟ᛶ㻌

18

㻌 17
Mokkink LB et al: J Clin Epidemiol. 2010 Jul;63(7):737-45.

㻌 18

୩ୠશ0,'ଢ଼஢૛ધਯ‫ق‬ધ൴‫ك‬
180
160
140
120
100
80
60
40% 0,'भଢ଼஢ऋ੗ः୩ୠ

20

㻌 19

厾叏௚
ෆศἪ
௓ㆤ⪅እയ

HIV
ච␿
㧗⾑ᅽ
叹呃呂吅呎
⭈⮚
⛣᳜
ᚰ⑌ᝈ
ṑ⛉ឤᰁ
፬ே
║⛉
⢾ᒀ⑓
୍⯡
⓶⭵
⫶⭠⑌ᝈ
⢭⚄
呁否吪呁
Ἢᒀჾ
⪥㰯ဗႃ
ᑠඣ
厮台
⚄⤒࿧྾ᩚᙧ ᅄ(⫥௨እ )㐠ືჾ ᅄ(⫥ )0

Suzukamo, 2016 㻌 20⮫ᗋⓗ䛻ព࿡䛾䛒䜛ᕪ䜢᳨ฟ䛩䜛᪉ἲ
Lydick and Epstein, 1993ศᕸ䛻ᇶ䛵䛟䜰䞁䜹䞊䛻ᇶ䛵䛟᪉ἲ᪉ἲ(Anchor-Based) (Distribution-Based)& 0,'भ೾৒্১㻌 21॔থढ़‫ش‬प੦तऎ্১㻌 22॔থढ़‫ش‬भਏ੯䠄Wyrwich KW et al. Qual Life Res. 2012䠅୦ैऊभਗ৓੦૆‫॔ق‬থढ़‫كش‬प੦तःथ0,'॑ৠ৒घॊ্১॔থढ़‫ش‬भரథ‫ق‬:\UZLFK.:HWDO4XDO/LIH5HV‫ك‬¾ঽഞਾઔ௬੼੐ఏ• ૗৲भ৸৬৓௬੼‫ؚ‬௏೨૾ଙभ੝ఒभங২‫ؚ‬ਃચ௽૩भங২‫ؚ‬ऩन¾౎঻ਾઔ௬੼੐ఏ• ૗৲भ৸৬৓௬੼¾௢௴৓௬੼੐ఏઉ૎৓ऩਔ௡॑੅ण੐ఏदँॊऒध
0,'॑௓৒घॊ352੐ఏेॉुੰ๸खृ
घः੐ఏदँॊऒध0,'॑௓৒घॊ352੐ఏधેীऩঢ়৴ऋ
ँॊ‫ق‬U ‫ع‬ਰ঱॑௓တ‫ك‬• ୮૙‫ؚ‬੒৒ਗभਭ൧
㻌 23

㻌 24॔থढ़‫ش‬प੦तऎ্১ীഘप੦तऎ্১ ॔থढ़‫ش‬प੦तऌ‫ؚ‬૘ख૗৲खञ೩঻धਂ૗भ೩঻पীథ஍ટ१ॖ६‫ق‬HIIHFWVL]H‫ك‬¾ ঽഞਾઔपेॊ૗৲भ৸৬௬੼

¾&RKHQbV'¾6'

¾ ୢ௜঻पेॊ૗৲भ৸৬௬੼

• n૘खଐऎऩढञ|‫؞‬n૘खபऎऩढञ|‫ط‬n૗ॎैऩः|• nೄ২੝ఒ|‫؞‬nೄ২ப৲|‫ਂط‬૗ਫ਼ল૭ચऩਈ৵଒भ୷

 0,'भ઴ল

¾ ਴಑க॑৷ःञ্১‫؟‬ਈ৵଒भ੎ਏऩ૗৲ණभ૗৲୤भ਴಑க॑0,&धघॊ¾ 52&॑৷ःञ্১‫؟‬૗৲खञ೩঻भસ়‫ق‬૎২‫ك‬ध૗৲भऩः೩঻भસ়‫્ق‬౮২‫॑ك‬৷ःञ52&ীෲ॑ৰ઱‫؛‬ढ़ॵॺड़ইக॑0,'धघॊ‫؛‬㻌 250,' PLQLPDOLPSRUWDQWGLIIHUHQFH ध0'& PLQLPDOGHWHFWDEOHFKDQJH ‫ق‬0LQLPDO'HWHFWDEOH&KDQJH0'&‫ك‬¾6WDQGDUG(UURURI0HDQ¾೾৒ෙ୷॑தइॊेअऩਈ৵୷MDC 1.96 u 2 u SEM㻌 26

0,' PLQLPDOLPSRUWDQWGLIIHUHQFH ध0'& PLQLPDOGHWHFWDEOHFKDQJH ଁੑ৓पથਔदऩऎ‫ؚ‬੎ਏदुऩः૗৲ଁੑ৓पથਔटऋ‫ؚ‬੎ਏदऩः૗৲
ଁੑ৓पથਔ‫ؚ‬ऊण੎ਏऩ૗৲

੎ਏटऋ೾৒ෙ୷धયશदऌऩः૗৲ଁੑ৓पથਔदऩऎ‫ؚ‬੎ਏदुऩः૗৲

de Vet & Terwee. J Clin Epidemiol. 2010

㻌 27ଁੑ৓पથਔ‫ؚ‬ऊण੎ਏऩ૗৲

de Vet & Terwee. J Clin Epidemiol. 2010㻌 28n॔থढ़‫ش‬प੦तऎ্১|धnীഘप੦तऎ্১|भਹਡधಳਡᐑᓮ㈗ஂᏊඛ⏕䠄ி㒔኱Ꮫ䚿సᡂ䝇䝷䜲䝗㻌 29䜰䞁䜹䞊䛻ᇶ䛵䛟᪉ἲศᕸ䛻ᇶ䛵䛟᪉ἲ฼Ⅼ• ⮫ᗋᐙ䛻䛸䛳䛶ゎ㔘䛜ᐜ᫆• ᝈ⪅䛾ホ౯䛸⮫ᗋᐙ䛾ホ౯䜢䝖䝷䜲䜰䞁䜼䝳䝺䞊䝅䝵䞁䠄」ᩘᡭ
⥆䛝䛾ే⏝䠅䛩䜛䛣䛸䛷䚸ᨵၿ䛜ྍ⬟• ኱䛝䛺㞟ᅋ䛾௦⾲್䛸ᝈ⪅䛾䝇䝁䜰䜢ẚ㍑䛩䜛䛣䛸䛜ྍ⬟• ᐃ䛾ᶆ‽ㄗᕪ䛿䚸㞟ᅋෆ ᐃ⠊ᅖ䛻䛚䛔䛶ẚ㍑ⓗ୍ᐃḞⅬ• ⮫ᗋᐙ䛻䛸䛳䛶┤ឤⓗ䛻䜟䛛䜚䛻䛟䛔• 㐣ཤ䛾೺ᗣ≧ែ䛾ホ౯䛿䚸⌧ᅾ䛾೺ᗣ≧ែ䛛䜙ᙳ㡪䜢ཷ䛡䜛䠄䜰䞁䜹䞊䛻ᇶ䛵䛟᪉ἲ䜢⤌䜏ྜ䜟䛫䜛䛣䛸䛷ᨵၿ䛷䛝䜛䠅䛣䛸䛜᥎ 䛥䜜䚸඲యⓗ䛺ኚ໬䜢䛸䜙䛘䜙䜜䛶䛔䜛䛛䛹䛖䛛䛾ၥ • ᑠ䞉୰䞉኱䛾ᇶ‽䛿᜛ពⓗ䛷䛒䜛䛸䛾ᢈ㢟䛜䛒䜛ุ䛒䜚• ᝈ⪅㞟ᅋ䛛䜙ồ䜑䜙䜜䛯䛯MID • SEM䛻䜘䜛MID䛿䚸ᑻᗘ䛾ಙ㢗ᛶ䠄0.9௨䜢ಶே䛻㐺⏝䛩䜛䛣䛸䛿䚸 ᐃୖ䠅䛻኱䛝䛟ᙳ㡪䛥䜜䜛䛜䚸䛣䛾ᇶ‽䜢‶ㄗᕪ䛜኱䛝䛔䛯䜑䛻ၥ㢟䛜䛒䜛
䛯䛩㉁ၥ⚊䛿䜋䛸䜣䛹䛺䛔• ᝈ⪅㞟ᅋ䛛䜙ồ䜑䜙䜜䛯MID䜢ಶே䛻㐺⏝䛩䜛䛣䛸䛿䚸ಶே䛾 ᐃ䛻䛚䛡䜛ᐃㄗᕪ䛜኱䛝䛔䛯䜑䛻ၥ㢟䛜䛒䜛ᅜ㝿QOL◊✲Ꮫ఍䛂⮫ᗋ䛻䛚䛡䜛ᝈ⪅ሗ࿌䜰䜴䝖䜹䝮䠄PRO)ホ౯䛾䛯䜑䛾䝴䞊䝄䞊䜺䜲䝗䛃䠄2015䠅㻌 300,'௓৒૛ધधણ৷૛ધ
0,'॑௓৒खञ૛ધ
௓৒औोञ0,'॑ણ৷खञ૛ધ

੯
੯

' 0,'भଢ଼஢ણ৷

㻌 31

㻌 32

0,'ણ৷
୻‫كڭ‬૗৲५॥॔भੰ๸प0,'ਹ৷

0,'ણ৷
୻‫كڮ‬0,' ས஍୻भ৒ଝप0,'ਹ৷

Strand V, et al. Physical function and health related quality of life: analysis of 2-year
data from randomized, controlled studies of leflunomide, sulfasalazine, or methotrexate
㻌 33
in patients with active rheumatoid arthritis. J Rheumatol. 2005;32(4):590-601.

Keystone E, et al. Improvement in patient-reported outcomes in a rituximab trial inpatients with severe rheumatoid arthritis refractory to anti-tumor necrosis factor
㻌 34therapy. Arthritis Rheum. 2008;59(6):785-93.

0,'ણ৷୻‫شॣكگ‬५ঞএ‫ॺش‬भੰ๸प0,'ਹ৷0,'௺ଁ৓ঞঅগ‫ش‬ऊैाइञൊ਱धୖ਻‫ڭ‬ ৷ୁभ೴૔
¾nGLIIHUHQFH|धnFKDQJH|मਔ௕৓पઞःীऐैो
थःॊ૛ધधઞःীऐथःऩः૛ધऋँॊ
¾n0LQLPXPGHWHFWDEOHFKDQJH 0'& |ध
n0LQLPDOLPSRUWDQWFKDQJH|ु৊஘
¾0&,'ऊै0,'प 352दऩः੐ఏदभ0,'૛ધऋ૘ऩऎऩः
¾୻‫؟‬ী৑నষ෱௞भ0,'䝉䝑䝅䝵䞁䠎䛛䜙3䜈䛾ኚ໬䛜MID䜢㉸䛘䛶䛔䜛䛸䛾グ㏙䛒䜚䚹
Clewley D, et al. Trigger point dry needling as an adjunct treatment for a patient with㻌 35adhesive capsulitis of the shoulder. J Orthop Sports Phys Ther. 2014;44(2):92-101

 0,'॑௓৒‫؞‬ણ৷खथःॊଢ଼஢ऋ੗ः୩ୠम
ତ஄‫&؞‬23'‫؞‬জक़ঐॳ
0,'௺ଁ৓ঞঅগ‫ش‬ऊैाइञൊ਱धୖ਻‫ڮ‬ 0,'पঢ়घॊ৷ୁ ଻যधૐ੮भ0,'
¾ૐ੮द௓৒औोञ0,'॑଻যपઞ৷घॊ੠भਖ਻
¾१থউঝਯऋ૘ऩःॹ‫॑ॱش‬0,'दੰ๸खथःॊ
૛ધऋ૘ऩऎऩः ঳৖भ੐ఏमളਯभ্১पेढथ0,'॑௓৒ ँॊૐ੮भ१ঈॢঝ‫ش‬উभ0,'
¾ૐ੮भ৒ଝपेॉ৊ग352Ⴣ২दु0,'ऋ౮ऩॊ‫؟୻ق‬੎ඪණभ0,'‫ؚ‬ೄඪණभ0,'‫ك‬ ਔ௡भँॊ୷मnਈ৵|୷टऐऊ‫ء‬

㻌 36

ऽधी

¾ థ๚भ਀ਠद৒ଝऋ૘खटऐ౮ऩॊुभध‫ؚ‬পऌऎਔ௡ऋ
౮ऩॊुभऋँॊ
¾ ੗ऎभଢ଼஢दम৒ଝभॽগ॔থ५ऋ૮ଳऔोथઞॎोथः
ॊ 0,'ଢ଼஢୩ୠ

¾ ତ஄‫ؚ‬ళลஓ୩ୠद੗ऎभଢ଼஢

 0,'भ௓৒্১

¾ ॔থढ़‫ش‬प੦तऎ্১धীഘप੦तऎ্১
¾ ௓৒্১पेढथகम౮ऩॊ‫ڀ‬ളਯभ্১ध෇೧॑અൟखथ‫ؚ‬ଢ଼஢भ૖੯‫ق‬ৌ଴঻ृ੘
௜‫ؚ॔‬क़ॺढ़঒भ્ਙऩन‫॑ك‬અൟखञણ৷॑

 42/௬੼षभણ৷

¾ ૗৲୤भੰ๸‫ؚ‬ණ৑୷भੰ๸‫ؚ‬ས஍୻भ৒ଝ

㻌 37

㻌 38