Download Schlattman - T Spine 2013 II IPTA

Brian Schlattmann, PT, DPT, OCS, CSMT, CSCS
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The “New” Model
Stabilization
Directional
Preference
Manipulation
Traction
Red Flags
Yellow Flags
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Prevalence of C-spine disorders
Neck pain in Hong Kong: a telephone survey on prevalence, consequences,
and risk groups.
The lifetime prevalence of neck pain was 65.4%
The 12-month prevalence was 53.6%
About 15.0% of these patients had moderate to severe pain.
65.4%
The Saskatchewan Health and Back Pain Survey. The prevalence of neck pain
and related disability in Saskatchewan adults.
In Europe, the lifetime and point prevalence of neck pain is almost as high as
the prevalence of low back pain.
The age-standardized lifetime prevalence of neck pain is 66.7%
The age-standardized 6-month prevalence of low-intensity and low-disability
neck pain is 39.7% (95% confidence interval, 36.7-42.7), whereas it is 10.1%
(95% confidence interval, 8.2-11.9) for high-intensity and low-disability neck
pain and 4.6% (95% confidence interval, 3.3-5.8) for significantly disabling
neck pain.
66.7%
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C-Spine: At least a start…
Neck Pain
Idiopathic
Whiplash
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What about the Jurassic Spine?
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Incidence of Thoracic Pain
• 1-year prevalence for thoracic spine pain
= 27% (Briggs et al, 2009)
• Lifetime prevalence for thoracic spine
pain = 31% (Briggs et al, 2009)
Evidence Based Medicine
• “The conscientious,
explicit and judicious
use of current best
evidence in making
decisions about the
care of the individual
patients.” – Sackett
(1996)
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Evidence Based Medicine
Quantitative
Research
Qualitative
Research
Randomized
Controlled Trials
Human
Experience
Procedure/
Education/
Intervention
Interaction
Stolen from Mark Jones, IFOMT, 2004
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What do patients want?
•
•
•
•
•
What is wrong with me?
How long will it take?
What can I (the patient) do?
What can you (the PT) do?
How much will it cost?
Bud Light 2013
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Clinical reasoning is the application of relevant
knowledge (information, procedures,
concepts) and clinical skills to patient
management on an individual level.
- Mark Jones, 1992
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Permeable Brick wall
Anatomy
Physiology
Biomechanics
Pain Science
Psychology
From: Maitland 1992
History
Signs
Symptoms
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The Role of the
Physician
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Collecting data: Questioning and Examining the Patient
Maitland GD. Vertebral
Manipulation. 6th ed.
London: Butterworths;
1986.
Interpret the Data
Reach a Decision based on the
Interpretation
Treatment
Assess the treatment and it’s effect
Precautions
Boissonnault WG, ed Examination in Physical Therapy
Diagnosis. 2nd ed. New York: Churchill Livingstone; 1995.
Clinical
Anatomy
of the
Thoracic
Spine
Thoracic Spine
• Challenging to treat,
most neglected
• Disorders thought to
be less common
• Less than 15% of all
spinal disorders
Thoracic Spine
• Transitional zone between C and L spines
• Second least mobile of the spinal regions
(pelvic girdle)
• Ribcage and low ratio of IVD height to vertebral
body height (1:5) said to account for  mobility
(DiGiovanna and Schiowitz, 1991)
Osteology
T6 Vertebra
• AP and transverse
dimensions almost equal
• Height of body is slightly higher posteriorly –
contributes to normal kyphosis
• Each body has paired costal demi-facets
posterolaterally (↑↓) except T10, 11 & 12
Osteology
• Pedicles protrude directly
posterior
• Not divergent as in
C spine, because spinal cord
smaller
(Williams et al, 1989)
Osteology
• Laminae are higher
than wide and
overlap ‘like tiles on a
roof’
• Limits extension
Osteology
T12 Vertebra
• Superior facet slightly convex and posteriorly oriented
60º from horizontal plane and 20º from frontal plane
• Inferior facet slightly concave and face anteriorly,
slightly inferiorly and medially to match superior facets
of vertebra below
Osteology
• Transverse processes
project laterally and
slightly posteriorly
• Spread laterally
diminishes from T1 to
T12 – where they
resemble those of L1
Osteology
• Spinous processes project
posteriorly and inferiorly to
varying degrees
(“rules of threes”)
Rule of ‘threes’
Vertebra
Spinous Process Level*
T1 – T3
Same level
T4 – T6
Half a level below
T7 – T9
One whole level below
T10
One whole level below
T11
Half a level below
T12
Same level
Sternum
Ribs
Ribs
Lateral costotransverse ligament
Ribs
• True/False Ribs
– 1-7 True ribs, i.e. attach directly to the sternum
– 8-12 False ribs, no direct sternal attachment
• 11-12 are ‘floating ribs”
• Typical/Atypical Ribs
– 3-9 are Typical
• Head attaches costovertebral demifacets on the body
• Two Articular facets, one above and one below
• Crest on head of rib that attaches to the disc
Typical/Atypical Cont’d
• Typical Cont’d
– Distal to head and neck is a tubercle with articular and
non-articular portions
• Articular portion is more medial, attaches to for the
costotransverse joint
• Non-articular portion is more lateral, costotranverse ligament
attachment
– Rib angle
Typical/Atypical Cont’d
• Atypical
– 1st rib
• Most curved of all ribs
• No angle
• Only one joint surface for costovertebral facet at T1
– 2nd rib
• Atypical due to attachment at junction of munibrium and body of
sternum
– 10th rib
• Single costal facet attachment to T10
– 11th and 12th ribs
• No direct sternal attachment
Arthrology
Ratio disc: body height
is 1:5 compared to
2:5 in C spine and
1:3 in L spine
Some report annulus is
stronger and this helps
T Spine resist rotational stress
Thoracic Disc
• Wood et al (1993) conducted T Spine MRI
evaluations on 90 asymptomatic subjects
• 68% had abnormalities
• 24% had frank disc herniation
FRANK
• 42% had bulging discs
• 46% had annular tears
Facet Joint Structure
Costovertebral Joint Structure
Costotransverse
Joint Structure
• Upper joints are convex/
concave
• Lower joints are planar
• Said to account for ‘spin’
(rotation) of ribs within
upper T spine, and ‘slide’
(elevation/ depression) of
ribs within lower T spine
Costochondral
Junction
• Costal cartilage fits into
depression in distal end of
each rib
• Secured by enveloping
periosteum which is
continuous with
perichondrium
Costochondral Junction
• Can be site of primary
sprains or irritations
(costochondritis)
or secondary pain
caused by rib cage
dysfunction
Ligaments of the T Spine
• “Continuous
ligamentous
stocking” in
which the
vertebrae and
ribs are
positioned
(Willard, 1997)
Neural Arch Ligaments
•
•
•
•
Ligamentum flavum
Interspinous ligament
Supraspinous ligament
Intertransverse ligament
Grade together at their
boundaries to unite and
function as a single unit
Capsular Ligaments
• Represents a bridge
between neural arch
ligaments and those
of the vertebral body
• Capsule reinforced
dorsally by multifidus
and ventrally by
ligamentum flavum
Ventral (Vertebral Body) Ligaments
• ALL
• PLL
Myology
• In the patient with T spine pain we should consider
the large muscles of the spine and shoulder girdle
as possible sources
• We often resort to palpation for muscle spasm and
check for imbalances
• Don’t forget the many small muscles intimately
associated with landmarks such as the rib angles,
transverse processes and costovertebral joints
Myology
Deep
↓
Superficial
Myology
Intertransversarii
Levatores
costarum
Myology
Rotatores
Thoracis
Myology
Myology
Myology
Myology
Biomechanics
of the Thoracic
Spine
The biomechanics of the Thorax is complex.
We will slow it down for you…
Biomechanics
•
•
•
Studies have concentrated on specimens without
an intact rib cage
Andriacchi et al (1974) studied effect of rib cage on
T spine and found that the rib cage (with sternum)
increased stiffness 2.64 times in E and 2.14 in F
(No sternum = no ribs)
Load bearing capacity of T spine was up to 3 to 4
times greater with addition of rib cage
Biomechanics
•
•
R-handed orthogonal
(90º angle) coordinate
system
Motion in 3 translations
and 3 rotations about
the X, Y and Z axes
Flexion
Flexion
Rib Kinematics
Forward motion through
superior demifacet of
costovertebral joint.
Facilitates anterior rotation
of rib.
Superior glide of
costotransverse joint.
Extension
Extension
Rib Kinematics
Backward motion through
superior demifacet of
costovertebral joint.
Facilitates posterior
rotation of rib.
Inferior glide of
costotransverse joint.
Lateral Flexion
Lateral Flexion
Lateral Flexion
• Ribs on ipsilateral side approximate before joint motion is
completed
• As transverse process ipsilateral to the side bending attempts
further motion in an inferior direction, the rib facet is forced
superiorly
• Creates an anterior rotation moment at the rib and forces superior
vertebrae forward at the costovertebral joint
• The ribs distract on contralateral side
• Reach their passive restraints, are forced inferiorly at
costotranverse joint as transverse process continues superior
• Posterior rotation moment created and posterior rotating rib head
forces the superior vertebrae back at the costovertebral joint
Lateral Flexion
Rotation
Coupling of rotation
with contralateral
translation (X) and
ipsilateral lateral
flexion (Z) – clinical
findings
Rotation
• Thus in R rotation the L translation of the vertebrae
above pulls the R rib with it and push the L away
• This causes costovertebral and costotransverse
ligaments to become taught anterior on the R and
posterior on the L
• The segment is therefore forced into same side
lateral bending
Rotation
Clinical Considerations
3 distinct regions
1. Upper T Spine (T1 – T2) –
functions as part of lower C Spine
2. Lower T Spine (T10 – T12) –
functions as part of upper L Spine
3. Functional T Spine (T3 – T9) –
‘true’ T Spine
Need some coffee?
Biomechanics
•
Dividing the T Spine into functional regions
consistent with patterns of clinical presentation of
mechanical disorders.
2 common patterns of clinical presentation:
1. Pain from loading – load attenuation
2. Symptoms related to movement/ motion restrictions
Loading/ Load Attenuation
• Compressive loads on T spine
increase caudally from 9% body
weight at T1 to 47% body weight at
T12 (White, 1989)
T6 Vertebra
• Design to handle increasing load
demand by progressive increase in:
– Vertebral body height
– End plate cross sectional area
– Bone content (esp. last 6 segments)
T12 Vertebra
Load/ Load Attenuation
• Upper T spine – 76% compressive load transferred
through vertebral body/ disc complex.
• Lower T spine – greater load transferred through
posterior column via interlocking lamina and facet
joints.
(Pal and Routal, 1987)
Load/ Load Attenuation
IVD
• Thinner than C spine and L spine discs
• Some reports that annulus fibrosis is stronger –
greater ability to resist rotational stress
• Evidence that disc lesions more evident
– MRI studies – 73% of asymptomatic population had
some form of disc lesion
Load/ Load Attenuation
• Upper and mid-thoracic discs undergo greater
deformation and creep
• More viscous mechanical behavior not because of
water content
• Due to morphology, biochemistry and structural
arrangement of annular lamellae
Load/ Load Attenuation
• In L Spine – compressive loading evenly
distributed across surface of end plate
independent of position of motion segment
• In T Spine – load distribution across the end
plate becomes asymmetric when loaded outside
the neutral position
– May explain common clinical finding of mid-thoracic
pain associated with sustained loading postures, e.g.
computers, driving
Movement/ Motion Restrictions
• Upper T spine mobility contributes to normal C
spine function and to functional movements of
the thorax.
• Restricted mobility in upper T spine can affect C
spine motion, as well as overall motion of thorax.
Clinical Considerations of Motion
Restriction
• Normal mechanics/ motion of C spine and shoulder
dependent upon normal mobility of upper T spine
• Habitually flexed upper T spine may reduce
capacity of muscles to provide cervicothoracic
retraction to work in the functional range
Clinical Considerations of Motion
Restriction
Clinical Considerations of Motion
Restriction
• Palpation for intersegmental accessory joint motion –
mainstay of Maitland Approach
• Changes in through-range resistance to movement
(stiffness) with PA can help identify symptomatic
segment
• Pain response to PA shown to be more reliable in
detecting symptomatic segments than stiffness alone –
don’t underestimate palpation skills
• Edmondston et al (1999)
found that PA stiffness of T
spine segments ↑ from
9.1 N/mm at T4 to
11.4 N/mm at T10
• Departure from this
segmental increase in PA
stiffness could indicate
abnormal motion segment
function if assoc w/ relevant
symptom response
PA to the T Spine
• When applying a PA to the T spine, care should be
taken with orientation of applied force
• PA to spinous process induces anterior translation
and posterior rotation (extension) of the related
vertebral segment
PA to the T Spine
• Lee (1989) – movement force (PA) of 200 N
applied perpendicular to spinal curvature causes
anterior translation of equivalent force at vertebral
segment but it is also accompanied by extension
moment of up to 5.5 Nm
• In contrast, equivalent force directed towards
vertebral body eliminates extension moment but
induces a longitudinal force of up to half the
applied load
PA to the T Spine
Applied anteriorly
PA to the T Spine
Applied to spinal curvature
PA to the T Spine
Applied towards center of vertebral body
Dinner last night…
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Thoracic Spine Pathology
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Thoracic Injury
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Injury to T Spine classified as:
•
•
•
•
•
Gradual arthritic disorders
Postural
Acute, traumatic
Referral from C spine
Visceral in origin
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Pathology
• Greatest % of pts presenting w/ T Spine symptoms
will have been involved in a trivial accident – fall,
bump or accident
• T Spine well supported with ribcage but it doesn’t
need strong force applied to strain ZPJ or
costochondral joint
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Pathology
• Musculoskeletal disorders common with pain
referral in/ around chest wall
• Differential diagnosis of visceral disorders
essential
• Study – 25% of ‘cardiac’ pts in ER had
T Spine disorder (other studies 11 – 16%)
• Confusion when breathing, coughing or posture
alteration aggravates pain
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T Disc Lesions
• Much more common that previously thought but
still less than in L Spine
• Attachment of ribs to annulus fibers may be one
reason for higher incidence
- blow to rib may affect/ disrupt the IVD
• Other reasons:
- higher viscosity of IVD in T Spine
- asymmetrical loading associated with
segmental motion
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T Disc Lesions
• Most affected – lower T Spine; most often – T/L
junction
• Disc lesions common on convex side of a
scoliosis or kyphosis
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T-Spine Disc Lesions
• Lower T
Spine refers
to abdomen
and iliac
crests
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Thoracic Nerve Root Lesions
• Nerve root pain either mechanical
compression or chemical irritation
• May occur due to disc lesions, facet
injuries/swelling, osteophytes,
scarring, etc.
• In true nerve root pain, distal pain
(anterior, next to sternum) will be
greater than proximal pain (back)
• Neurological symptoms (numbness,
P & N) may be present if
compression only
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Thoracic Nerve Root Lesions
• Costochondritis may closely simulate
T-nerve root symptoms b/c pain located
anteriorly at sternum
• Upper T spine will refer symptoms into upper
extremities
• Spinal dura can produce vague symptoms up
and down the spine – least mobile at T6 and is
common source of pain in pts w/ +
neurodynamic signs
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Facet Joint Dysfunction
• Commonly injured – seat
belts in MVA
• Usually produce localized
sharp pain unilaterally
• In chronic stage – pain
may be dull, aching
• Pain more likely to be
aggravated by
compressing/ closing
down facet joint
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Facet Joint Dysfunction
• Pain may be referred into nerve root distribution but no
neuro symptoms
• Referred pain will be more intense proximally (back) vs.
distally (sternum)
• Acutely swollen/ damaged joints – pain with coughing,
sneezing or deep breathing
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Ligamentous Injuries
• Pain in T Spine can be from highly ligamentous
reinforced joints
• Any force applied to ribcage can affect ligaments
which not only stabilize joints but play important
role in proprioception
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Ligamentous Injuries
• Pain from ligamentous structures commonly
described as vague, ill defined, spread around
the area, not producing symptoms distally nor
producing neuro symptoms
• Both ALL and PLL innervated by SVN and will
cause pain that spreads up and down spinal
canal
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Rib Cage Injuries
• Rib injuries common
• Force applied to ribcage
dissipated by ribs
• Rib fractures may be present
in severe traumatic injuries –
usually very painful
• Breathing may increase pain
• Area very tender to palpation
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Rib Cage Injuries
• In acute injuries – hematoma
may be present – tap test with
reflex hammer or vibration with
tuning fork will produce pain
• Old, chronic, slow healing rib
fractures may become a chronic
source of discomfort
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Muscle Injuries
• True muscle injuries of the spine are very uncommon, yet often the
focus of physical therapy intervention.
• The musculoskeletal system does, however, get affected through
joint injuries and postural changes.
• Muscle spasms and especially trigger points are very common in the
upper thoracic spine, especially the muscles surrounding the
scapula.
• In assessing trigger points be sure to assess the posterior primary
rami from the nervous system - a possible source/ mechanism for
maintained pain/ tender spots in TP areas.
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Trigger Points
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Thoracic Outlet Syndrome
Subclavian artery vs. Brachial
plexus
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TOS
• Vascular: Rare
– 1.5% of TOS patients
– Hard to treat conservatively
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TOS: Neurogenic
• 98.5% of TOS patients
• Responds to conservative care
• True neurogenic TOS: axonal compression
–
–
–
–
–
hand weakness
muscle wasting
cervical rib
positive EMG for axon loss
special tests: Adson’s test (Plewa and Delinger 1998)
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TOS
Common clinical presentation of all TOS patients
• Numbness/tingling in the ring and small fingers but can encompass
the entire hand
• Paresthesias occur at night and/or during daily activities
• Vague pain in the involved extremity
• (Can occur in the hand, elbow, shoulder and/or cervical spine)
• Subjective complaints of hand/arm weakness especially with arm
raised overhead
• Subjective complaints of swelling in the arm in the absence of true
swelling
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T4 Syndrome
• Well described in clinical field by Maitland
• Precise etiology is unknown
• May be an autonomic syndrome or mechanical
problem involving ZPJs
• Sometimes referred to as “glove-syndrome”
because of dull aching symptoms covering
whole hand (non dermatome) and +/- neuro
symptoms (P & N)
• Symptoms usually unilateral
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T4 Syndrome
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Thoracic Hypomobility
• Very common
• Sudden onset of
symptoms
• Can be severe at times
• Often aggravated by
movements – breathing,
coughing and sneezing
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Thoracic Hypomobility
• Localized posteriorly slightly off midline towards one
side (suggesting CT joint)
• One side – radiates slightly a few inches
• Chest wall pain common
• Costochondral region
• Low back pain – T/L junction
• Great response to mobs + manips
• Marked relief in few sessions
• Need exercises for prevention
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MRI
Thoracic
Fractures
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Vertebroplasty vs. Kyphoplasty
PMMA
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Kyphoplasty
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Vertebroplasty vs. Kyphoplasty
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Kyphoplasty and PT
• Thirty-eight patients (10 men and 28 women) were treated for 47
levels initially.
• L1 and L2 were the most common level of fracture.
• Over the follow-up period (average, 8 months), 10 patients
sustained 17 subsequent fractures.
• Eight patients sustained fractures in the first 2 months after the
index procedure, all with at least one fracture at an adjacent level.
• Of the 17 subsequent fractures, there were nine at the adjacentabove levels, four at adjacent-below levels, and four at remote
levels.
Incidence of Subsequent Vertebral Fracture after
Kyphoplasty. Spine. 29(20):2270- 2276, October 15, 2004.
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Kyphoplasty & PT
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Referral from the C-spine
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C-Facet Joints
•
•
•
•
Synovial
Ceiling tile setting
Vascularized
++ Nerve supply
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C-Facet
- Car accident
- Fracture of superior articular process
- Missed on x-ray
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C-Facet: Crush injury MVA
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C-Facet Ligamentum flavum bruise: MVA
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C-Facet Pain referrals
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There is growing evidence that trigger points (TP’s) are in fact an epi-phenomenon,
and rather than being the originator of the pain, they are more a consequence of the
damaged tissue. (Cohen 1996, Wall 1993)
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