SACROILIAC JOINT BIOMECH CHANICS AND ITS POTENTIAL CLINICAL IM - - PowerPoint PPT Presentation

SACROILIAC JOINT BIOMECH CLINICAL IM

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b Sergio Marcu Master of Science in Oste A.T. Still University of Health Private Practice of Osteopathic

CHANICS AND ITS POTENTIAL MPLICATIONS

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by ucci, DO, MSc teopathic Clinical Research lth Sciences, Kirksville, USA c Medicine, Luxembourg, Europe

STRUC

Chapter 1: SINGULAR Chapter 2: SACROILIAC JOINTS B

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Chapter 3: SACROILIAC JOINTS P Chapter 4: POTENTIAL CLINICAL

CTURE

BIOMECHANICS

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PAIN PATTERNS L IMPLICATIONS

Chapter 1:

Sacroiliac joint anatomical complex

Largest axial joint in the body. (Dijkstra et al, Capable of producing pain (Fortin, et al.1994,a Surrounded by ligaments and muscles a

1995; Willard, 1997).

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Capable of producing pain (Fortin, et al.1994,a Diagnosis and treatment of sacroiliac jo

• literature. (Zelle et al., 2005)

Significant extra-articular pain exists. Int underestimate the prevalence of sacroil

1: SINGULAR

l, 1989; Bernard & Cassidy, 1991). 4,a,b; Vilensky et al. 2002).

s and receives innervations L5-S4 (Grob et al,

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4,a,b; Vilensky et al. 2002).

joint (SIJ) dysfunction poorly defined in the Intra-articular diagnostic blocks iliac region pain. (Borowsky and Fagen, 2008).

EPIDEMI

SIJ pain is common cause of axial low b and 25% of people (Bernard & Kirkildy, 1987; Fort Fourth common cause of lbp and pelvic 6-13% source of lbp, pelvis or referred l

Bogduk, 1995).

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SIJ & posterior SIJ ligaments source of

Vleeming, et al., 2002).

10.000.000 in USA have osteoporosis (N Foundation,2010),34.000.000 have low fractures (Am Academy of Orthopaedic Surgeons,1993 One in 2 women,1 in 4 men older 50 ost

(Office of the Surgeon General, 2004).

MIOLOGY

back pain (lbp) affecting between 10%

rtin, et al., 1994a; Cohen, 2007).

vic pain (Paris & Viti, 2007). lower extremity pain (Schwarzer, et al., 1995a,

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f posterior pelvic pain (Fortin, et al., 1994b; s (National Osteoporosis w bone density increase the risk for

93,(revised 2009)).

steoporosis-related fracture during lifetime

EPIDEMIOLOG

SIJ bridging (Dar et al.,2006). SIJ surface area is greater in males than biomechanical loading in males (Vleeming e European guideline: PGP (pelvic girdle Myofacial hypertonicity biomechanica

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Bony pelvis widens more than 20 mm o Manual therapists (i.e. physical therapist procedures when treating SIJ dysfunctio These treatments are based on belief th SIJ (Kapandji, 1987; Sturesson, et al., 1989; Aldernik, 199 Myofacial hypertonicity biomechanica lesions observed in ankylosing spondilit

GY, Continued

an females (Ebraheim & Biyani, 2003) increased

et al.,2012).

e pain) is specific from LBP (Vleeming et al.,2008). ically link characteristics spinal & SIJ

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• ver the course of a lifetime (Berger et al. 2011).

ist, chiropractors, and osteopaths) various ction (Mooney, 1997). that a small range of movements exists in

991; Itoi, 1991; Vleeming, 1992; Oldreive, 1996; Cibulka, 2002).

ically link characteristics spinal & SIJ ilitis (AS) (Masi et al.,2007; Masi et al.,2011; Vleeming et al.,2012)

WHY IS IT THE LEAST U

Very difficult to scientifically analyze Reliable tests need to be : 3-dimensional multiple titanium spheres into the bones or rigidly fixed external devices In vivo- standing, prone, supine,

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In vivo- standing, prone, supine, hip movements

UNDERSTOOD JOINT ?

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TERMINO

SIJ dysfunction is defined by : Pain in or around the region of SIJ. Hypo- or hypermobility. (Dreyfuss, et al., 19

Cibulka,

Chapter 2: SACROILIAC

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Cibulka,

From Hippocrates (460-377 BC) till Vesa No movement in SIJ, other than during pre Gynecologists were the first, to be intere

• rthopedic physicians (Klein & Sommerfeld,2004).

OLOGY

(Dreyfuss et al.,1994) 1994; Tulberg, et al., 1998; Van der Wurff, et al., 2000a; , 2002; Riddle and Freburger, 2002).

JOINTS BIOMECHANICS

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, 2002; Riddle and Freburger, 2002).

salius (1514-1564), regnancy and birth. (Lynch,1920) rested in this joint, followed later by

Chapter 2: SACROILIAC

AGE YEARS

S

0-20 Smooth 20-50 Interlock

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>50 Hypomo >80 Osteoph

JOINTS BIOMECHANICS SIJ

th gliding planes cking irregularities

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• bility

phytic, Immobile

SACROILIAC JOI

Diarthrodial joint with two bony surfa Joint surfaces are lined with hyaline ca

thinner and more fibrocartilaginous than

Superior third of hyaline iliac cartilage

stabilizing ligaments, forming wide marg

Inferior third of the joint along iliac bo

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Inferior third of the joint along iliac bo

a “synovial joint”.

(Puhakka e

INT STRUCTURE

rfaces, sacrum and ilium 1-2 mm wide. e cartilage, and the iliac cartilage seems an that of sacrum side. ge is strongly attached to surrounding rgins of fibrocartilage. bone has some histologic characteristics of

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bone has some histologic characteristics of

et al., 2004)

ARTICULAR SURFACES AN

Hyaline cartilage on sacral side moves a

Cassidy, 1981).

Numerous ridges and depressions indica motion (Schwarzer, 1995a; Hungerford et al., 2003). SIJ articular surfaces not smooth but ha and ridges (Solonen, 1957; Vleeming, 1990; Vleeming SIJs act as important stress-relievers in

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SIJs act as important stress-relievers in trunk and lower limb (Snijders et al., 1993a, 1993

ND FUNCTIONAL ANATOMY

s against fibrocartilage on iliac side (Bowen & icating its function for stability more than have interdigitating symmetrical grooves

ng et al., 1990a, 1990b).

s in “force-motion” relationships between

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s in “force-motion” relationships between

93b; Vleeming et al., 1997; Lee, 2007).

THE LIGA

Strong passive, viscoelastic ligamentou extensive network of ligaments and fasci The primary function of this ligamentous allowing for adequate range of motion in

(Mitchell,1995)

The ligaments include:

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GAMENTS

us system (McGill, 1992). Surrounded by an scias. us system is to bolster stability while in multiple planes of movement.

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THE LIGA Articulation of pelvis, Anterior v

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GAMENTS view of sacroiliac ligament

(Gray, 1918)

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THE LIGA Interosseous ligament (Harrison et al., 1

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GAMENTS

1997)

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THE LIGA The long dorsal sacroiliac ligam

(Vleeming, A., Pool-Goudzwaard, A.L., Hammudoghlu, 1996

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GAMENTS ment

96)

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THE LIGA Articulation of pelvis. Posterior

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GAMENTS r view (Gray, 1918)

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THE LIGA Pelvis and Ligaments, Rear View

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GAMENTS ew, Female (edoctoronline.com)

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A project of 25 years presents the follo

• 1. Ligaments (Ligt) major sensory organ
• 2. Excitatory & inhibitory reflex arcs, re
• 3. Synergy of Ligt: Joint Stability.
• 4. Viscoelastic elastic properties & clas

effectiveness as joint & exposes the join

SENSORY-MOTOR CONTROL AN OF LIGAMENTS, AS MAY NEUROMUSCULAR DIS

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• 5. Long-term exposure to static or cycl
• 6. Continued exposure to static or cycl

neuromuscular disorder; cumulative tra

• 7. Knowledge: basic & applied research

infrastructure for translational research.

• 8. Knowledge: basic & applied research

lowing 8 hypothesis: ans, kinesthetic and proprioceptive data. recruit/de-recruit: Joint Stability. assical responses, decreases int to injury.

AND BIOMECHANICAL ASPECTS Y BE CONTRIBUTORY TO ISORDERS (SOLOMONOW, 2006)

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clic loads/movements. clic load: chronic inflammation & chronic trauma disorder. h on the senory-motor function of ligts as ch new therapeutics modalities.

B

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(Langevin & Sh

BROADER MODEL OF CARE

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Sherman, 2006)

MAJOR MUSCLE GROUP LUMBOSACRAL LIGAM

35 muscles attach directly to the sa Five Major muscle groups associ 1) MULTIFIDUS divided in 5 bands (Macin 2) LATISSIMUS DORSI (Willard,2007). 3) GLUTEUS MAXIMUS (Willard, 2007; Vleem 4) BICEPS FEMORIS (long Head) (Ericson, Nise 5) PIRIFORMIS (Vleeming et al.,1989a).

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5) PIRIFORMIS (Vleeming et al.,1989a).

PS ASSOCIATED WITH MENTOUS STRUCTURES

sacrum and/or innominate (Lee, 2007). ssociated with the lumbosacral structures:

cintosh,Valencia, Bogduk & Munro,1986). ming et al,1995b). isell,& Ekholm, 1986; Vleeming et al.,1989a).

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MUSCLE SLINGS OF THE

A. Posterior oblique Sling (Vleeming et al., B. Anterior oblique Sling (Snijders et al., 19

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E LUMBOPELVIC REGION

l., 1993; Vleeming, 1995b) 993b; Vleeming 1995b)

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INNERVA

Solonen (1957) SIJ innervated by Bradley (1985) supply from dorsal Ikeda (1991) supply by fifth lumba Grob et al. (1995) exclusively inne

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Willard et al. (1998) dorsal sacral Various studies demonstrated the cl and adjacent neural structures (Forti

• COMPLEXITY OF SIJ

VATIONS

y L4-S1. sal rami L5, S1, S2 and S3. bar nerve. nervated by S1-S4 dorsal rami.

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l plexus (S1-S3). e close relationships between SIJ capsule

rtin et al., 1999b; Atlihan et al., 2000).

J INNERVATIONS !!!

SACROILIAC JOINTS

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NERVES PIRIFORMIS

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SACROILIAC JOINT

SIJ designed primarily for stability Rotating and translating along thre Motion about X, Y and Z axes (Egund et al.,

Hungerford et al., 2004).

Definitions of Movement Axis and Mo

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These axes constitute a Cartesian coor account for the 3-D Sacral motion at SIJ in

• ccasional alterations of X and Z axes (Egu

Smidt et al., 1995; Sturesson et al., 1999; Sturesson et al.,

NT BIOMECHANICS

y (Dreyfuss, 2004). ree axes (Smidt et al., 1995).

l., 1978; Sturesson et al., 2000a, 2000b; Bussey et al., 2004;

• bility

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• rdinate system & used by investigators to

J in reference to a fixed pelvis with

gund et al., 1978; Miller et al., 1987; Sturesson et al.,1989; l., 2000a, 2000b; Bussey et al., 2004; Hungerford et al., 2004

SACROILIAC JOINT

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Three axes for angular and tran relative to the sacral segment (H

NT BIOMECHANICS

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anslational motion of innominate

(Hungerford et al., 2004)

SACROILIAC JOINT

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(Wang & Dumas, 199

NT BIOMECHANICS

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998)

SACROILIAC JOINT

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Centers of rotation from S models (Klein & Sommerfeld, 2004)

NT BIOMECHANICS

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SIJ in the conventional

4)

SACROILIAC JOINT

Recent M

Colachis et al. (1963) inserted Kirchne Egund et al. (1978) used RSA: max. ro nutation: iliac tuberosities. Lavignolle et al. (1983) tridimensional

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Miller et al. (1987) studied load-displac SIJ; one leg immobile: movements in al those measured with both legs fixed. Sturesson et al. (1989,2000a, 2000b) R and asymptomatic joints.

NT BIOMECHANICS

t Models

er wires PSIS:5mm of translation.

• rot. & translations 2.0° & 2 mm. Axis of

l oblique axis.

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acement behavior of single and paired all planes ranged 2 to 7.8 times more than RSA, no difference between symptomatic

SACROILIAC JOINT

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(Lavignolle et al., 198

NT BIOMECHANICS

Orthopedics & Rheumatology San Francisco 2014

983)

SACROILIAC JOINT

Jacob and Kissling (1995) Kirchner wire investigate mobility of SIJ. They measur three rotation components. Smidt et al. (1995) SIJ & Pelvic in neutra always fit the expected movement in fun Bussey et al.(2004) RSA to investigate S

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Bussey et al.(2004) RSA to investigate S flexion.

NT BIOMECHANICS

ires into iliac bones & sacrum, used RSA to sured motion amplitude a helical axis with tral and straddle position. iliac position not unction of the hip joint position. e SIJ motion in prone position with knees in

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e SIJ motion in prone position with knees in

SACROILIAC JOINT

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Localization and orientation of h

NT BIOMECHANICS

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helical (Jacob & Kissling,1995)

SACROILIAC JOINT

Summary of Recent SIJ B

Range of motion 2 to 4 degrees. No significant differences women & men Tulberg et al. (1998) RSA, no difference All studies detected Helical oblique axi

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All studies detected Helical oblique axi dimensional movement in SIJ. Major movement component Sagittal No common axis exists for both joints. (K

NT BIOMECHANICS

Biomechanics Findings

en. ce before and after manipulation. xis indicating the existence of a three

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xis indicating the existence of a three al plane. (Klein & Sommerfeld,2004)

(Klein & Sommerfeld,2004)

SACROILIAC JOINT

Limited Moveme

Multifidus muscle (MacIntosh & Bogduk, 1991): sacrum) Transfer load through pelvis depends Optimal function of bones, joints an Optimal function of muscles and fa

Snijders et al., 1998; Vleeming et al., 1995a, 1995b);

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Appropriate neural function (Hodges &

NT BIOMECHANICS

ents of the SIJ

: limiting nutation (anterior flexion of ds (Hungerford, 2004): and ligaments (Vleeming et al, 1989b, 1990); fascia (Hungerford et al., 2003; Richardson et al., 2002;

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s & Richardson, 1997; Hungerford et al., 2003).

Chapter 3: SACROILIA

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IAC JOINTS PAIN PATTERNS

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A B

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(Kuchera,2007, Journal of American Osteopathic Association, ES

Myotomal pain referral regions from muscle (A) quadratus lumborom. (B) piriformis. (C) iliopsoas. (D) rotatores and multifidis muscles.

C D

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S31, Suppl6, 107, 11)

scle trigger points:

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(Kuchera,2007, Journal of American Osteopathic Association, ES

A B

Sclerotomal pain referral regions from ligam (A) iliolumbar ligament, (B) sacrospinous and sacrotuberous ligame (C) posterior sacroiliac ligament. according to my exp

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S31, Suppl6,107,11)

C

ments: ents. xperience

VARIATION IN THE LUM

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(Briggs & Chandraraj,C

UMBOSACRAL LIGAMENT

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j,Clin Ana.,1995)

Chapter 4: POTENTIAL C

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CLINICAL IMPLICATIONS

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Chapter 4: POTENTIAL C

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(Varga

CLINICAL IMPLICATIONS

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a et al.,Injury,2008)

Differential diagnosis in SIJ pain: pain g can present as low back pain, leg pain, pain.(Norman, 1968). New aspects for SIJ pain treatment have biomechanics of SIJ. Clinical manual movement tests unreliab Recent research reveals that the pelvis maturation and cessation of longitudinal

POTENTIAL CLINIC

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maturation and cessation of longitudinal response to compensate for loss of stre

(Berger et al. 2011).

Altered motor function of the deep abdo leads to insufficient bracing of the pelvis Chronic spinal overloading:(Masi et al., 2007;

• SIJ micro-damage & repair p
• Synovitis, erosions & later st

IMPORTANCE OF PRACTICING A generated in SIJ or surrounding structures , sacral pain, pelvic pain, or gluteal ve to be taken in consideration as well as iable for SIJ (Vleeming et al., 2008) vis does not stop expanding after skeletal al growth, this is thought to be adaptive

ICAL IMPLICATIONS

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al growth, this is thought to be adaptive rength produced by endocortical bone loss

• minal muscles in patients with PGP

vis (Vleeming et al.,2012).

7; Francois et al., 2000; Masi et al., 2011; Vleeming et al., 2012)

r pathways stages enchondral ankylosing A SPORT ACTIVITY!!!!

POTENTIAL CLINIC

According to McGrath (2010): First, where is the pain generator in the Second, do SIJ pain provocation tests a Third, do physical tests stress the joint

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Third, do physical tests stress the joint generators ? Fourth, are all pain generators in the re Fifth, is intra-articular injection an effect putative SIJ pain ?

ICAL IMPLICATIONS

e absence of discernible pathology ? s achieve what they purport to achieve ? t to the exclusion of all other potential

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t to the exclusion of all other potential region identified ? ctive ‘gold standard’ for the elimination of

QUESTIO

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IONS

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Thank you for

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r your attention

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