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Copyright 2009Wolters Kluwer Health | Lippincott Williams & Wilkins
Lumbar Spinal Conditions
Chapter 11
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AnatomyAnatomy
lumbar spine
forms convex curve anteriorly
5 lumbar, 5 fused sacral,& 4 small, fusedcoccygeal vertebrae
sacrum articulates with ilium - sacroiliac joint.
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Anatomy (Contd)Anatomy (Contd)
F11.1
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Anatomy (Contd)Anatomy (Contd)
ligaments responsible forarticulation with sacrum
iliolumbar ligaments
posterior sacroiliacligaments,
sacrospinous ligamen7
sacrotuberous ligament
F11.2
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Anatomy (Contd)Anatomy (Contd)
muscles of trunk
paired unilaterally: produce lateral flexion and/or rotation of the
trunk
bilaterally: trunk flexion or extension
primarymovers back extension - erector spinae muscles
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Anatomy (Contd)Anatomy (Contd)
F11.3
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Anatomy (Contd)Anatomy (Contd)
F11.4
nerve plexus
lumbar (T12 L5)
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Anatomy (Contd)Anatomy (Contd)
F11.5
nerve plexus
sacral (portion oflumbar (L4-L5)
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KinematicsKinematics
movements involve a number ofmotion segments
flexion/extension/ hyperextension
lateral flexion
rotation
spinal flexion vs. hip flexion vs. forward pelvic tilt
hyperextension
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KinematicsKinematics
movements involve a number ofmotion segments
flexion/extension/ hyperextension
lateral flexion
rotation
spinal flexion vs. hip flexion vs. forward pelvic tilt
hyperextension
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KineticsKinetics
effects ofbody position
line ofgravity passes anterior to spinal column
trunk flexion
o moment arm for body weight;o bendingmoment
counteract moment via tension in back muscles
o tension in back o compression lumbar spine
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Anatomic Variations: Injury PotentialAnatomic Variations: Injury Potential
lordosis
abnormal exaggeration oflumbar curve
causes include
congenital deformities
weak abdominalmusculature
poor posture
activities with excessivehyperextension
F11.7
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Anatomic Variations: Injury PotentialAnatomic Variations: Injury Potential
swayback
increased lordotic curve and kyphosis
causes include
muscle weakness; compensatorymuscle tightness
entire pelvis shifts anteriorly, causing the hips to move intoextension
impact on COG
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Anatomic Variations: Injury Potential (Contd)Anatomic Variations: Injury Potential (Contd)
flat back
decrease in lumbar lordosis (20deg) potential causes
clinical sign - tendency to lean forward when walkingor standing
impact on COG
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Anatomic Variations: Injury Potential (Contd)Anatomic Variations: Injury Potential (Contd)
pars interarticularis
area between superior and inferior facets
weakest part of the vertebrae
spondylolysisfracture
congenital or mechanical stress
repeated weight-loading in flexion,hyperextension, & rotation
occur early age (age 8);asymptomatic until ages 1015
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Anatomic Variations: Injury Potential (Contd)Anatomic Variations: Injury Potential (Contd)
spondylolisthesisbilateral separation
anterior displacement of a vertbra common sitelumbosacral joint
ages 1015
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Anatomic Variations: Injury Potential (Contd)Anatomic Variations: Injury Potential (Contd)
Spondylolysis
stress fracture of the pars interarticularis.
Spondylolisthesis
a bilateral fracture of pars interarticularisaccompanied by anterior slippage of involvedvertebra.
F11.8
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Anatomic Variations: Injury Potential (Contd)Anatomic Variations: Injury Potential (Contd)
Spondylolisthesis
MRI demonstrates anterior shift of L5
F11.9
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Anatomic Variations: Injury Potential (Contd)Anatomic Variations: Injury Potential (Contd)
spondylitic conditionsmechanical stress
do not typically heal with time
S&S
low back pain
associated neurologic symptoms
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Anatomic Variations: Injury Potential (Contd)Anatomic Variations: Injury Potential (Contd)
particularly susceptible
female gymnasts, interior footballlinemen,weight lifters, volleyball players, pole vaulters,wrestlers, and rowers
slippage severity
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Prevention of Spinal InjuriesPrevention of Spinal Injuries
protective equipment
rib protectors
weight-trainingbelts/abdominalbinders
physical conditioning
strength & flexibility
proper technique
proper lifting
posture
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Lumbar Spine InjuriesLumbar Spine Injuries
contusions, strains, and sprains
est. 80% of population has LBP at sometime
nearly 97% stems frommechanical inj. tomuscles, ligaments, or connective tissue
chronic LBP: associated w/LBP, reducedspinal flexibility, repeated stress, andactivities that require maximal extension ofthe lumbar spine
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
LBP
pain & discomfort can range (local or diffuse)
no radiating pain
no signs of neural involvement
management: standard acute; stretching
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
LBP in runners
associated w/ tightness in hip flexors &
hamstrings S&S
localized pain, w/ active & resisted backextension
no radiating pain
no signs of neural involvement
possible anterior pelvic tilt & hyperlordosis
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
management
ice, NSAIDs, muscle relaxants, TENS, and EMS avoiding excessive flexion activities & a
sedentary posture
decrease incidenceuse progressive trainingtechniques
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
myofascial pain
referred pain that emanates from a myofascial
trigger point
common trigger point sites: piriformis muscleand quadratus lumborum
S&S- piriformis
referred pain in sacroiliac area, posterior hip,and upper 2/3s of posterior thigh
Aching and deep pain increases with activityor with prolonged sitting with the hipadducted, flexed, and internally rotated
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
myofascial pain (contd)
S&S quadratus lumborum
false sign of disk syndrome
superficial fibers- sharp, aching pain inlow back,iliac crest, greater trochanter can extend toabdominal region
deep fibers- sacroiliac joint or lower buttockregion; pain increases duringlateralbendingtoward the involved side, while standing for longperiods of time, and during coughing or sneezing
management: involves stretching the involvedmuscle back
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
facet joint pathology
may involve:
subluxation or dislocation of the facet
facet joint syndrome
degeneration of the facet itself
exact pathophysiology is unclear toward involved side, & w/ torsionalload
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
S&S
nonspecific low back, hip, &buttock paindeep & achy
pain may radiate to post. thigh, but not below knee
pain aggravated by rest & hyperextension; relieved byrepeated motion
flattening oflumbar lordosis
point tendernessunilateral or bilateral paravertebralarea
opain w/ trunk rotation, stretching into full extension,lateralbending
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
facet joint pathology (contd)
possible clinical findings
abnormal pelvic tilt & hip rotation secondary totight hamstrings, hip rotators, & quadratus
MMT normal; but subtle weakness in erectorspinae & hamstrings may contribute to pelvic tilt
abnormalities
+ straight leg raising test
definitive diagnosis
management: standard acute; education
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
sciatica
classification levels sciatica only
no sensory or muscle weakness
modify activity appropriately, and develop
rehabilitation and prevention program
any increased pain requires immediatereevaluation
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
sciatica with soft signs
some sensory changes mild or no reflex change
normalmuscle strength
normalbowel and bladder function
remove from sport participation for 612 wks.
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
sciatica with hard signs
sensory and reflex changes
muscle weakness due to repeated, chronic, or acutecondition
normalbowel and bladder function
remove from participation 12 to 24 weeks.
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
sciatica with severe signs
sensory and reflex changes
muscle weakness
altered bladder function
consider immediate surgical decompression.
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd) potential causes:
herniated disc radiatingleg pain > back pain
pain sitting &leaning forward, coughing,sneezing, & straining
neurologic deficits are usually present + ipsilateral straight leg raising test
annular tears back pain > leg pain pain sitting &leaning forward, coughing,
sneezing, & straining may have muscle spasm and loss oflordosis + ipsilateral straight leg raising test
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
spinal stenosis
back and leg pain develop after walking alimited distance, and increase as distanceincreases
leg weakness or numbness is present, with orwithout sciatica
negative straight leg raising test
positive pain on prolonged spine extension,relieved with spine flexion
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
facet joint arthropathy
pain over joint on spinal extension, exacerbated
with ipsilateral trunk lateral flexion
compression from piriformis
symptoms mimic lumbar disc conditions, exceptfor the absence of true neurologic findings
pain increases with medial rotation of the thigh
management: physician referral
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
lumbar disc conditions
protruded disc (A)
eccentric accumulation of nucleus w/ slight deformity ofannulus
prolapsed disc (B)
eccentric nucleus produces a definite deformity as it
works its way through fibers of annulus fibrosus.
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
extruded disc (C)
nuclear materialbulges into spinal canal and runs riskof impinging adjacent nerve roots
sequestrated disc (D)
nuclear material from intervertebral disc is separatedfrom disc itself and potentiallymigrates
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
F11.10
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
S&S
sharp pain & spasm at site of herniation; painshoots down extremity
walk in slightly crouched position, leaning awayfrom side oflesion
compression on spinal nerve
sensory &motor deficits alteration in tendon reflex
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
F11.11
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)SIGNSAND SYMPTOMS
L3L4(L4 root)
L4L5(L5 root)
L5S1(S1 root)
pain lumbar region and buttocks lumbar region, groin, andsacroiliac area
lumbar region, groin, andsacroiliac area
dermatome and sensory
loss
anterior midthigh over
patella, medial lower leg togreat toe
lateral thigh, anterior leg, top
of foot, middle three toes
posterior lateral thigh &lower
leg to lateral foot and 5th toe
myotome weakness ankle dorsiflexion toe extension (extensor hallux)
ankle plantar flexion(gastrocnemius)
reduced DTR quadriceps medial hamstrings Achilles tendon
straight leg raisingtest normal reduced reduced
management
significant signs: immediate physician referral
standard acute; activitymodification
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd) lumbar fractures and dislocations
transverse or spinous process fracture
due to extreme tension from attached muscles
direct blow
additional injury to surrounding soft tissues
compression fracture hyperflexion crushes anterior aspect of vertebral
body
primary dangerpossibility ofbony fragmentsmoving into spinal canal, damaging cord or spinalnerves
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Lumbar Spine Injuries (Contd)Lumbar Spine Injuries (Contd)
spinal cord endsL1 or L2 level
fx below not a serious threat, but handle w/ care to
minimize potential damage to cauda equina
management
fracture or dislocation: activate EMS
conservative treatment: initialbed rest, cryotherapy,
and minimizing mechanicalloads
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Sacrum and Coccyx ConditionsSacrum and Coccyx Conditions sacroiliac joint sprain
mechanisms
single traumatic episode involvingbending and/or
twisting repetitive stress fromlifting
fall on buttocks
excessive side-to-side or up-and-down motion
during running running on uneven terrain
suddenly slipping or stumbling forward
wearing new shoes or orthoses
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Sacrum And Coccyx Conditions (Contd)Sacrum And Coccyx Conditions (Contd) S&S
unilateral, dull pain that extends into buttock &posterior thigh
ASIS or PSISmay appear asymmetric bilaterally. leg-length discrepancy
pain w/ standing on one leg & stair climbing
forward bending reveals block to normalmovementw/ the PSIS on injured side moving sooner than
uninjured side pain w/ lateral flexion toward injured side
pain w/ straight leg raises beyond 45
management: standard acute;gentle stretching
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Sacrum And Coccyx Conditions (Contd)Sacrum And Coccyx Conditions (Contd)
coccygeal conditions
contusions and fractures
mechanism: direct blows
pain from fx maylast severalmonths
coccygodynia
irritation of the coccygeal nerve plexus
prolonged or chronic pain
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Sacrum And Coccyx Conditions (Contd)Sacrum And Coccyx Conditions (Contd)
management
analgesics use of padding for protection
ring seat to alleviate compression duringsitting
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Spinal AssessmentConscious IndividualSpinal AssessmentConscious Individual
history
important to ask questions about
pain location (i.e., localized or radiating)
type (i.e., dull, aching, sharp, burning)
sensory changes (i.e., numbness, tingling, or absence of
sensation) muscle weakness or paralysis
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Spinal AssessmentConscious IndividualSpinal AssessmentConscious Individual
observation/ inspection
postural assessment
scan exam
gait analysis
inspection of injury site
gross neuromuscular assessment
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Spinal AssessmentConscious Individual (Contd)Spinal AssessmentConscious Individual (Contd)
palpation
patient prone
pillow under the hip region to tilt the pelvis back andrelax the lumbar curvature
physical examination testing
if at anytime, movement leads to increased acute pain orchange in sensation, or the individual resists moving thespine, a significant injury should be assumed and EMSactivated
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Range of MotionRange of Motion
active range ofmotion (AROM)
cervical flexion
forward trunk flexion
trunk extension
lateral trunk flexion(left and right)
trunk rotation
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ROM (Contd)ROM (Contd)
active range ofmotion (AROM)
F11.14
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ROM (Contd)ROM (Contd)
Normal ranges
forward trunk flexion4060
trunk extension2035
lateral trunk flexion (left & right)1520
trunk rotation3550
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ROM (Contd)ROM (Contd)
passive ROM
seldom performed
resisted ROM
weight of the trunk will stabilize the hips
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Stress and Functional Tests (Contd)Stress and Functional Tests (Contd)
straight leg raising
well straight leg raising bowstring test
F11.18
sync w/ straight leg
F11.19
sync w/ bowstring
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Stress and Functional Tests (Contd)Stress and Functional Tests (Contd)
Brudzinskis
Kernigs test
F11.20
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Stress and Functional Tests (Contd)Stress and Functional Tests (Contd)
bilateral straight legraising
Valsalvas
Milgram test
piriformis muscle stretch
F11.21
sync w/ Milgram
F11.22
sync w/ piriformis
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Stress and Functional Tests (Contd)Stress and Functional Tests (Contd)
prone knee bending
spring test for joint
mobility
F11.23
sync w/ prone knee
F11.24
sync w/ piriformis
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Stress and Functional Tests (Contd)Stress and Functional Tests (Contd)
Farfan torsion test
trunk extension test
F11.25
sync w/ Farfan
F11.64
sync w/ trunk
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Stress and Functional Tests (Contd)Stress and Functional Tests (Contd)
femoral nerve tractiontest
quadratus lumborumstretch test
F11.27
sync w/ femoral
F11.28
sync w/ quad
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Stress and Functional Tests (Contd)Stress and Functional Tests (Contd)
single leg stance
quadrant test
F11.29
sync w/ single leg
F11.30
sync w/ quadrant
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Stress and Functional Tests (Contd)Stress and Functional Tests (Contd)
Hoover test
Burns test
F11.31
sync w/ Hoover
F11.32
sync w/ Burns
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Stress and Functional Tests (Contd)Stress and Functional Tests (Contd)
Sacroiliac compression &distraction test
approximation test
F11.33
sync w/ sacoiliac
F11.34
sync w/ approximation
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Stress and Functional Tests (Contd)Stress and Functional Tests (Contd)
squish test
Faber (Patrick) Test
F11.35
sync w/ Faber
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Stress and Functional Tests (Contd)Stress and Functional Tests (Contd)
Gaenslens test
long sitting test
F11.36
sync w/ Gaenslens
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Neurologic TestsNeurologic Tests
Babinski
Oppenheim
F10.27
this is not a mistake
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Neurologic Tests (Contd)Neurologic Tests (Contd)
myotomes
Nerve Root Segment Action Tested
L1L2 hip flexion
L3 knee extension
L4 ankle dorsiflexion
L5 toe extension
S1 plantar flexion of the ankle, foot eversion, hip extension
S2 knee flexion
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Neurologic Tests (Contd)Neurologic Tests (Contd)
cutaneous patterns
F5.8
this is not a mistake
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Neurologic Tests (Contd)Neurologic Tests (Contd)
referred pain
F5.1
this is not a mistake
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Copyright 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
RehabilitationRehabilitation
relief of pain and muscle tension
AROM exercises vs. prolonged position
conscious relaxation training
Grade I and II mobilization exercises
restoration ofmotion
Grade III and IV mobilization exercises
flexibility and range-of-motion exercises
pelvic and abdominal stabilizing exercises
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Rehabilitation (Contd)Rehabilitation (Contd)
restoration of proprioception and balance
Closed-chain exercises
muscular strength, endurance, & power
neck strength
abdominal strength
erector spinae strength
cardiovascular fitness
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