hn1 anatomy of the spine
TRANSCRIPT
ANMT Head & NeckNotes 5/27/2016
HN1 Anatomy of the Spine
Anatomy of the Spine - Prentice, Chapter 25, pg. 754 - 763
Bones of the Vertebral Column (overview)
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The Cervical Spine & Intervertebral Articulations
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Intervertebral Disks
Disks (23)Cartilaginous end plate – hyaline cartilage that attaches to disc bodyAnnulus Fibrosus – laminated collagen fibers obliquely arranged to form the outer layerNucleus Pulposus – central, semi-elastic spongy hydrodynamic structure with mucoplysacharride, collagen and physaliphorous cells.
Dynamic, hydraulic suspension forming a mobile segment which distributes compressive forces.
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Ligamentous Structures
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Spinal Ligaments ( Trailguide workbook, p.115-117)Anterior Longitudinal Posterior LongitudinalLigamentum FlavumSupraspinousInterspinous
Anatomy Review (LP1 Handout)
Head/Cervical Ligaments (Trailguide workbook, p.113-114)Ligamentum Nuchae (head to C7, supraspinous ligament)Alar LigamentsTransverse ligament of the atlas
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Functional Anatomy (1st 2 paragraphs only)
Prevention of lnjuries (Cervical Spine only)
Student Handout — Anatomy Review
Vertebrae
Ligaments
Disks
NOTES:
C1 – Atlas - No body home (no body, contains brain stem), No SP but tubercles, large TVPAtlanto-Occipital joint – AO – 1 year old says “yes yes” - 10*flexion, 20* extension
C2 – Axis, Dens or ondontoid process (“body” of atlas), body, SP, TVPAtlanto-Axial joint – AA – 2 year old says “no no” - 8-10* rotation each direction
Cervical spinous processes pronged for ligamentum nuchae
Uncinated joints – Luschka's joints (also called uncovertebral joints, neurocentral joints)[1] are formed between uncinate processes above, and the uncus below. They are located in the cervical region of the vertebral column between C3 and C7. Two lips project upward from the superior surface of the vertebral body below, and one projects downward from the inferior surface of vertebral body above. They allow for flexion and extension and limit lateral flexion in the cervical spine.
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C1-C3: upper cervical, C4-C8,T1: brachial plexus
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https://en.wikipedia.org/wiki/Cutaneous_innervation
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HN2 Head / Neck Muscles
Temporalis (Travell, V 1, Ch 9, pg. 349)
Trigger Points
Attachments
Superiorly from the temporal fascia and the whole temporal fossa (zygomatic, frontal, parietal, sphenoid, temporal bones), superior to the zygomatic arch.
Inferiorly to the medial and lateral surfaces of the coronoid process of the mandible and along the anterior ramus of the mandible, almost to last molar.
Deep 90% slow twitch, superficial anterior/middle 74% and superficial posterior 52% slow twitch.
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Action
Elevation (all), lateral deviation (same side) and retraction (posterior) of the mandible
Symptoms
Head pain, toothache or tooth site pain, rarely aware of restricted jaw opening. Hypersensitive teeth and “teeth don't meet right” sensation.
Activation & Perpetuation
Bruxism, trauma, immobilization, dental procedure, neck traction, postural stress, activity stress, reflex contraction from infection/inflammation/other pain, excessive tension in supra/infra hyoids.
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Occipitofrontalis (Travell, V 1, Ch 14, pg. 427)
Trigger Points
“Wilson” TrP pattern
Attachments
Frontalis anteriorly, occipitalis posteriorly, connected superiorly by galea aponeurotica, which is firmly connected to the skin but glides over the periosteum.
Frontalis attaches below and in front to the skin over the eyebrow where it interdigitates with the orbicularis oculi muscle.
Occipitalis attaches below and behind to the superior nuchal line of the occipital bone.
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Action
Raises the eyebrow and wrinkles the forehead, expressing surprise and opening the eyes widely. Associated with overall increased muscle tension.
Symptoms
Deep aching pain, cannot bear weight of pillow due to pain,
Activation & Perpetuation
TrPs satellite to clavicular SCM TrPs, work overload due to anxiety, facial expressions, etc.
Platysma (Travell, V 1, Ch 13, pg. 416)
Trigger Points
Attachments
Subcutaneous fascia of lower neck, above fibers interlace with orbicularis oris, corner of the mouth, other facial muscles and lower margin of the mandible.
Below attaches to the subcutaneous fascia of the upper thorax.
Action
Pulls angles of the mouth downward and the thoracic skin upward.
Symptoms
Prickly pain,
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Activation & Perpetuation
Secondary to SCM/scalene TrPs.
Orbicularis Oculi (Travell, V 1, Ch 13, pg. 416)
Trigger Points
Attachments
Palpebral portion in eyelids and orbital portion surrounding the lids. Fibers of the orbital portion form bony attachments alond the superior medial part of the orbit and attach medially to a short fibrous band (medial palpebral ligament). The fibers surround the palpebral fissure in concentric circles.
Palpebral – relating to the eyelids
Action
Palpebral portion gently closes eye. Activation of orbital portion strongly closes eye.
Symptoms
Pain, “jumpy print”, difficulty focussing.
Activation & Perpetuation
Frowning, squinting, TrPs in sternal SCM.
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Zygomaticus Major (Travell, V 1, Ch 13, pg. 416)
Trigger Points
Attachments
Muscle of mouth control attaches above to the malar surface of the zygomatic bone and below to the angle of the mouth, blending with orbicularis oris.
Action
Draws angle of mouth upward as in smiling or saying “wheee”.
Symptoms
Pain
Activation & Perpetuation
Myofascial dysfunction of masticatory muscles casusing trismus (spasm/lock jaw) may cause zygomaticus major TrPs.
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Buccinator (Travell, V 1, Ch 13, pg. 416)
Trigger Points
Attachments
Primary cheek muscle forming the lateral wall of the oral cavity. Anteromedially fibers converge toward the angle of the mouth where they become continuous with the orbicularis oris muscle. Laterally, it attaches to the pterygomandibular raphe, the tendinous inscription that anchors the superior pharyngeal constrictor. Posterolaterally, some fibers attach tot he outer surfaces of the alveolarprocesses of the maxilla above and the mandible below. The muscle is pierced by the parotid duct.
Action
Movement of food around the mouth, whistling, blowing, and swallowing, in addition to facial expression.
Symptoms
Subzygomatic jaw pain aggravated by chewing, perceived difficulty swallowing.
Activation & Perpetuation
Ill fitting dental appliances, excessive blowing (i.e. snorkelling, SCUBA, etc.)
NOTE:
Platysma stretch – pin muscle on thorax/clavicle, extend, rotate opposite side, protract jaw
Buccinator internal massage reduce time, internal skin more sensitive
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HN3 Anterior Neck
Suprahyoids (Travell, V 1, Ch 12, pg. 397)Stylohyoid
Mylohyoid
Geniohyoid
Digastric (see below)
Trigger Points
Mylohyoid can refer to tongue. Head / neck pain stylohyoid & digastric.
Attachments
All have inferior attachment to hyoid bone.
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Stylohyoid attaches above to the styloid process of the temporal bone.
Mylohyoid attaches above to the entire length of the mylohyoid line of the mandible.
Geniohyoid attaches above, deep to mylohyoid, on the inner surface of the midportion of the mandible at the symphysis menti.
Action
Open the mouth, with the hyoid bone stabilized by the infrahyoids.
Infrahyoids (Travell, V 1, Ch 12, pg. 397)Sternohyoid
Thyrohyoid – Sternothyroid
Omohyoid
Trigger Points
Attachments
All, except sternothyroid, attach superiorly to the hyoid bone.
Sternohyoid attaches below to the sternum.
Thyrohyoid sttaches below to the thyroid cartilage and omohyoid, where Sternothyroid attaches above,then attaches below to the sternum.
Omohyoid has a superior and inferior belly seperated by a central tendon. The inferior belly attaches below to the cranial border of the scapula near the scapular notch. Above it attaches to the clavicle/firstrib by a fibrous expansion over the central tendon, passing over the anterior/middle scalenes, but deep to SCM.
The superior belly attaches to the hyoid.
Action
Stabilize the hyoid for normal subrahyoid operation of opening the mouth.
Symptoms
Omohyoid tension can contribute to first rib dysfunction and pain in superior shoulder blade.
Activation & Perpetuation
Whiplash, mouth breathing, overuse chewing, etc.
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Digastrics (Travell, V 1, Ch 12, pg. 397) “Pseudo-SCM P”
Trigger Points
Attachments
Posterior belly arises from the mastoid notch of the mastoid process of the temporal bone, deep to longissimus capitus, spenius capitus and SCM. The anterior belly arises from the infereior border of the mandible, close to the its symphysis. The anterior belly passes posteriorly/inferiorly and the posterior belly passes anteriorly/inferiorly to join at a common tendon that usually attaches indirectly tothe hyoid bone through a fibrous loop or sling called the suprahyoid aponeurosis. This common tendonperforates the stylohyoid muscle, near the front half of the posterior belly.
Action
Mandibular depression, nearly always bilaterally. Coughing, swallowing and retrusion of the mandible activate.
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Symptoms
Difficulty swallowing, lump in the throat, , something stuck in throat, CL likely to point to SCM superior attachment but with no reduction in ROM (Posterior Digastric). Anterior digastric primarily pain referal into teeth.
Activation & Perpetuation
TrPs typically secondary to masseter /SCM TrPs. Bruxing, retruding mandible, mouth breathing, Eagle syndrome (long styloid process), visual blurring, trauma, whiplash, etc.
Longus Colli (Travell, V 1, Ch 12, pg. 397)
Trigger Points
Jaw, ear, back of neck
Attachments
Three portions, superior oblique, inferior oblique and vertical, attach to the anterior vertebral bodies from T3 to the tubercle on the anterior arch of the atlas.
Action
Weak neck flexor w/ lateral flexion to same side w/ rotation to the same side.
Longus Capitus (Travell, V 1, Ch 12, pg. 397)
Trigger Points
Jaw, ear
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Attachments
Extends upwards from the anterior tubercles of C3-6 to the basilar part of the occipital bone.
Action
Flexes the head with rotation to the same side.
Other Anterior Neck MusclesRectus Capitas Anterior lies deep to longus capitis and passes upward and slightly medially from the lateral mass of the atlas to the basilar part of the occipital bone in front of the foramen magnum.
Rectus Capitas Lateralis arised form the superior surface of the transverse process of the atlas, attaching superiorly at the lateral part of the occipital bone.
Symptoms
Unresolved posterior neck pain, difficulty swallowing, dry mouth, sore throat w/o infection, hoarse voice, peristent throat tickle/lump,
Activation & Perpetuation
Forward head posture, whiplash, trauma, etc.
Notes:
Paul St. John diagrams for deep anterior cervical muscles
omo – shoulder
glossus – tongue
genio – chin
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HN4 Scalenes
Scalenes (Travell, V 1, Ch 20, pg. 504)
Trigger Points
Attachments
Anterior scalene attaches above to the anterior tubercles of the transverse processes of C3-6. Below it attaches by a tendon to the scalene tubercle on the inner border of the first rib and upper surface of the rib anterior to the groove for the subclavian artery.
Middle scalene attaches above to the posterior tubercles on the transverse processes of C2-7 (sometimes only 4/5). Below it attaches to the cranial portion of the first rib, posterior and deep to the groove for the subclavian artery.
Posterior scalene attaches above to the posterior tubercles on the TVP of C5/6-7 and below to the lateral surface of the second and sometimes third rib.
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Scalene minimus, if present, extends above to the anterior tubercle on the transverse process of C6/7 and below to the fascia surrounding the plural dome and the inner border of the first rib.
Action
Functions: Stabilize Cervical Spine Laterally, Assist Inhalation by Elevating Ribs, Assist Contralateral, Control of Unilateral Actions Below
Actions:
Fixed Below
Unilaterally
Laterally flex cervical spine
Move head obliquely forward and sideways
Bilaterally
Anterior flex cervical spine
Fixed Above
Elevate Ribs
Auxiliary Respiration Muscle
Symptoms
Referred pain to shoulder/upper arm, scalene anticus syndrome (pain ant/post arm, medial border scapula and anterior scalene tenderness), venous obstruction, vasomotor changes, arterial insufficiency, elevated first rib, neurovaso entrapment, TOS, numbness, tingling, edema of arm/hand, entrapment of subclavian vein,
Activation & Perpetuation
Trauma, pulling, lifting, carrying awkward objects, playing musical instruments, over respiration, paradoxical breathing, coughing, sleep w/ head/neck low, small hemipelvis/upper arm, loss of limb/breast, awkward leaning position, whiplash.
Often secondarily to SCM/LS TrPs.
Differential Diagnosis
Carpal Tunnel — pg. 515-518
Thoracic Outlet Syndrome — pg. 518—521
Scalenus Anticus Syndrome & First Rib Involvement —- 521- 522
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Myofascial Pseudothoracic Outlet Syndrome - pg. 522
Scalene cramp test – place chin in hollow behind clavicle, positive is pain.
Scalene relief test – abduct arm, medially rotate – symptom relief?
Scalene finger flexion test – hold MCP straight and flex fingers. Positive scalene is no fingers can reach MCP/palm, positive ED 1-2 fingers cannot reach.
Corrective Actions
Stretching — pg. 530 – Side bending in supine w/ ipsilateral hand under buttocks, combine contralateral flexion with ipsi/contralateral rotation.
Coordinated Respiration — pg. 531-532 supine and prone belly breathing, breathing into hands, etc.
Notes:
Seated breathing with flexion on exhale, extension on inhale
Prone breathing w/ MT hands on abdomen/side to monitor and guide breathing into abdomen/sides
Shoulder issues: suboccipitals, scalenes, shoulder
Brachial plexus – no trapezius innervation or axilla sensory
Sibson's fascia – supraplural membrane
GTO sense tension, spindle sense stretch/length
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HN5 Sternocleidomastoid
Sternocleidomastoid (Travell, V 1, Ch 7, pg. 310)
Trigger Points
Attachments
Action
Symptoms
Activation & Perpetuation
Differential Diagnosis
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HN6 Splenius, Semis, Longissimus, Multifidi, Rotatores
Splenius Capitis (Travell, V 1, Ch 15, pg. 432)
Trigger Points
Attachments
Action
Splenius Cervicis (Travell, V 1, Ch 15, pg. 432)
Trigger Points
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Attachments
Action
Symptoms
Activation & Perpetuation
Semispinalis Capitis (Travell, V 1, Ch 16, pg. 445)
Trigger Points
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Attachments
Action
Longissimus Capitus (Travell, V 1, Ch 16, pg. 445)
Trigger Points
Attachments
Action
Multifidi (Travell, V 1, Ch 16, pg. 445)
Trigger Points
Attachments
Action
Rotatores (Travell, V 1, Ch 16, pg. 445)
Trigger Points
Attachments
Action
Symptoms
Activation & Perpetuation
Differential Diagnosis
Fibromyalgia, Osteoarthritis and Cervicogenic Headache - Pg 456—457
Neuropathy — Pg 459
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HN7 Suboccipitals
Suboccipitals (Travell, V 1, Ch 7, pg. 310)
Trigger Points
Attachments
Action
Symptoms
Activation & Perpetuation
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HN8 Cervical Posture
Military Neck, Packet
Etiology
Symptoms and Signs
Management
Forward Head Posture, Packet
Etiology
Symptoms and Signs
Management
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HN9 Neck Strains & Sprains
Neck/Back Strains, Prentice, Ch 25, pg 779
Etiology
Symptoms and Signs
Management
Cervical Sprain (whiplash), Prentice, Ch 25, pg 780
Etiology
Symptoms and Signs
Management
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HN11 Cervical Vertebrae Issues
Cervical Disk Injuries — Prentice, Chapter 25, pg 784
Etiology
Symptoms and Signs
Management
Cervical Fractures - Prentice, Chapter 25, pg 776 — 777
Etiology
Symptoms and Signs
Management
Cervical Dislocations - Prentice, Chapter 25, pg 777 — 779
Etiology
Symptoms and Signs
Management
Cervical Spine Stenosis — Prentice, Chapter 25, pg 781 — 783
Etiology
Symptoms and Signs
Management
Special Tests - Prentice, Chapter 25, pg 769 & 771
Cervical Compression and Spurling’s Test
Slump Test
Vertebral Artery Test
Shoulder Abduction Test
Distraction Test (Packet)
Valsalva Test (Packet)
Swallowing Test (Packet)
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HN12 Cervical Nerve Issues
Brachial Plexus Neuropraxia (Burner) — Prentice, Chapter 25, pg783 — 784
Etiology
Symptoms and Signs
Management
Pinched Nerve Syndrome — Student Packet
Etiology
Symptoms and Signs
Management
Cervical Cord and Nerve Root Injuries -— Prentice, Chapter 25, pg 780 - 781
Etiology
Symptoms and Signs
Management
Acute Torticollis (Wryneck) —— Prentice, Chapter 25, p. 780, Packet
Etiology
Symptoms and Signs
Management
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HN13 Headaches
Diagnostic Categories for Head, Neck and Facial PainTravell, Chapter 5, pg. 241 —245
Migraine Headache —- Pg. 241
Tension—type Headache —- Pg. 241-242
Cluster Headaches and Chronic Paroxysmal Hemicrania —- Pg. 244-245
Miscellaneous Headaches, Unassociated with Structural Lesion & Head and Neck Pain Associated with Head Trauma — Pg. 245-246
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HN14 TMJ
TMJ Packet, Travell, Vol. 2, Chapter 5, pg 248-260
Temporomandibular Joints & Anatomy -— pg 248
Biomechanics —- pg 248
Biomechanics in Internal Derangement —- pg 249-250
First paragraph (end at “Clicking occurs when...”)
Second paragraph (“Clicking occurs when...”) to the end of this section.
Role of Occlusmn in TM Disorders
Impact of TMJ Disorders on Myofascial TrPs (do not include case study)
Screening Examination for Temporomandibular Joint Disorders
Joint Capsule Tenderness — pg 256
Exam Procedures
Clinical Significance
Joint Sounds - pg 257
Exam Procedures
Clinical Significance
Mandibular Range of Motion — pg 259
Exam Procedures
Clinical Significance
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Masseter —— Travell, Chapter 8, pg. 331
Trigger Points
Attachments
Action
Symptoms
Activation & Perpetuation
Psychological Stresses
Other Stresses
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HN15 Pterygoids
Lateral Pterygoid —— Travell, Chapter 11, pg. 379
Trigger Points
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Attachments
Action
Symptoms
Activation & Perpetuation
Medial Pterygoid —— Travell, Chapter 10, pg. 365
Trigger Points
Attachments
Action
Symptoms
Activation & Perpetuation
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HN17 HOPRS
HOPRSHistory
Observation
Palpation
ROM (active, passive, manual resistive)
Special Orthopedic Tests
OHSHITOccupation
Hobbies
Surgeries - scars
Hospitalization
Illness
Trauma - scars
BLESS ME (Biopsychosocial)Body
Lifestyle
Emotions
Society
Spirit
Mind
Environment
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OPQRHN
Onset – acute or gradual
Provocation or Palliative – what changes pain
Quality of pain – sharp, dull ache
Radiate
Site – where is it
Time of day – behavior over course of day
OPQRHN Nerve Joint Muscle
Onset Acute Acute Acute or gradual
Provocation Likes cold, not heatDoesn't like stretch or compression
Likes cold, not heatPosition can change P
Likes heat, not coldPosition can change P
Quality Numb, tingle, burn, sharp
Ache, deep, stiff, sharp Dull ache
Radiates Along nerve, dermatone Local Referral, fascial, embryological development
Site Nerve or path Specific, non moving Vague, changing
Time of Day AM OK, PM ^P AM Stiff, PM OK, but overuse can ^P
AM stiff, warm up w/ use, overuse can ^P
Posture - ask to exaggerate, how do you like to stand, how do you feel, etc. - drive to more natural
Palpation – temperature, texture, tenderness, tone
Myotome – myfascial pain referral pattern
Please read to prepare for class:
Pat Archer: Therapeutic Massage in Athletics
Ch. 12 pg. 225-240 Evaluation: identifying Problems and Assessing
needs
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Additional resources to have in this class:
Pat Archer: Therapeutic Massage in Athletics
Ch. 6 pg 100 — 106 The Physiology of Healing
Ch. 7 pg 111 — 127 Lymphatic Facilitation Techniques
Table 6-1 Summary of Healing Process, pg 106
Table 13-2 Treatment Massage According to Stage of Healing, pg 245
Prentice: Neuromuscular Therapy lniugy Assessment
Ch. 22, The Shoulder Complex
pg 659 — 660 Table 22-1: Muscles of the Shoulder Complex
pg 663 — 670 Assessment of the Shoulder Complex
Ch. 25, The Spine
pg 759 Table 25-1: Muscles That Move the Vertebral Column
pg 764 — 776 Assessment of the Spine
Travell: Myofascial Pain and Dysfunction, Vol 1
Part 2: Head and Neck Pain-and-Muscle Guide
Part 3: Upper Back, Shoulder, and Arm Pain-and-Muscle Guide
NOTES:
VALUES
Values
Actions
Lifestyle / Habits
Universe / Understanding
Environment
Society
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