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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 15  |  Issue : 1  |  Page : 22-27

Immediate effect of thoracic distraction thrust versus upper thoracic crossed hand manipulation in mechanical neck pain: A randomized clinical trial


Department of Orthopaedic Manual Therapy, KLE Institute of Physioytherapy, Belagavi, Karnataka, India

Date of Submission09-Apr-2020
Date of Decision28-May-2020
Date of Acceptance28-Dec-2020
Date of Web Publication19-Aug-2021

Correspondence Address:
Dr. Anand Heggannavar
Department of Orthopaedic Manual Therapy, KLE Institute of Physiotherapy, JNMC Camspus, Nehru Nagar, Belagavi - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/PJIAP.PJIAP_8_20

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  Abstract 


OBJECTIVES: The aim is to compare the immediate effect of thoracic spine distraction thrust and upper thoracic crossed hand manipulation on pain, range of motion, and disability in individuals with mechanical neck pain.
METHODS: A randomized clinical trial was conducted on 40 individuals of mean age 27.35 ± 6.78 with mechanical neck pain. Individuals were allocated to one of the two groups. Group A (n = 20) received thoracic spine distraction thrust and Group B (n = 20) received upper thoracic crossed hand manipulation. Both the groups were also given Transcutaneous Electrical Nerve Stimulation (TENS) , hot moist pack, stretching, and exercises. The outcome measures used were the Numerical pain Rating (NPR) scale, cervical ranges, and Northwick Park Neck Pain Questionnaire (NPQ). The outcome measures were assessed pre- and post-intervention.
RESULTS: The data were statistically analyzed using an independent t-test for comparing the two groups and dependent t-test for comparison of pre and post of each group. Pre- and post-mean difference values in Group A were 2.00 ± 0.86 and 11.13 ± 5.39, for NPR scores and NPQ scores. Whereas, in Group B, pre- and post-mean difference values were 2.00 ± 0.73 and 10.54 ± 10.05 for NPR scores and NPQ scores. In Group A and Group B, there was improvement seen in cervical ranges. The comparison within groups showed a statistically significant difference (P < 0.05) in all the outcome measures in both Groups. There was no significant difference seen when between-group comparisons were done in all outcome measures.
CONCLUSION: Thoracic spine distraction thrust and upper thoracic crossed hand manipulation, both were seen to be effective in pain, ranges, and disability.

Keywords: Crossed hand thrust, distraction thrust, manipulation, manual therapy, mechanical neck pain, Northwick Park neck pain questionnaire, thrust


How to cite this article:
Heggannavar A, Battula L. Immediate effect of thoracic distraction thrust versus upper thoracic crossed hand manipulation in mechanical neck pain: A randomized clinical trial. Physiother - J Indian Assoc Physiother 2021;15:22-7

How to cite this URL:
Heggannavar A, Battula L. Immediate effect of thoracic distraction thrust versus upper thoracic crossed hand manipulation in mechanical neck pain: A randomized clinical trial. Physiother - J Indian Assoc Physiother [serial online] 2021 [cited 2021 Dec 3];15:22-7. Available from: https://www.pjiap.org/text.asp?2021/15/1/22/324133




  Introduction Top


By definition, neck pain is pain perceived as arising in a region bounded superiorly by the superior nuchial line, laterally by the lateral margins of the neck and inferiorly by an imaginary transverse line through the T1 spinous process.[1] In general, most of the neck pain is called as soft-tissue rheumatism or muscular/mechanical/postural neck pain.[1],[2],[3] Patients with neck pain are common to visit outpatient physical therapy.[2],[3] It was hypothesized by Bogduk and Aprill that mechanical dysfunction of the cervical spine very commonly leads to neck pain.[4]

It is seen that neck pain is associated with self-reported poor general health status, psychological distress, and previous neck injury as well as to a range of factors like occupational tasks and obesity.[5] In women, the prevalence is higher and is seen to be increasing with age, and cultural variation is noted as prevalence is lower in Asian populations.[5],[6]

There are many treatment options for neck pain such as massage, exercise, electromagnetic therapy, traction, collars, TENS, ultrasound, spray and stretch, acupuncture, spinal manipulation, local corticosteroid injections, trigger point injections, and laser therapy. With these interventions, the effect on mobility and function is not long-lasting or is not satisfactory.[7]

The focus of any intervention for neck pain is to decrease the pain and improve the function of the cervical spine.[4] A randomized clinical trial was conducted to explore the inclusion of thoracic spine thrust manipulations into an electro-therapy/thermal program for the management of patients with acute mechanical neck pain, concluded that inclusion of thoracic manipulation into electrotherapy/thermal program was effective in reducing neck pain and disability, and in increasing active cervical mobility in patients with acute neck pain.[8]

A recently published guideline for the management of patients with neck pain has recommended the use of thoracic spine thrust manipulation in the management. A study to compare the immediate effects of spinal manipulative therapy with muscle energy technique on pain and range of motion (ROM) in the cervical spine found that cervical ranges increased by both the treatments, but pain reduction was more by spinal manipulation than muscle energy technique. The thrust manipulation is effective may be due to synovial folds or plica release, because of sudden stretching the hypertonic muscles may be relaxed, articular or periarticular adhesions disruption or due to unbuckling of motion segments that have undergone disproportionate displacements.[9]

There are studies that showed positive effects of thoracic thrust manipulation in subjects with mechanical neck pain.[8],[9] The disturbances in joint mobility in the thoracic spine may be an underlying contributor to musculoskeletal disorders in the cervical spine therefore improvement in cervical ranges and decrease in pain post manipulation. There is a lack of study comparing the immediate effects of two manipulation techniques, therefore, in present study, two manipulation techniques are compared. It is hypothesized that one of the manipulation techniques may have better effects.


  Methods Top


Ethical clearance was obtained from the institutional ethical committee to conduct a randomized clinical trial in tertiary health care centers to compare the immediate effect of thoracic distraction thrust and upper thoracic crossed hand technique in individuals with chronic mechanical neck pain. The study was conducted from February 2016 to December 2016. The study was retrospectively registered under CTRI/2017/06/008805. Subjects were patients at tertiary care center visiting physiotherapy department. Subjects included in the study were males and females between 18 years and 44 years of age with mechanical neck pain (symptoms provoked by neck movement and/or palpation of musculature of the cervical region). Subjects were excluded with a history of trauma to the cervical and thoracic region, diagnosed with pathological conditions of the cervical and thoracic spine, have undergone spinal manipulative therapy in the previous 2 months and with “red flag” signs (e.g., Osteoporosis, infection).[8] [Figure 1] shows the details regarding the recruitment of subjects. The eligible subjects were enrolled in Group A (thoracic distraction thrust) and Group B (upper thoracic crossed hand manipulation) using the envelope method. One therapist assessed the subjects and recorded the data and the principal investigator carried out the intervention. There was no increase in symptoms postintervention for any subject.
Figure 1: CONSORT flow diagram

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Outcome measures

Numeric pain rating scale

Eleven point numerical pain rate scale (0 = no pain, to 10 = maximum pain). Reliability is 0.96 and its validity is high (0.86–0.95).[10] Subjects were administered the 10 cm scale of 11 points (0–10) and was asked to quantify the intensity of the pain.

Northwick Park neck pain questionnaire

The NPQ is a self-administered questionnaire that includes 9 sections on typical daily activities that may be affected by the patient's neck pain: intensity, sleeping, numbness, duration, reading, television, carrying, work, social role, and driving.[11] Each section is scored on a scale from 0 to 4, with 4 representing the greatest disability, and the total score is obtained by summing the scores for the 9 sections (possible score 0–36). Questionnaire showed good short-term repeatability (r = 0.84, K = 0.62) and internal consistency is also seen. The questionnaire was given to the subjects and was asked to mark the one of the given 4 options for available 9 questions.

Cervical range of motion

Cervical ROM was measured using goniometer. When ranges were taken by the same therapist universal goniometer have good to high reliability.[12] Subject was in sitting position with arms resting on the arm of the chair. For flexion the fulcrum was external auditory meatus, the stable arm was perpendicular to the ground and movable arm was parallel to the ground. For measuring side-flexion, the fulcrum was spinous process of C7 vertebra the movable and stable arm, both were perpendicular to the ground and movable arm was then moved to the movement of the neck. For the rotation vertex of the head was considered as the fulcrum. The movable and stable arms were parallel to ground. The movable arm was moved along with the rotation of neck considering nose as reference.

Procedure

The procedure was explained and informed consent was obtained from subjects. Demographic details were noted. Pain score and All cervical ROM were assessed and recorded. Northwick Park neck pain questionnaire (NPQ) was filled by recruited subjects. After conventional therapy, Group A was given thoracic spine distraction thrust and Group B was given upper thoracic crossed hand technique Immediately, Post-intervention pain score and all Cervical ROM were noted. Northwick park NPQ was again filled by the subjects after 1 day of the intervention.

Conventional therapy

TENS

A frequency of 100 Hz and 250 ms stimulation for 20 min, two electrodes placed bilaterally to the spinous process of C7 vertebra with the patient in sitting position with head resting on hands on the table.[13]

Hot moist pack

Patient in sitting position with head resting on hands placed on the table. Hot moist pack placed on neck for 15 min.

Exercises

10 repetitions of cervical flexion, extension, side flexion, and rotation .Isometric neck muscle contractions, in flexion, extension, side flexion, and rotation for 5 s and repeat this for 10 repetitions and Stretching exercise of the upper trapezius and scalene muscles, for 5–8 s for 10 repetitions of the neck.[14]

Thoracic spine distraction thrust

A high-velocity distraction force to the mid-thoracic and lower thoracic spine was given. The patient was sitting with the arms crossed over the chest and hands passed over the shoulders. The therapist placed his upper chest at the level of the patient's middle thoracic spine and grasped the patient's elbows. Gentle flexion of the thoracic spine was introduced until slight tension was felt in the tissues at the contact point between the therapist's chest and patient's back. Then, a high-velocity distraction thrust manipulation in an upward direction was applied[8] [Figure 2].
Figure 2: Thoracic distraction thrust

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Upper thoracic crossed hand

A high-velocity, end range, thrust force applied through crossed hand to the upper thoracic spine. This technique was performed with the patient positioned prone, neck side bent to opposite side and the head was slightly rotated to the same side of the transverse process to be treated to obtain ligamentous tension locking. One hand of the therapist on patient's head and hypothenar or thenar eminence of other hand over T1 transverse process (For treating Left T1 Transverse process left hand of the therapist was used for Thrust and vice versa). The patient was asked to breathe in and out several times as the tissue lack is taken up localizing the forces. High-velocity low amplitude thrust is given. The postero-anterior force on the transverse process of T1 was introduced while stabilizing hand on head effects a slight relative rotation in an opposite direction[15] [Figure 3].
Figure 3: Upper thoracic crossed hand manipulation

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Statistical analysis for the present study was done using SPSS software version 20.0 (IBM, Armonk, NY, USA) to verify the results obtained. All variables pre- and post-intervention scores of both groups follow a normal distribution, it was analyzed using Kolmogorov–Smirnov test. Therefore, parametric tests are applied. The nominal data such as age, gender, height, and weight distribution were analyzed using Chi-square and t-test. Comparison between pre- and post-intervention outcome measures like Numerical pain rating (NPR) scores, Northwick Park NPQ and cervical ranges within Group A and Group B and between Group A and Group B was done by using dependent t-test. Probability values <0.05 were considered to be statistically significant.


  Results Top


The demographic profile of the participants of both groups was homogeneous. Group A had 2 males and 18 females with a mean age of 25.80 + 5.81 and mean body mass index (BMI) of 22.32 + 2.73. Group B had 3 males and 17 females with a mean age of 28.90 + 7.45 and mean BMI of 22.79 + 4.77 [Table 1] and [Table 2].
Table 1: Gender distribution

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Table 2: Age and body mass index comparison

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Pre-intervention NPR scale (NPRS) score was 6.15 ± 0.88 which reduced to 4.15 ± 0.99 after the intervention. 2.0 ± 0.86 was mean reduction in pain. 32.52% reduction was seen immediately in Group A. Preintervention NPRS score was 6.35 ± 1.14 which reduced to 4.35 ± 1.18 after the intervention. 2.0 ± 1.15 was mean reduction in pain. 31.50% reduction was seen immediately in Group B.

The mean increase in flexion ROM was 6.75 ± 4.94 in Group A and 14.50 ± 4.84 in Group B. Mean increase in extension ROM was 5.50 ± 3.59 in Group A and 6.75 ± 4.94 in Group B. Mean increase in left side flexion ROM was 7.25 ± 3.80in Group A and 6.50 ± 3.28 in Group B. Mean increase in right side flexion ROM was 6.25 ± 4.83 in Group A and 6.50 ± 4.89 in Group B. Mean increase in left rotation ROM was 9.75 ± 6.38 in Group A and 10.50 ± 4.84 in Group B. Mean increase in right rotation ROM was 9.0 ± 6.20in Group A and 11.25 ± 4.83 in Group B.

Preintervention Northwick Park NPQ score was 36.56 ± 9.43 which reduced to 25.44 ± 7.59 after intervention. 11.13 ± 5.39 was mean reduction. 30.44% reduction was seen immediately in Group A and in Group B, Northwick Park NPQ score of 35.31 ± 11.44 reduced to 24.78 ± 10.31. 10.54 ± 10.05 was mean reduction and 29.84% reduction was seen immediately .

In Group A and Group B from pre- to post-intervention values, there was a statistically significant change in NPR scores, all cervical ROM degrees and NPQ score with P = 0.001 respectively.

When the NPR score, all cervical ranges and NPQ score were analyzed between Group A and Group B from baseline to post-intervention, it revealed no statistical significance with P values more than 0.05 [Table 3], [Table 4], [Table 5].
Table 3: Comparison of numerical pain rating scores between and within Group A and Group B by independent and dependent t-test respectively

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Table 4: Comparison of cervical ranges between and within Group A and Group B by independent and dependent t-test respectively

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Table 5: Comparison of Northwick park neck pain questionnaire scores (percentage) between and within Group A and Group B by independent and dependent t-test respectively

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  Discussion Top


The present study was conducted to find the immediate effects of two manipulative techniques in Mechanical neck pain. It is evident according to the previous studies conducted that the prevalence of neck pain is more in women than in men.[16] In the present study, there were total 35 females and 5 males.

The conventional therapy included TENS, hot moist, stretching, and isometrics exercises. TENS and hot moist pack lead to reduction in pain levels. The mechanism behind the pain relief by conventional TENS is that the stimulation by TENS will enable the impulses to be carried through the large-diameter afferent nerve which leads to presynaptic inhibition of nociceptive Aβ and C fibers at the level. Hot moist when applied there is nerve stimulation as well as there is an increase in the rate of metabolism which causes the sedative effect, increase in local blood flow, and facilitating healing and repair which leads to pain relief.[13]

The explanation for reduction in pain post the manipulation remains yet unclear, the possible reason could be the correction of biomechanics of the thoracic spine, leading to the equal distribution of forces. Few previous studies demonstrated that when manual therapy interventions are directed at the spine there may be improvements recorded in pain in regions distant to the area, in which the treatment is actually directed. In addition, other studies have demonstrated that mobilization/manipulation techniques directed at impaired motion segments were no more beneficial than the treatment of randomly selected segments.[2] Manipulation techniques have neurophysiological effects on sensory receptors in peripheral tissues, on neural tissue within the intervertebral foramen, on central facilitation, somatosomatic reflexes, on somatovisceral reflexes. Thoracic distraction thrust and Crossed hand manipulation technique both are shown to have similar effects in individuals with mechanical neck pain. Manipulation techniques have no one definite explanation for its mechanism in reducing pain and improving movement. A model proposed that manipulation techniques work by various mechanisms, namely, mechanical stimulus, neurophysiological mechanism, peripheral mechanism, spinal mechanism, supraspinal mechanism.[17]

The increase in cervical ranges in the present study correlates to a randomized controlled trial which was conducted to assess the effectiveness of thoracic manipulation on patients with chronic mechanical neck pain, they had two groups experimental group who were given thoracic manipulation and the controlled group who did not receive thoracic manipulation, both the groups were given infra-red radiation and standard education material. They had found that the in the experimental group had shown the higher measure of pain reduction and improvement in dysfunction, significant increase in neck ROM s and were maintained even at 6-month follow-up.[14] Though in the present study, only 1-week follow-up was done, the effect could have been maintained if long-term follow-up would have been done. They suggest that the improvement may be due to biomechanical restoration of cervical-thoracic junction movement which leads to reduced stress and therefore, pain reduction with an increase in ranges and also improving quality of life.[8],[14] The increase in range according to the previous studies could be due to the biomechanical rearrangement of the region and reduction in pain.[8],[14] The restoration of zygopophyseal joint mobility and joint play, leads to the major mechanical changes after performing the manipulation. The combined effect of manipulation with exercises has helped to reduce the pain and increase the cervical ranges in both the groups.[8],[9],[14]

There was a study conducted to examine the immediate effect of thoracic manipulation in patients with mechanical neck pain, in which they had experimental group whom thoracic manipulation was given and another group was the placebo group. They had found similar results like the present study, the pain had reduced along with disability.[2] The improvement in disability showed enhanced functional activity which was due to decreased pain and improved ranges which is evident with NPQ scores.

There are some limitations of the study, as study has only analyzed immediate effects unequal distribution of gender and control group was lacking. In future studies, isolated comparison of both the manipulation techniques can be done and long-term effects can be studied.


  Conclusion Top


Thoracic spine distraction thrust and upper thoracic crossed hand manipulation, both were seen to be effective in decreasing pain, increasing ranges, and improving functional disability. In individuals with mechanical neck pain, any of the two manipulations techniques may be used as an adjunct treatment.

Acknowledgment

We are grateful to the head of the institution for granting us permission to conduct the study and use the research related infrastructure. We are thankful to the statistician for helping us with the data analysis. We also thank all the volunteer students for participating in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Misailidou V, Malliou P, Beneka A, Karagiannidis A, Godolias G. Assessment of patients with neck pain: A review of definitions, selection criteria, and measurement tools. J Chiropr Med 2010;9:49-59.  Back to cited text no. 1
    
2.
Cleland JA, Childs JD, McRaed M, Palmer JA, Stowell T. Immediate effects of thoracic manipulation in patients with neck pain: A randomized clinical trial. Man Ther 2005;10:127-35.  Back to cited text no. 2
    
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Cross KM, Kuenze C, Grindstaff TL, Hertel J. Thoracic spine thrust manipulation improves pain, range of motion, and self-reported function in patients with mechanical neck pain: A systematic review. J Orthop Sports Phys Ther 2011;41:633-42.  Back to cited text no. 3
    
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Martínez-Segura R, Fernández-de-las-Peñas C, Ruiz-Sáez M, López-Jiménez C, Rodríguez-Blanco C. Immediate effects on neck pain and active range of motion after a single cervical high-velocity low-amplitude manipulation in subjects presenting with mechanical neck pain: A randomized controlled trial. J Manipulative Physiol Ther 2006;29:511-7.  Back to cited text no. 4
    
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Lau KT, Cheung KY, Chan KB, Chan MH, Lo KY, Chiu TT. Relationships between sagittal postures of thoracic and cervical spine, presence of neck pain, neck pain severity and disability. Man Ther 2010;15:457-62.  Back to cited text no. 5
    
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Croft PR, Lewis M, Papageorgiou AC, Thomas E, Jayson MI, Macfarlane GJ, et al. Risk factors for neck pain: A longitudinal study in the general population. Pain 2001;93:317-25.  Back to cited text no. 6
    
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Hurwitz EL, Carragee EJ, vander Velde G, Carroll J, Nordin M, Guzman J, et al. Treatment of neck pain: Noninvasive interventions. Results of the bone and joint decade 2000–2010 task force on neck pain and its associated disorders. Eur Spine J 2008;17:123-52.  Back to cited text no. 7
    
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Gonzalez-Iglesias J, Fernandez-de-las-Penas C, Cleland JA, Alburquerque-Sendın F, Palomeque-del-Cerro L, Mendez-Sanchez R. Inclusion of thoracic spine thrust manipulation into an electrotherapy/thermal program for the management of patients with acute mechanical neck pain: A randomized clinical trial. Man Ther 2009;14:306-13.  Back to cited text no. 8
    
9.
Evans DW. Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: Previous theories. J Manipulative Physiol Ther 2002;25:251-62.  Back to cited text no. 9
    
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Cleland JA, Childs JD, Whitman JM. Psychometric properties of the neck disability index and numeric pain rating scale in patients with mechanical neck pain. Arch Phys Med Rehabil 2008;89:69-74.  Back to cited text no. 10
    
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Leak AM, Cooper J, Dyer S, Williams KA, Turner-Stokes L, Frank AO. The northwick park neck pain questionnaire, devised to measure neck pain and disability. Br J Rheumatol 1994;33:469-74.  Back to cited text no. 11
    
12.
Youdas JW, Garrett TR, Suman VJ, Bogard CL, Hallman HO, Carey JR. Normal range of motion of the cervical spine: An initial goniometric study. Phys Ther 1992;72:770-80.  Back to cited text no. 12
    
13.
Robertson V, Ward A, Low J Reed A. Electrotherapy Explained. Principle and Practice. 4th ed. Butterworth-Heinemann oxford UK: Elsevier; 2006.  Back to cited text no. 13
    
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Lau HM, Wing Chiu TT, Lam TH. The effectiveness of thoracic manipulation on patients with chronic mechanical neck pain – A randomized controlled trial. Man Ther 2011;16:141-7.  Back to cited text no. 14
    
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Robert C. Ward. American Osteopathic Association. Foundations of osteopathic medicine, 2nd edition - Philadelphia: Lippincott Williams & Wilkins, 2003.  Back to cited text no. 15
    
16.
Sheilah HJ, Gabrielle van der V, Linda JC, Lena WH, David CJ, Jamie G, et al. The burden and determinants of neck pain in the general population. Results of the bone and joint decade 2000–2010 task force on neck pain and its associated disorders. Eur Spine J 2008;17 Suppl 1:S39-51.  Back to cited text no. 16
    
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Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Man Ther 2009;14:531-8.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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