Dysfunctional endogenous analgesia during exercise in patients with chronic pain: To exercise or not to exercise? (original) (raw)
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Pain Practice, 2014
Objective: Temporal summation (TS) of pain, conditioned pain modulation (CPM), and exercise-induced analgesia (EIA) are often investigated in chronic pain populations as an indicator for enhanced pain facilitation and impaired endogenous pain inhibition, respectively, but interactions are not yet clear both in healthy controls and in chronic pain patients. Therefore, the present double-blind randomized placebo-controlled study evaluates pains cores, TS, and CPM in response to exercise in healthy controls, patients with chronic fatigue syndrome and comorbid fibromyalgia (CFS/ FM), and patients with rheumatoid arthritis (RA), both under placebo and paracetamol condition. Methods: Fifty-three female volunteersof which 19 patients with CFS/FM, 16 patients with RA, and 18 healthy controlsunderwent a submaximal exercise test on a bicycle ergometer on 2 different occasions (paracetamol vs. placebo), with an interval of 7 days. Before and after exercise, participants rated pain intensity during TS and CPM.
PAIN, 2010
The aim of this study was to investigate how exercise influenced endogenous pain modulation in healthy controls, shoulder myalgia patients and fibromyalgia (FM) patients. Twenty-one healthy subjects, 20 shoulder myalgia patients and 20 FM patients, all females, participated. They performed standardized static contractions, that is, outward shoulder rotation (m. infraspinatus) and knee extension (m. quadriceps). Pressure pain thresholds (PPTs) were determined bilaterally at m. infraspinatus and m. quadriceps. During contractions PPTs were assessed at the contracting muscle, the resting homologous contralateral muscle and contralaterally at a distant site (m. infraspinatus during contraction of m. quadriceps and vice versa). Myalgia patients had lower PPTs compared to healthy controls at m. infraspinatus bilaterally (p < 0.01), but not at m. quadriceps. FM patients had lower PPTs at all sites compared to healthy controls (p < 0.001) and myalgia patients (p < 0.001). During contraction of m. infraspinatus PPTs increased compared to baseline at the end of contraction in healthy controls (all sites: p < 0.003), but not in myalgia or FM patients. During contraction of m. quadriceps PPTs increased compared to baseline at the end of contraction in healthy controls (all sites: p < 0.001) and myalgia patients (all sites: p < 0.02), but not in FM patients. In conclusion, we found a normal activation of endogenous pain regulatory mechanisms in myalgia patients during contraction of the non-afflicted m. quadriceps, but a lack of pain inhibition during contraction of the painful m. infraspinatus. FM patients failed to activate their pain inhibitory mechanisms during all contractions.
The Clinical Journal of Pain, 2014
Exercise is an AQ4 effective treatment strategy in various chronic musculoskeletal pain disorders, including chronic neck pain, osteoarthritis, headache, fibromyalgia, and chronic low back pain. Although exercise can benefit those with chronic pain, some patients (eg, those with fibromyalgia or chronic whiplash-associated disorders) encounter exercise as a pain-inducing stimulus and report symptom flares due to exercise. This paper focuses on benefits and detrimental effects of exercise in patients with chronic pain. It summarizes positive and negative effects of exercise therapy in migraine and tension-type headache and provides an overview of the scientific evidence of dysfunctional endogenous analgesia during exercise in patients with certain types of chronic pain. Further, the paper explains the relationship between exercise and recovery highlighting the need to address recovery strategies as well as exercise regimes during rehabilitation. The characteristics, demands, and strategies of adequate recovery to compensate stress from exercise and return to homeostatic balance will be described. Exercise is shown to be effective in the treatment of chronic tension-type headache and migraine. Aerobic exercise is the best option in migraine prophylaxis, whereas specific neck and shoulder exercises is a better choice in treating chronic tension-type headache. Besides the consensus that exercise therapy is beneficial in the treatment of chronic pain, the lack of endogenous analgesia in some chronic pain disorders should not be ignored. Furthermore, optimizing the balance between exercise and recovery is of crucial merit to avoid stress-related detrimental effects and achieve optimal functioning in patients with chronic pain.
Musculoskeletal pain and exercise-challenging existing paradigms and introducing new
British journal of sports medicine, 2018
Traditional pain models that describe tissue pathology as a source of nocioceptive input directly linked with pain expression, have been insufficient for assessing and treating musculoskeletal pain. The need for pain to be avoided or alleviated as much as possible during physical activity has recently been challenged, with a paradigm shift from traditional biomedical models of pain towards a biopsychosocial model of pain.
The Journal of Pain, 2012
A controlled experimental study was performed to examine the efficacy of the endogenous pain inhibitory systems and whether this (mal)functioning is associated with symptom increases following exercise in patients with chronic whiplash-associated disorders (WAD). In addition, 2 types of exercise were compared. Twenty-two women with chronic WAD and 22 healthy controls performed a submaximal and a self-paced, physiologically limited exercise test on a cycle ergometer with cardiorespiratory monitoring on 2 separate occasions. Pain pressure thresholds (PPT), health status, and activity levels were assessed in response to the 2 exercise bouts. In chronic WAD, PPT decreased following submaximal exercise, whereas they increased in healthy subjects. The same effect was established in response to the self-paced, physiologically limited exercise, with exception of the PPT at the calf which increased. A worsening of the chronic WAD symptom complex was reported post-exercise. Fewer symptoms were reported in response to the self-paced, physiologically limited exercise. These observations suggest abnormal central pain processing during exercise in patients with chronic WAD. Submaximal exercise triggers post-exertional malaise, while a self-paced and physiologically limited exercise will trigger less severe symptoms, and therefore seems more appropriate for chronic WAD patients.
Osteoarthritis and Cartilage, 2016
Objective: Patients considering or engaged in exercise as treatment may expect or experience transient increases in joint pain, causing fear of exercise and influencing compliance. This study investigated the pain trajectory during an 8-week neuromuscular exercise (NEMEX) program together with acute exercise-induced pain flares in persons with knee or hip pain. Design: Individuals above 35 years self-reporting persistent knee or hip pain for the past 3 months were offered 8 weeks of supervised NEMEX, performed in groups twice weekly. The program consisted of 11 exercises focusing on joint stability and neuromuscular control. Participants self-reported joint pain on a 0e10 numerical rating scale (NRS) at baseline and 8-weeks follow-up. NRS pain ratings were also collected before and immediately after every attended exercise session. Results: Joint pain was reduced from baseline (NRS 3.6; 95% CI 3.2e4.1) to 8-weeks follow-up (2.6; 95% CI 2.1e3.1), (P < 0.01). Pain decreased 0.04 NRS (95% CI 0.02e0.05, P < 0.01) on average per exercise session and pre-to post-exercise pain decreased 0.04 NRS (95% CI 0.03e0.05, P < 0.01) on average per session, approaching no acute exercise-induced pain in the last weeks. Conclusion: This study found a clear decrease in size of acute exercise-induced pain flares with increasing number of exercise sessions. In parallel, pain ratings decreased over the 8 weeks exercise period. Our findings provide helpful information for clinicians, which can be used to educate and balance patient expectation when starting supervised neuromuscular exercise.
Muscle activity pattern dependent pain development and alleviation
2014
Muscle activity is for decades considered to provide health benefits irrespectively of the muscle activity pattern performed and whether it is during e.g. sports, transportation, or occupational work tasks. Accordingly, the international recommendations for public health-promoting physical activity do not distinguish between occupational and leisure time physical activity. However, in this body of literature, attention has not been paid to the extensive documentation on occupational physical activity imposing a risk of impairment of health -in particular musculoskeletal health in terms of muscle pain. Focusing on muscle activity patterns and musculoskeletal health it is pertinent to elucidate the more specific aspects regarding exposure profiles and body regional pain. Static sustained muscle contraction for prolonged periods often occurs in the neck/shoulder area during occupational tasks and may underlie muscle pain development in spite of rather low relative muscle load. Causal mechanisms include a stereotype recruitment of low threshold motor units (activating type 1 muscle fibers) characterized by a lack of temporal as well as spatial variation in recruitment. In contrast during physical activities at leisure and sport the motor recruitment patterns are more dynamic including regularly relatively high muscle forces -also activating type 2 muscles fibers -as well as periods of full relaxation even of the type 1 muscle fibers. Such activity is unrelated to muscle pain development if adequate recovery is granted. However, delayed muscle soreness may develop following intensive eccentric muscle activity (e.g. down-hill skiing) with peak pain levels in thigh muscles 1-2 days after the exercise bout and a total recovery within 1 week. This acute pain profile is in contrast to the chronic muscle pain profile related to repetitive monotonous work tasks. The painful muscles show adverse functional, morphological, hormonal, as well as metabolic characteristics. Of note is that intensive muscle strength training actually may rehabilitate painful muscles, which has recently been repeatedly proven in randomized controlled trials. With training the maximal muscle activation and strength can be shown to recover, and consequently allow for decreased relative muscle load during occupational repetitive work tasks. Exercise training induces adaptation of metabolic and stress-related mRNA and protein responses in the painful muscles, which is in contrast to the responses evoked during repetitive work tasks per se.
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Ciencia & saude coletiva, 2018
Interest in the quality of life of people with mental disorders living in therapeutic residential care facilities is an important indicator for the evaluation of therapeutic interventions in the area of health. Physical activity can contribute to a good quality of life. This study evaluated the quality of life and levels of physical activity of people living in therapeutic residential care facilities in the metropolitan area of Porto Alegre. This case series study (n = 68) used SF-36, EuroQol and IPAQ and social-demographic questions. The SF-36 results showed that the domain of general health received the lowest scores (57.47 ± 14.27). The highest scores were in terms of social aspects (77.39 ± 20.21) and physical aspects (77.57 ± 39.71). When using EuroQol, at least one problem (mild or extreme) in at least one dimension was evident among 82% of the residents. The physical activity levels showed that most of the participants were insufficiently active (48.5%) and 14.7% were sedenta...
Journal of Pain Research
Background: Evidence-based clinical guidelines consider physical exercise one of the best nonpharmacological interventions for low-back pain (LBP), but it is necessary to clarify the exercise-induced hypoalgesia effect of different modalities of exercise in chronic pain populations. Purpose: This study focused on exploring acute changes in tactile and pressure-pain perception and lumbar strength and flexibility in patients with nonspecific chronic LBP (NSCLBP) after performing one of three 20-minute physical exercise modalities. Methods: A total of 81 patients with NSCLBP were pseudorandomly distributed into three groups of 20-minute physical exercise-1) aerobic (n=21, mean age 42±9.72 years, nine men), 2) stretching (n=21, mean age 40±11.37 years, ten men), and 3) strengthening (n=20, mean age 35.80±11.56 years, ten men)-and 4) a control group (n=19, mean age 38.64 ±10.24 years, eight men), and completed self-reported questionnaires during the same period. Tactile and pressure-pain thresholds and isometric lumbar muscle endurance and flexibility were assessed before and after this brief exercise-based intervention. Results: All groups were comparable in terms of sociodemographic and clinical data, cardiovascular capacity, and self-reported data onphysical disability, mood, motivation, psychological response to stimulus properties of physical exercise, and physical activity enjoyment. Our analyses revealed higher tactile sensitivity (p<0.001) and pressure-pain thresholds (p<0.001) at the forefinger than other body locations. We also found lower pain sensitivity (p=0.010) and pressure pain-intensity ratings (p=0.001) and higher lumbar flexibility (p<0.001) after intervention. After calculation of absolute pre-post differences, higher tactile sensitivity was observed at the gluteus medius muscle than the erector spinal muscle only after aerobic intervention (p=0.046). Conclusion: These results add some evidence about different modalities of exerciseinduced hypoalgesia in NSCLBP. However, the fact that we also found improvements in the control group limits our conclusions.
Specific versus Non-Specific Exercises for Chronic Neck or Shoulder Pain: A Systematic Review
Journal of Clinical Medicine, 2021
The current systematic review aimed to compare the effect of injury-focused (specific) exercises versus more general (non-specific) exercises on pain in patients with chronic neck or shoulder pain. We searched PubMed, EMBASE, and Web of Science. Two reviewers screened and selected studies, extracted outcomes, assessed risk of bias, and rated the quality of evidence. A total of nine eligible studies, represented in 13 articles, were identified, with a considerable risk of bias. One article investigated the acute effect of single bouts of exercise on pain and reported an immediate pain reduction after non-specific exercise. Regarding short-term effects, seven out of the nine studies found no differences in pain between interventions, with inconsistent results among two other studies. Concerning the long-term effects, while pain reduction seems to be favored by specific exercises (two out of four articles), the best format is still unclear. Based on the acute effects, a single bout of ...
Advances in targeting central sensitization and brain plasticity in chronic pain
The Egyptian Journal of Neurology, Psychiatry and Neurosurgery, 2022
Maladaptation in sensory neural plasticity of nociceptive pathways is associated with various types of chronic pain through central sensitization and remodeling of brain connectivity. Within this context, extensive research has been conducted to evaluate the mechanisms and efficacy of certain non-pharmacological pain treatment modalities. These include neurostimulation, virtual reality, cognitive therapy and rehabilitation. Here, we summarize the involved mechanisms and review novel findings in relation to nociceptive desensitization and modulation of plasticity for the management of intractable chronic pain and prevention of acute-to-chronic pain transition.
Aerobic Upper-Limb Exercise-Induced Hypoalgesia: Does It Work?
Applied Sciences
Background: Aerobic exercise reduces pain sensitivity, a phenomenon known as exercise-induced hypoalgesia (EIH); however, little is known about EIH when the upper limbs are aerobically exercised. This study aimed to test the acute effect of a single aerobic upper-limb exercise on pain threshold and pain intensity in healthy participants, with two different protocols for controlling intensity. Methods: 31 participants performed two 20 min exercise sessions a week apart. In each session, the intensity was controlled by a target heart rate (THR) of 60% of heart rate reserve or by a rate of perceived exertion (RPE) of 7/10 on the Borg scale. Pain threshold for pressure (PPT) heat (HPT) and pain intensity in response to Tonic Heat Pain (THP) were measured pre- and post-exercise. To examine the effect of exercise in each protocol on pain sensitivity, rmANOVA was conducted. Results: Pain sensitivity remained unchanged following arm exercise in both protocols (PPT, p = 0.67; HPT, p = 0.56; ...
Prescription of therapeutic exercise for chronic low back pain management: a narrative review
Bulletin of Faculty of Physical Therapy
Background The results of recent systematic reviews have concluded that most exercise types are more effective than minimal treatment for improving outcomes in the management of non-specific chronic low back pain. However, exercise prescriptions are criticised for being prescribed without a clear rationale and with a high level of uncertainty. The preferred mode of exercise in this population is not outlined in clinical guidelines. The objective of this review is to describe the indications and dosimetry for the most common exercise interventions prescribed. Methods Literature was sourced from searches of MEDLINE, CINAHL, SPORTDiscus, and PEDro databases until October 2021 using descriptors related to pain, exercise, and prescription, totaling 33 articles that fulfilled the inclusion and exclusion criteria. The first author independently selected studies and extracted data on study characteristics of interest. Any doubts were resolved through discussion with the other reviewers. Res...
Physical Activity in Women with Endometriosis: Less or More Compared with a Healthy Control?
International Journal of Environmental Research and Public Health
Background: Endometriosis, i.e., endometrial-like tissue outside the uterus, is a chronic inflammatory condition affecting physical functioning. However, the specific levels of physical activity (PA) in the context of endometriosis and different disease symptoms remain unclear. Methods: This multi-center, cross-sectional study compared PA levels and influencing factors in endometriosis patients and non-endometriosis patients. Data were collected through questionnaires. Endometriosis was surgically confirmed. A statistical analysis was performed with appropriate tests. Results: The study included 460 women with endometriosis and 460 age-matched women without this condition. The two groups did not differ significantly in terms of age, education level, or stable partnership. Women with endometriosis exhibited lower PA levels, practicing fewer hours of sports weekly and climbing fewer stairs daily compared to the control group. These differences remained significant after controlling fo...
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Neurobiology of Pain, 2023
Dysfunctional top-down pain modulation is a hallmark of fibromyalgia (FM) and physical exercise is a cornerstone in FM treatment. The aim of this study was to explore the effects of a 15-week intervention of strengthening exercises, twice per week, supervised by a physiotherapist, on exercise-induced hypoalgesia (EIH) and cerebral pain processing in FM patients and healthy controls (HC). FM patients (n = 59) and HC (n = 39) who completed the exercise intervention as part of a multicenter study were examined at baseline and following the intervention. Following the exercise intervention, FM patients reported a reduction of pain intensity, fibromyalgia severity and depression. Reduced EIH was seen in FM patients compared to HC at baseline and no improvement of EIH was seen following the 15-week resistance exercise intervention in either group. Furthermore, a subsample (Stockholm site: FM n = 18; HC n = 19) was also examined with functional magnetic resonance imaging (fMRI) during subjectively calibrated thumbnail pressure pain stimulations at baseline and following intervention. A significant main effect of exercise (post > pre) was observed both in FM patients and HC, in pain-related brain activation within left dorsolateral prefrontal cortex and caudate, as well as increased functional connectivity between caudate and occipital lobe bordering cerebellum (driven by the FM patients). In conclusion, the results indicate that 15-week resistance exercise affect pain-related processing within the cortico-striatal-occipital networks (involved in motor control and cognition), rather than directly influencing top-down descending pain inhibition. In alignment with this, exercise-induced hypoalgesia remained unaltered.
The Journal of Pain, 2001
Exercise activates endogenous opioid and adrenergic systems, but attenuation of experimental pain by exercise has not been shown consistently. In this study, effects of exercise on temporal summation of late pain responses to stimulation of unmyelinated (C) nociceptors were assessed. When a preheated thermode was applied repetitively to glabrous skin of the hand in a series of brief contacts at rates of 0.2 to 0.5 Hz, the perceived intensity of late thermal sensations increased after successive contacts. This summation of pain sensations provides information regarding the status of central opioid and N-methyl-D-aspartate receptor systems. For normal subjects, temporal summation of late pain sensations was substantially attenuated when testing began 1.5 or 10 minutes after exercise. Individuals diagnosed with fibromyalgia syndrome (FMS) report generalized chronic pain that is increased after exercise. Therefore, we hypothesized that strenuous exercise would increase summation of late pain sensations in this cohort. Patients with FMS and control subjects exerted to similarly high metabolic rates, as shown by physiologic monitoring. Ratings of late pain sensations increased for patients with FMS after exercise, an effect opposite to a decrease in ratings for age/sex-matched control subjects. In contrast to this result for experimentally induced pain, clinical pain ratings were not substantially altered after strenuous exercise by patients with FMS.
Principles and Practice of Clinical Research Journal
Background: The use of exercise is a potential treatment option to modulate pain (exercise-induced hypoalgesia). The pain threshold (PT) response is a measure of pain sensitivity that may be a useful marker to assess the effect of physical exercise on pain modulation. Aim: The aim of this systematic review and meta-analysis is to evaluate the PT response to exercise in healthy subjects. Methods: We searched in MEDLINE, EMBASE, Web of Science, Lilacs, and Scopus using a search strategy with the following search terms: "exercise" OR "physical activity" AND "Pain Threshold" from inception to December 2nd, 2019. As criteria for inclusion of appropriate studies: randomized controlled trials or quasi-experimental studies that enrolled healthy subjects; performed an exercise intervention; assessed PT. Hedge's effect sizes of PT response and their 95% confidence intervals were calculated, and random-effects meta-analyses were performed. Results: For the final analysis, thirty-six studies were included (n=1326). From this, we found a significant and homogenous increase in PT in healthy subjects (ES=0.19, 95% CI= 0.11 to 0.27, I2=7.5%). According to subgroup analysis, the effect was higher in studies: with women (ES=0.36); performing strength exercise (ES=0.34), and with moderate intensity (ES=0.27), and no differences by age were found. Confirmed by the meta-regression analysis. Conclusion: This meta-analysis provides evidence of small to moderate effects of exercise on PT in healthy subjects, being even higher for moderate strength exercise and in women. These results support the idea of modulation of the endogenous pain system due to exercise and highlight the need for clinical translation to the chronic pain population.
Pain Medicine
Objective. Physically active individuals show greater conditioned pain modulation (CPM) compared with less active individuals. Understanding the effects of acute exercise on CPM may allow for a more targeted use of exercise in the management of pain. This study investigated the effects of acute isometric exercise on CPM. In addition, the between-session and within-session reliability of CPM was investigated. Design. Experimental, randomized crossover study. Setting. Laboratory at Marquette University. Subjects. Thirty healthy adults (19.361.5 years, 15 males). Methods. Subjects underwent CPM testing before and after isometric exercise (knee extension, 30% maximum voluntary contraction for three minutes) and quiet rest in two separate experimental sessions. Pressure pain thresholds (PPTs) at the quadriceps and upper trapezius muscles were assessed before, during, and after ice water immersions. Results. PPTs increased during ice water immersion (i.e., CPM), and quadriceps PPT increased after exercise (P < 0.05). CPM decreased similarly following exercise and quiet rest (P > 0.05). CPM withinsession reliability was fair to good (intraclass correlation coefficient [ICC] 5 0.43-0.70), and the between-session reliability was poor (ICC 5 0.20-0.35). Due to the variability in the systemic exerciseinduced hypoalgesia (EIH) response, participants were divided into systemic EIH responders (N 5 9) and nonresponders (N 5 21). EIH responders experienced attenuated CPM following exercise (P 5 0.03), whereas the nonresponders showed no significant change (P > 0.05). Conclusions. Isometric exercise decreased CPM in individuals who reported systemic EIH, suggesting activation of shared mechanisms between CPM and systemic EIH responses. These results may improve the understanding of increased pain after exercise in patients with chronic pain and potentially attenuated CPM.
Exercise‐induced analgesia and the role of reactivity in pain sensitivity
Journal of sports sciences, 1994
The present study was designed to evaluate whether pain perception and pain tolerance are altered by submaximal aerobic exercise. Sixty male volunteers were randomly assigned to one of two control or experimental groups in the first of two sessions. In session 1, baseline measures of pain tolerance and pain perception were obtained for half of the subjects in each of the experimental and control groups, respectively. In addition, all subjects completed the Reactivity Scale, followed by estimation of their maximum aerobic power (VO 2 max) using the Canadian Home Fitness Test. In session 2, the subjects in the two experimental groups exercised for 12 min by climbing a double step to pre-recorded musical cadences, working on average at 63% VO 2 max, whereas the subjects in the two control groups spent approximately 12 min completing two short unrelated questionnaires. Measures of pain tolerance and pain perception were obtained from all subjects after exercising or completing questionnaires. Pain tolerance was assessed by the amount of time (up to 10 min) that subjects could voluntarily endure a 2300 g pressure to the index finger of their dominant hand. Pain perception was defined by participants' intensity ratings on an 11-point scale, made at 30 and 60 s. The results showed that reactivity and exercise were significant predictors of pain tolerance, together accounting for approximately 22% of the variance. The finding that submaximal workloads produce analgesia supports the potential usefulness of exercise in therapeutic intervention.
Current Pain and Headache Reports, 2012
Chronic pain is one of the most common complaints seen in general practitioners' offices, and it contributes to social, emotional, physical, and economical losses. The management of this problem poses challenges for health care providers when the current treatment of choice for chronic pain is pharmacological management, which may not be a sufficient and/or holistic approach to the management of chronic pain. Our goal is to increase awareness of the significance of physical activity, as well as examine additional cost-effective, integrated approaches to help manage the complex and debilitating effects of this condition. This article summarizes the types of exercise in the rehabilitation of chronic pain patients and provides practical recommendations for the clinician based on empirical and clinical experience. This safe, cost-free, nonpharmacologic way of managing pain has been found to reduce anxiety and depression, improve physical capacity, increase functioning and independence, and reduce morbidity and mortality.
Pain complaint-exercise performance relationship in chronic pain
Pain, 1981
Chronic pain patients typically display reduced activity level attributed to pain and implying a positive correlation between exercise or activity and pain complaints. This study correlated observed pain complaints with amount of prescribed exercise performed by chronic pain patients when exercising to tolerance. Patients were in evaluation of earliest stages of multi-modal treatment. Exercises were physician prescribed to assess use of involved body parts and to promote general activity level. Patients were instructed to do exercise repetitions until pain, weakness or fatigue caused them to stop. Patients decided when to stop. Observations of amount of exercise performed were correlated with observed visible or audible indications of pain or suffering (pain behaviors). Results indicate a consistent negative relationship, i.e., the more exercise performed, the fewer the pain behaviors. This finding is contrary to the frequently observed physician prescription with chronic pain to limit exercise when pain increases.
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