Tape That Increases Medial Longitudinal Arch Height Also Reduces Leg Muscle Activity: A Preliminary Study

Clinical Investigations Tape That Increases Medial Longitudinal Arch Height Also Reduces Leg Muscle Activity: A Preliminary Study MELINDA FRANETTOVICH 1,2, ANDREW CHAPMAN 1,2, and BILL VICENZINO 2 1 Australian Institute of Sport, Canberra, AUSTRALIA; and 2 University of Queensland, Brisbane, AUSTRALIA ABSTRACT FRANETTOVICH, M., A. CHAPMAN, and B. VICENZINO. Tape That Increases Medial Longitudinal Arch Height Also Reduces Leg Muscle Activity: A Preliminary Study. Med. Sci. Sports Exerc., Vol. 40, No. 4, pp. 593 600, 2008. Purpose: To evaluate the initial effects of antipronation taping (APT) on foot posture and electromyographic (EMG) activity of tibialis anterior (TA), tibialis posterior (TP), and peroneus longus (PL) muscles during walking. Methods: Five asymptomatic individuals who exhibited lower medial longitudinal arch height on a clinical assessment of gait walked on a treadmill for 10 min before and after the application of an APT technique specifically, the augmented low-dye. Arch height (AH) in standing as well as peak and average amplitude, duration, time of onset, and time of offset of recorded EMG activity during walking were analyzed for each condition. Results: APT produced a mean (95% confidence interval (CI)) increase in AH of 12.9% (6.5 19.3; P = 0.005). Mean (95% CI) reductions in peak and average EMG activation of TA (peak: j23.9% (j34.0 to j13.9); average: j7.8% (j13.6 to j2.0)) and TP (peak: j45.5% (j77.3 to j13.7); average: j21.1% (j41.6 to j0.6)) were observed when walking with APT (P G 0.05). The APT also produced a small increase in duration of TA EMG activity of 3.7% (0.9 6.5) of the stride cycle duration, largely because of an earlier onset of EMG activity (4.4%; j8.1 to j0.8 of a stride cycle; P G 0.05). Conclusion: APT reduces activity of the TA and TP muscles during walking while increasing AH, which provides preliminary evidence of its role in reducing the load of these key extrinsic muscles of the ankle and the foot. Follow-up study is required to evaluate these findings. Key Words: PRONATION, GAIT, FOOT, POSTURE, ELECTROMYOGRAPHY Antipronation taping (APT) is frequently used by clinicians in the management of lower-extremity musculoskeletal pain and injury. Several studies support this practice, reporting that APT reduced pain scores in individuals with heel and foot pain immediately after application (20,34), during an intervention period of 1 5 d (20,26,34), and 24 h after removal of APT (34). These studies hypothesized that the reduction of pain was attributable to mechanical changes induced by APT, such as alteration in forefoot pressures, navicular height, calcaneal angle, and tibial position (20,34). In support of this Address for correspondence: Bill Vicenzino, Division of Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia; E-mail: b.vicenzino@uq.edu.au. Submitted for publication August 2007. Accepted for publication November 2007. 0195-9131/08/4004-0593/0 MEDICINE & SCIENCE IN SPORTS & EXERCISE Ò Copyright Ó 2008 by the American College of Sports Medicine DOI: 10.1249/MSS.0b013e318162134f hypothesis, several studies have reported mechanical changes induced by APT, including increased navicular height, decreased calcaneal eversion, and decreased internal tibial rotation in both resting standing posture (15,16,37,39) and during walking and running (11,23,38). In contrast, there is a lack of specific research of any possible neuromuscular effects of APT. It is probable that APT will engender such effects because tape has been shown to produce these effects at other regions, for example, in the ankle and patellofemoral joints. Taping techniques that resist inversion sprains have been shown to alter the peroneal muscle response latency to an inversion perturbation in unstable ankles (22,35) as well change activity of leg muscles (1,43). Several studies on patellofemoral taping have shown that it results in earlier onset (8,13) and increased vastus medialis oblique activity (7,27) in individuals with patellofemoral pain. It would, therefore, be reasonable to expect that APT may change neuromuscular control of the foot and ankle. On the basis of APT-induced antipronation effects (11,15,16,37 39), we hypothesized that the application of 593

TABLE 1. Electrode placement for tibialis anterior (TA), tibialis posterior (TP), and peroneus longus (PL) recordings. Muscle Electrode Type Landmark 1 Landmark 2 Distance (%) Depth (%) TA Surface Medial joint line of knee Medial malleolus of tibia 30 N/A TP Intramuscular Medial joint line of knee Medial malleolus of tibia 50 50 PL Intramuscular Head of fibula Lateral malleolus of fibula 8 50 APT would reduce the requirement from the muscular system in the control of foot posture and, therefore, that APT would reduce the activity of leg muscles during walking. Our aim was to conduct a preliminary evaluation of the initial effects of an APT on muscle activity during walking in asymptomatic individuals who exhibit lower arch foot posture. METHODS Participants. We recruited five (three female, two male) asymptomatic individuals who were (mean T standard deviation) 36.4 T 7.5 yr, 169.4 T 8.3 cm, and 70.2 T 14.7 kg in age, height, and weight, respectively. They were recruited because they were rated as having a lower medial longitudinal arch height (e.g., excessive pronation) during the stance phase of walking by a sports and musculoskeletal physiotherapist (36). We chose this method of participant selection because there is currently no consensus or established clinical method to validly determine pronators or those with low arch and, thereby, to identify those individuals who may benefit from APT. The authors decided to rely on a decision made by an experienced practitioner, in an attempt to replicate current practice. Participants were excluded from the study if they had a current lower-limb injury, a lower-limb injury in the past 6 months that required treatment or interfered with work or leisure, surgery on the lower limbs, a neurological FIGURE 1 A, The foot was positioned in approximately two-thirds supination and the first ray plantar flexed. For the low-dye technique, a spur was applied from the medial aspect of the neck of the first metatarsal and was directed posteriorly around the back of the calcaneum to the lateral aspect of the neck of the fifth metatarsal. The spur was applied with the forefoot slightly adducted. To complete the low-dye technique, mini-stirrups were applied from the lateral aspect of the spur, running under the plantar surface approximately perpendicular to the foot and ending at the medial aspect of the spur. B, An anchor was then applied one-third up the length of the leg, with application of a circumferential strip. Each reverse six was applied from the medial malleolus, directed laterally across the dorsum of the foot, under the midfoot in a lateral-to-medial direction, then crossed over its origin and continued up to the anchor strip. C, Each calcaneal sling was applied from the anterior aspect of the anchor, coursed distally and posteriorly over the medial Achilles tendon, around the posterior lateral calcaneum, under the calcaneum and midfoot, and, finally, coursed proximally up the anteromedial aspect of the distal leg to insert on its origin. D, The finished augmented low-dye technique consisting of a low-dye, three reverse sixes, and two calcaneal slings. 594 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org

condition, a family history of heart problems, an allergy to strapping tape, previously experienced APT, or were unable to walk for 20 min on a treadmill. All participants were informed about the procedures and gave written consent. The study was approved by the institutional human research ethics committees in accordance with the Declaration of Helsinki. Arch height. Measurements of arch height (AH) were performed as an indication of foot posture and changes brought about by the tape. We selected this measurement of foot posture in preference to other methods, because of its validity and high reliability (9,12,38,41). The participant stood on a template in bilateral stance with weight evenly distributed between both feet. The template ensured standardized and repeatable foot position between and within subject trials. A digital caliper (Mitutoyo) was used to measure AH as the vertical distance from the template (ground) to the dorsal surface of the foot at the midfoot (i.e., 50% foot length). Electromyography. Electromyographic (EMG) activity of tibialis anterior (TA), tibialis posterior (TP). and peroneus longus (PL) muscles was recorded using bipolar intramuscular or surface electrodes. The decision to use surface or intramuscular electrodes was governed by the anatomic and geometric factors of the muscles of interest. For example, intramuscular electrodes are located within the muscle of interest, and recordings from intramuscular electrodes avoid contamination from attenuation of the signal by overlying soft tissue or cross-talk of adjacent muscles (2,3,30), which is advantageous for evaluation of deep or small muscles such as TP and PL. Intramuscular electrodes, for TP and PL, were fabricated from 75-Km Teflon-coated stainless-steel wire (AM Systems). Two millimeters of insulation was removed from the end of each wire to form the recording surface before insertion into a hypodermic needle (0.65 32 mm). The exposed tips were bent back by staggered lengths of 2 and 4 mm to prevent contact. Surface EMG was used to record EMG activity from TA, a large superficial muscle, using silver/ silver chloride electrodes of 10-mm-diameter contact area and fixed interelectrode distance of 20 mm (Nicolet Biomedical). A ground electrode was positioned over the iliac crest (3M Health Care). Electrode positions were chosen with reference to recommendations from Perotto (29) and innervation zone locations reported by Rainoldi et al. (31) (Table 1), consistent with established methodology (5). A standard procedure for skin preparation was followed for application of all electrodes (17). Intramuscular electrodes were inserted using real-time ultrasound guidance (5-MHz curved array transducer (GEC)). TP insertions were made from the posteromedial aspect of the leg. All insertions were performed by A.C. EMG data were amplified with a gain of 2000, band-pass filtered between 10 and 1000 Hz, sampled at 2000 Hz, and digitized by a 16-bit analog-to-digital converter. EMG recordings from TA and PL were obtained from all five participants. Recordings from TP were obtained from four participants; recordings from one participant were unsuccessful. Taping technique. The taping technique was the augmented low-dye (Fig. 1), which has been described previously (36) and demonstrated to be superior to the low- Dye technique (12,15,37 39). The augmented low-dye CLINICAL SCIENCES FIGURE 2 Illustration of indices of muscle activity. Example data and the criteria used for determining timing of EMG onset, timing of EMG offset, EMG duration, and peak amplitude are illustrated. A burst of muscle activity is identified in panel A as the amplitude of muscle activity exceeding 15% of peak activation for more than 10% of the stride. Onset and offset of muscle activity are selected as the start and finish of this burst of activity. Duration of muscle activity is the percentage of the stride that the muscle is active, as determined by the difference between onset and offset times. In contrast to panel A, a burst of muscle activity is not identified in panel B, because muscle activity does not exceed 15% of peak activation for more than 10% of the stride, and, subsequently, no onset or offset times are identified. These procedures for data management and analysis are consistent with the literature (4 6). TAPE CHANGES MUSCLE ACTIVITY DURING WALKING Medicine & Science in Sports & Exercise d 595

TABLE 2. The repeatability of EMG variables (peak, average, duration, onset, offset) for each muscle is indicated by the intraclass correlation coefficient (ICC) and standard error of measurement (SEM). Tibialis Anterior Tibialis Posterior Peroneus Longus Variable ICC SEM ICC SEM ICC SEM Peak 0.662 6.7 0.913 7.3 0.802 9.4 Average 0.973 0.8 0.788 5.4 0.976 2.5 Duration 0.967 1.1 0.948 2.1 0.928 2.7 Onset 0.992 0.5 0.994 0.8 0.889 1.9 Offset 0.974 0.4 0.677 3.2 0.988 0.6 For amplitude variables (peak, average), SEM values are a percentage of normalized EMG. For temporal variables (duration, onset, offset), SEM values are a percentage of stride time. involves the low-dye technique, consisting of spurs and mini-stirrups, with the addition of two calcaneal slings and three reverse sixes that are anchored on the distal third of the leg. A rigid sports tape (38-mm zinc oxide adhesive, Leukosport, BDF) was applied to all participants by an experienced sports and musculoskeletal physiotherapist. Procedure. After screening and completion of the informed written consent process, each participant underwent a standard preparation and experimental procedure. An accelerometer (PCB Piezotronics Inc.) was attached to the heel of the test leg and was used to signal contact with the treadmill. The test leg was determined by the sports and musculoskeletal physiotherapist as the foot that exhibited the lowest AH. For the baseline condition, participants walked barefoot on a treadmill (Life Fitness) through a period of acclimatization, which began at a selfselected speed and then gradually increased to the test speed of 4.5 kmih j1, all with no inclination. Each participant walked for 10 min while EMG data were recorded. The taping technique was then applied to the test foot before the participant again walked on the treadmill for a further 10 min at the same pace as previously. The order of condition exposure was not randomized, because untaped (baseline) trials performed after taped trials may not be representative of the participants` true gait pattern, because of a possible carryover effect of the tape (33). AH measurement was made in triplicate before and after the 10 min of baseline walking, immediately after tape, and after 10 min of walking with tape in situ. The tape and electrodes were removed after testing, and the area was inspected for any adverse response to the study procedures. Data management and analysis. The EMG recordings were adjusted for DC offset, full-wave rectified, and filtered with a 10-Hz high-pass filter. Individual strides were defined from foot contact to ipsilateral foot contact, as determined from accelerometer recordings of foot contact. From each minute of the 10 min of data collected, we selected for analysis the 10 strides with duration nearest the mean stride time. Each stride was time normalized to 100 points. Data were averaged across the 10 min (i.e., 10 strides per 10 min = total 100 strides per condition). For each participant, EMG amplitude was normalized to the maximum baseline EMG amplitude (5,28,42). From a total of 280 recordings, 272 (97%) were successful and included in the analyses. Peak and average amplitude, duration, and time of onset and offset of muscle activity (EMG) for each individual stride were taken from EMG recordings (Fig. 2). Peak EMG amplitude was identified as the maximum signal intensity during the individual stride. To encapsulate the effect of tape on overall muscle activity during the stride, average EMG amplitude was calculated for the duration of muscle activity (i.e., when the muscle was active during the stride). A muscle was considered active when the amplitude of EMG activity exceeded 15% of the peak amplitude for more than 10% of the stride cycle (4 6). Onset and offset of muscle activity were then visually confirmed as the time point that the burst of muscle activity started and finished (Fig. 2). The duration of muscle activity was the percentage of the stride cycle that the muscle was active; this was calculated from the determined onset and offset of muscle activity. Identification of temporal EMG measures (duration, onset, offset) using computer-based methods is less reliable when EMG trace characteristics, such as background activity and rate of increase in signal amplitude, are variable (5,18). Visual identification was, therefore, deemed more appropriate for this analysis, because of variation in these characteristics between different muscles. The reliability of AH measurements and EMG variables were expressed as intraclass correlation coefficient (ICC) and standard error of measurement (SEM). Consistency of EMG recordings was further evaluated by the root mean square error (RMSE) and the coefficient of multiple correlations (CMC) between the average stride for each minute of data. Paired t-tests (SPSS 15.0 for Windows) were performed to investigate differences in the dependent variables between baseline and taped conditions. Significance was TABLE 3. The repeatability of EMG recordings from tibialis anterior (TA), tibialis posterior (TP), and peroneus longus (PL) for each condition as indicated by the group root mean square error (RMSE) and coefficient of multiple correlation (CMC). CMC (95% Confidence Interval) RMSE (Normalized EMG) (Standard Deviation) Muscle Baseline Tape Baseline Tape TA 0.94 (0.92 to 0.97) 0.94 (0.93 to 0.96) 19.22% (3.62) 15.22% (2.48) TP 0.87 (0.78 to 0.96) 0.84 (0.73 to 0.95) 25.07% (4.22) 13.75% (4.28) PL 0.86 (0.80 to 0.92) 0.87 (0.83 to 0.92) 23.90% (2.41) 22.62% (3.36) CMC values approaching 1 are indicative of high repeatability. 596 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org

set at 0.05. Point estimates of effect were presented as standardized mean differences (i.e., effect size estimates = mean difference/standard deviation). Standardized mean differences equal or greater than 1.0 were considered meaningful (http://www.sportsci.org/resource/stats). Visual comparisons of individual muscle-recruitment patterns through the entire stride were also used to corroborate differences in EMG variables between the two conditions. RESULTS Repeatability of AH and EMG. AH displayed excellent repeatability, with an ICC (95% CI) of 0.996 (0.993 0.998) and an SEM of 0.44 mm, which equated to less than 1% of mean AH values. Table 2 displays the ICC and SEM values for EMG variables (peak, average, duration, onset, offset). Eighty-percent of EMG variables displayed high repeatability (ICC > 0.8), with the remaining 20% of substantial repeatability (ICC 0.662, 0.677, 0.788) (25). SEM values will be discussed in the corresponding results sections for each variable. Table 3 displays the overall repeatability of the EMG recordings for each muscle. Mean CMC values were above 0.8 for all muscles and were therefore considered high (25). The high CMC values reported in this study are comparable with previous work (21). The consistency of the EMG pattern across the 10 min of walking in the baseline condition suggests that there is no accommodation or variation during walking. For the taped condition, the consistency of the EMG pattern across the 10 min of walking suggests that the tape-induced neuromuscular effect is maintained throughout the 10-min duration of walking. FIGURE 4 The 95% confidence interval of the average patterns of muscle activation during one stride for baseline (shaded) and tape (unshaded) conditions are illustrated for a representative individual. Stride duration (1 100%) is displayed on the x-axis. Amplitude (percent, normalized to maximum baseline EMG) is displayed on the y-axis. Foot posture/ah. As seen in Figure 3, there was a mean increase in AH by 8 mm (12.9%) immediately after application of the APT (P = 0.005). After 10 min of walking, this initial effect was reduced to 5 mm (8.5%) but was still greater than the baseline values (P = 0.002). EMG. An impression of the effect of tape on EMG can be seen by reference to a representative individual (Fig. 4); that is, there is a reduction in the peak activation of TA and TP, some alteration in the timing of activation for TA, and CLINICAL SCIENCES FIGURE 3 Mean differences T 95% confidence intervals for arch height between baseline (BL) and tape (TAPE) conditions at 0 and 10 min of walking. For example, BL 0 j BL 10 corresponds to the mean difference in arch height between the baseline condition at 0 min of walking and the baseline condition at 10 min of walking. Mean differences are statistically significant where confidence intervals do not contain 0 mm. TABLE 4. Mean (SD) for baseline (BL) and tape (TAPE) conditions, and mean differences (95% CI) at the tibialis anterior (TA), tibialis posterior (TP), and peroneus longus (PL). BL TAPE Difference TA Peak 100.0 (14.3) 76.1 (8.1) j23.9 (j34.0 to j13.9)* Average 39.3 (6.7) 31.5 (2.4) j7.8 (j13.6 to 2.0)* Duration 54.6 (5.2) 58.3 (6.7) 3.7 (0.9 to 6.5)* Onset 56.3 (5.0) 51.9 (7.3) j4.4 (j8.1 to j0.8)* Offset 10.8 (2.2) 10.2 (1.8) j0.5 (j1.4 to 0.4) TP Peak 100.0 (29.1) 54.5 (19.9) j45.5 (j77.3 to j13.7)* Average 48.2 (3.4) 27.1 (10.1) 21.1 (j41.6 to j0.6)* Duration 53.5 (9.7) 51.8 (6.6) j1.7 (j9.2 to 5.8) Onset 17.1 (8.9) 18.3 (14.5) 1.1 (j8.4 to 10.7) Offset 55.1 (5.4) 53.8 (3.9) j1.3 (j12.4 to 9.9) PL Peak 100.0 (7.7) 105.1 (17.9) 5.1 (j17.2 to 27.4) Average 67.4 (10.9) 66.5 (13.4) j0.9 (j4.4 to 2.6) Duration 48.7 (5.5) 44.5 (7.9) j4.2 (j10.8 to 2.4) Onset 22.0 (3.7) 22.3 (1.7) 0.3 (j2.9 to 3.6) Offset 56.1 (5.8) 53.8 (4.0) j2.3 (j4.8 to 0.2) Peak and average values are percentages of maximum EMG, whereas the duration, onset, and offset are a percentages of stride. * Significant at 0.05 level. TAPE CHANGES MUSCLE ACTIVITY DURING WALKING Medicine & Science in Sports & Exercise d 597

FIGURE 5 Individual effect sizes (mean difference/standard deviation) for EMG variables. Effect sizes of 1 or greater are likely to indicate a strong effect. very little change in PL. This is reflected in the group peak, average, duration, and on- and offsets of EMG data (Table 4). Amplitude of muscle activity. Tape produced substantial reductions of 23.9% and 45.5% in the peak activation of TA and TP, respectively (P = 0.003, 0.02), but not in PL (5.1%; P = 0.561). Reductions in average activation of 7.8% and 21.1% were also observed for TA and TP (P = 0.021, 0.047), but not for PL (j0.9%; P = 0.520). The changes in TA and TP occurred consistently in each participant, with effect sizes considerably greater than 1 (Fig. 5), and they were in excess of the associated measurement error (see Table 2 for SEM). This was not the case for PL. Temporal measures of muscle activation. Duration of TA muscle activity during an entire stride cycle was moderately increased by tape (mean difference of 3.7% (38.32 ms); individual effect sizes 9 0.7; P = 0.022 (Fig. 5)). There were no such effects for TP and PL (P 9 0.05). There was a substantially earlier onset of TA muscle activity when taped (4.4% or 46.23 ms; effect sizes 91; P = 0.028), which seemed not to be the case for TP and PL activity (P > 0.05). The changes in TA duration and onset of muscle activity were in excess of the SEM (Table 2). The smallest effect sizes were found in offsets of muscle activity, indicating that tape may not influence muscle activity offset. DISCUSSION This preliminary study is the first to evaluate the concurrent initial effects of augmented low-dye tape on foot posture and EMG activity of leg muscles during gait. We found evidence that the augmented low-dye would reduce leg muscle activity during walking, and we confirmed previous findings that this taping technique increases medial longitudinal AH in asymptomatic individuals. The tape-induced increase in medial longitudinal AH conceivably represents a plantarflexion of the forefoot on the rearfoot and an inversion of the rearfoot, which occurs concurrently with a reduction of TP activity, a major invertor and plantarflexor of the foot and ankle. Further research in a larger study involving asymptomatic and symptomatic people is now warranted to confirm or refute this proposition. We observed a large, APT-induced reduction in peak and average activity of TA and TP, and an earlier onset and increased duration of TA activity, in all participants. Except for PL, our data are in line with pilot work of Wall et al. (40), who also have reported an APT-induced reduction of peak muscle activation during the dynamic tasks of cutting, back-pedaling, drop jumps, and hopping in individuals with and without leg pain. Interestingly, several previous studies comparing normal versus flat feet have reported increased extrinsic muscle activity in flat-footed individuals during walking (14,19). It is compelling to speculate that the tape has a physiological basis in the treatment of people with flat feet. The results of the current study support the hypothesis that muscle activity would be reduced with APT; however, how the tape-induced increase in medial longitudinal AH is related to the changes in EMG activity observed in our study is unknown. Tape, in changing foot posture, could alter lever arms of the TP and TA muscles, which may conceivably lead to a reduction in demand on these muscles. However, this is unlikely, because Klein et al. (24) have shown in a cadaveric study (N = 10) that there is minimal change in moment arm length of these muscles during talocrural and subtalar joint movements. Also, the neuromuscular modulation seen with tape could occur directly through stimulation of cutaneous receptors (7,27). For example, Fallon et al. (10) report that there was modulation of TA, lateral gastrocnemius, and soleus 598 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org

activity after stimulation of individual, low-threshold mechanoreceptors in the foot. Further research is required to evaluate the relationship between the changes in foot posture and muscle activity, to better understand how tape works. Inferences made from the current study should be tempered, considering the small subject numbers (N = 5). Notwithstanding this, we found strong effects for TA and TP (mean reductions in peak activity of 23.9% and 45.5%, respectively), which were not only larger than the error (RMSE of 19.2 and 25.1; SEM of 6.7 and 7.3) but also statistically significant (i.e., the study was sufficiently powered for those comparisons). Furthermore, the EMG data were consistent across the 10 min of testing (CMC > 0.8), and the recruitment patterns of TA, TP, and PL were representative of those described in the literature (14,19,21,32). Gender may be a factor in the effects of taping; however, this is unlikely to unduly influence the within-subject comparison of the effects of the tape measured in this study. CONCLUSION This is preliminary evidence that tape that increases height of the medial longitudinal arch also produces large and reliable reductions in EMG activity of extrinsic muscles of the foot and ankle. Health care practitioners may consider using this tape when managing patients who exhibit lower medial longitudinal AH and increased muscle activity during walking. Melinda Franettovich is supported by the National Health and Medical Research Council. Andrew Chapman is supported by the Australian Research Council. There are no conflicts of interest relevant to this study for any author. CLINICAL SCIENCES REFERENCES 1. Alt W, Lohrer H, Gollhofer A. Functional properties of adhesive ankle taping: neuromuscular and mechanical effects before and after exercise. Foot Ankle Int. 1999;20(4):238. 2. 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