MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Neck pain is a common problem which often causes significant disability. Chiropractic manipulation has become one of the most popular forms of alternative treatment for such symptoms. This seems surprising considering that neck manipulations are neither convincingly effective nor free of adverse effects.

The current Cochrane review on this subject could not be clearer: “Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior.” In the absence of compelling evidence for efficacy, any risk of neck manipulation would tilt the risk/benefit balance into the negative.

Adverse effects of neck manipulations range from mild symptoms, such as local neck tenderness or stiffness, to more severe injuries involving the spinal cord, peripheral nerve roots, and arteries within the neck. A recent paper reminds us that another serious complication has to be added to this already long list: phrenic nerve injury.

The phrenic nerve is responsible for controlling the contractions of the diaphragm, which allows the lungs to take in and release air and make us breathe properly. The phrenic nerve is formed from C3, C4, and C5 nerve fibres and descends along the anterior surface of the scalenus anterior muscle before entering the thorax to supply motor and sensory input to the diaphragm. Its anatomic location in the neck leaves it vulnerable to traumatic injury. Phrenic nerve injury can result in paralysis of the diaphragm and often leads to deteriorating function of the diaphragm, which can lead to partial or complete paralysis of the muscle and, as a result, serious breathing problems.

Patients who experience such problems may require emergency medical treatment or surgery. Sudden, severe damage to the phrenic nerve can make it impossible for the diaphragm to contract on its own. In order to make sure that the patient can breathe, a breathing tube needs to be inserted, a process called intubation. Artificial respiration would then be required.

American neurologists published a case report of a healthy man who consulted a chiropractor for his neck pain. Predictably, the chiropractor employed cervical manipulation to treat this condition. The result was bilateral diaphragmatic paralysis.

Similar cases have been reported previously, for instance, here and here and here and here. Damage to other nerves has also been documented to be a possible complication of spinal manipulation, for instance, here and here.

The authors of this new case report conclude that physicians must be aware of this complication and should be cautious when recommending spinal manipulation for the treatment of neck pain, especially in the presence of preexisting degenerative disease of the cervical spine.

I know what my chiropractic friends will respond to this post:

  • I am alarmist,
  • I cherry-pick articles that are negative for their profession,
  • these cases are extreme rarities,
  • conventional medicine is much more dangerous.

To this I reply: Imagine a conventional therapy about which the current Cochrane review says that it has no proven effect for the condition in question. Imagine further that this therapy causes mild to moderate adverse effects in about 50% of all patients in addition to very dramatic complications which are probably rare but, as no monitoring system exists, of unknown frequency. Imagine now that the professionals using this treatment more regularly than any other clinicians steadfastly deny that the risk/benefit balance is way out of kilter.

Would you call someone who repeatedly tries to warn the public of this situation ‘alarmist’?

Would you not consider the professionals who continue to practice the therapy in question to be irresponsible?

29 Responses to Phrenic nerve injury: a rare but serious complication of chiropractic neck manipulation

  • No Edzard you are not alarmist, if there is an article on it then it should be discussed even if the event is extremely rare and we are discussing chiropractic and not conventional medicine.

    • @ Edzard

      I agree with Thinking Chiro that you are not being alarmist and it is important to highlight side effects of treatments particularly when there are safer and more effective forms of treatment. Just one small suggestion – if you feel that chiropractors perform a particular type of neck manipulation maybe you should put “chiropractic neck manipulation” instead of “neck manipulation” in the body of the article. However, if there is no difference between in how neck manipulation is done between the professions who use it, then maybe you should just refer to “neck manipulation”.
      Also, what was the reason for not using the latest Cochrane review for neck manipulation and mobilisation? The authors conclusions were as follows:

      Cervical manipulation and mobilisation produced similar changes. Either may provide immediate- or short-term change; no long-term data are available. Thoracic manipulation may improve pain and function. Optimal techniques and dose are unresolved. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

      p.s. – when i refer to professions i am referring to CAM professions not conventional professions (even though they do neck manipulation too)

  • I would add to your list the response I usually get when I outline the lack of evidence for and the risks of chiropractic:

    “That may be the case, but MY Chiropractor is great!. S(he) always makes me feel better”. Feeling better is never defined other than, “my back is better now”. Mind you, most of them have been seeing the Chiro for up to twenty years. Either the back is a chronic problem and a real doctor should be consulted, or they just like the Chiro who “cares” about the worried well way more than the busy MD. When they add that the Chiro told them NOT to get a flu shot, a mammogram, or some other type of normal (truly) preventative health care, I really start to get my dander up.

    And let’s not forget all the useless supplements that come with the “treatment” because “everyone knows that doctors know nothing about nutrition”. What is there to know? Eat decent food in an amount that doesn’t cause you to gain weight and concentrate on the veg, fruit and whole grains/beans. Avoid overindulgence especially of processed foods. Who needs an MD for that? If you are already fat, you must eat less and there is no magic–nor can your doctor do this for you. More could be done to support people in their efforts but this takes time and who is to pay for it? Weight Watchers offers this at a reasonable price. Can any alternative practitioner demonstrate that he or she has been responsible for anyones weigh loss, let alone the maintainance of that loss for any length of time? I’d love to see such data.

  • I was interested to find out what the chiropractors actually did to cause the adverse event.
    The 2015 case report in The Neurologist is behind a paywall even when I tried to access it through the Royal Australian College of GP’s library, one of the benefits of COCA membership here is https://www.coca.com.au/professional-development/infolink-introduction/ It would be interesting to know the exact details!, the abstract gives none!
    Edzard also cites similar cases from 2001, 2007, 2010 and 2011 so I looked them up and accessed the full articles. The last three all just reference the 2001 article and add chiropractic manipulation to their list of causes. So what did the 2001 article say?
    “the chiropractor did a number of manipulations that the patient described as forcing his shoulders downward and turning his head laterally.”
    That is not a manipulation or thrust, it is a fairly standard stretch used by physio’s, chiro’s, exercise physiologists remedial masseurs etc etc to release the levator scapulae muscle.
    https://www.google.com.au/?gws_rd=ssl#q=passive+stretching+of+levator+scapulae
    It is also prescribed as a standard home exercise by all.
    https://www.google.com.au/?gws_rd=ssl#q=levator+scapulae+home+exercises
    So the 2001 article made an assumption which has then been perpetuated! Interesting!
    I have also seen it referenced on several medical sites like here http://radiopaedia.org/articles/phrenic-nerve-palsy

    • Once again and example of poor quality case reports and people jumping to conclusions. The technique described does indeed look like a muscular stretch (PNF/PIR) that is used (mostly) by physiotherapists and other manual therapy practitioners. Poor quality case reports do little to help extend our knowledge of association and causation see http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3604043/. More care should be used when using such reports particularly when trying to highlight shortcomings of just one of the manual therapy professions.

    • @TC
      Did you miss reading the 2007 article where there is a clear description of the mechanism of trauma:

      A 65-year-old woman, with well-controlled asthma, complained of sudden dyspnea and orthopnea 2 hours after a cervical chiropractic session. She had sought chiropractic care for pain and stiffness in her neck lasting for several days and described the chiropractic manipulations as turning the head to its limit toward each side, causing great discomfort. A chest radiograph demonstrated elevation of the left hemidiaphragm;

      The 2015 article describes the case, including the mechanism of trauma:

      A 49-year old right-handed male was transferred to our hospital for evaluation of orthopnea. Two weeks before admission, the patient had visited a chiropractor for chronic neck pain and underwent manipulation of the neck. Immediately after the procedure, the patient reported worsening neck pain and developed severe orthopnea, which promptly improved with upright posture. Chiropractor records were unavailable, but he reported rapid rotations of the head in both directions. The orthopnea was maximal at onset and persisted over the next 2 weeks at which time he presented to a local hospital.

      In the 2001 article the case description is as follows:

      A previously healthy, nonsmoking, 41-year-old male produce manager sought chiropractic care for pain and stiffness in his neck and shoulders. He stated that the pain developed after sleeping on a sofa while on vacation the previous week. After obtaining neck and chest radiographs, the chiropractor did a number of manipulations that the patient described as forcing his shoulders downward and turning his head laterally. His neck pain and stiffness were slightly relieved immediately after the visit. However, when he went to bed that evening he was unable to breathe in the recumbent position. He was forced to sit up in a recliner in order to breathe and did not sleep the entire night.


      In the 2001 case report they refer to four earlier case reports:
      1)
      http://www.ncbi.nlm.nih.gov/pubmed/8389491

      South Med J. 1993 Jun;86(6):688-90.
      Phrenic nerve palsy accompanying chiropractic manipulation of the neck.
      Tolge C1, Iyer V, McConnell J.
      Abstract
      We have described a case of bilateral diaphragmatic palsy temporally related to chiropractic manipulation of the neck. Severe orthopnea of acute onset during cervical manipulation was the main symptom.

      2)
      http://www.ncbi.nlm.nih.gov/pubmed/3977525

      Arch Intern Med. 1985 Mar;145(3):562-4.
      Diaphragmatic paralysis following chiropractic manipulation of the cervical spine.
      Heffner JE.
      Abstract
      We present a case of phrenic nerve damage resulting in unilateral diaphragmatic paralysis following chiropractic manipulation of the neck. Related vascular and neurologic complications of spinal manipulation are reviewed.

      3)
      http://www.ncbi.nlm.nih.gov/pubmed/1519197

      Thorax. 1992 Mar;47(3):201.
      An unusual cause of bilateral diaphragmatic paralysis.
      Pandit A1, Kalra S, Woodcock A.
      Abstract
      In a patient who had a sudden onset of bilateral diaphragmatic paralysis after forceful neck manipulation complete, though gradual, recovery in lung function and transdiaphragmatic pressures was seen over three years. This is a previously unrecognised risk of neck osteopathy.

      The culprit in this case was a 100kg osteopath as described in the article I was able to obtain:

      In February 1988 a 69 year old retired insurance agent developed pain in his shoulders. He saw an osteopath (a man weighing 100 kg) at 6.30 pm. The patient was asked to lie prone and the osteopath applied extreme pressure with his thumbs on both sides of the patient’s neck posteriorly and with his fingers anteriorly. He forcefully abducted, adducted, flexed, and extended the patient’s neck continuously for 20 minutes. Immediately after the session the patient was breathless.


      4)
      The last reference does not seem to be readily retreivable but the details are:

      N Z Med J. 1995 Jul 14;108(1003):279-80.
      Diaphragmatic palsy and chiropractic manipulation.
      Sivakumaran P, Wilsher M.


      In the 2001 article they state that:

      All reported cases of diaphragmatic paralysis associated with chiropractic manipulation result from stretching or compression of the phrenic nerve by the manipulative force. In cervical strain, forced flexion or rotation of the occiput toward a fixed depressed shoulder can cause a stretch (traction) injury to the cervical plexus and result in phrenic nerve paralysis

      Seems to me that we can be genuinely concerned about this type of injury from cervical manipulation of differing types, whether perpetrated by “real” chiropractor or not.

    • I don’t care what you call a so called “manipulation.” It has to be enough movement of the neck/spine area to cause phrenic nerve damage and diaphragmatic paralysis! I’m living proof!

  • In reply to Björn Geir:
    Thanks for the 2015 reference. Mechanism is clearly described! Good science!
    2001 is a poor case study! Assumes even after they describe what was done in the patients own words!
    1993 couldn’t access full article!
    1992 “forceful neck manipulation”, osteopath could mean mobilization/stretch? Not clear!
    1995 no details!
    2007 “turning the head to its limit toward each side” cervical range of motion test?? No thrust! Again assumed! Then it references 2001 to add credibility/weight!
    The 1988 article decsribes 20 minutes of forceful joint mobilization with thumbs! I would be black,blue and purple after that and I would jump up and thump the osteo after 1 minute! No thrust!
    Am I concerned and will I take this into account? Yes, especially when the next patient with levator scapulae issues comes in!

    • All but one of these cases clearly state that the culprit in each case was a practitioner of the “chiropractic” kind. Does that not say something about the methods used and adverse results caused by practitioners identifying themselves with the term?
      Or are we yet again faced with the dilemma of “not a real Scotsman”?

    • People who turn to chiropractors expect miracles, they do not study methods and gather references about particular chiro, so they do not know whether he/she is doing right (from the point of view of chiros), and even if patient realised something was very wrong? If he/she did not have either wheapon or martial art kniowledge to neutralise chiro?

  • So a Levator Scapulae stretch that caused a traction injury to the phrenic nerve is now incorrectly labelled chiropractic manipulation! Cervical passive range of motion followed by active provocation test at end range causing phrenic nerve injury incorrectly labeled chiropractic manipulation!
    Will either of these case studies help physio’s, doctors, exercise physiologists, chiro’s, specialists, remedial masseurs etc who utilise these as standard procedures avoid further adverse events? Do other papers citing these poor case studies help prevent further adverse events?
    Or is it a case of its a chiropractor so he must have tried to rip the patients head off?

    • A rip-off any which way.

      • Presently I suffer this. I was seeing a chiropractor for about 3-4 months. Didn’t consciously take notice of anything. In one of my last visits to the chiropractor an X-ray was taken that showed elevated left hemidiaphragm. No one noticed it. Following an elbow surgery in August (the next month) during the two weeks following the surgery I began having severe breathing issues, leading to panic attacks. I finally went to the doctor and after they took X-rays and CT scans, they admitted me to the hospital. No one knew what was going on or why. I spent a week at the Mayo Clinic in Rochester, MN and a weekend in NE seeing specialists. The NE specialist is he o my one that discovered the pre-existing elevated left hemidiaphragm. All others worked around the hypothesis that it was tied to the elbow surgery and anesthesia.
        Eliminating the elbow surgery and seeing it clearly in the chiropractors X-rays, how do you definitively tie it to the neck manipulations? I had an MRI prior to seeing the chiropractor which showed lots of damage to my spine and even that the C3-C5 nerves were close to the vertebrae and could easily make contact. But the chiropractor never even requested a copy to review prior to treating me. And he notes in his reports that they were available. How can I “prove” it was the neck manipulation that damaged my phrenic nerve?

        • Doug,

          My situation is nearly identical to yours! If you are still having breathing problems, I strongly urge you to seek out Dr. Matthew Kaufman in NJ. SEE: AdvancedReconstruction.com. He is the ONLY KNOWN SURGEON IN THE WORLD TO DO PHRENIC NERVE GRAFTS. He has improved my life significantly, though the healing process is a long journey.

          First of all, there may not be any way to prove that your chiropractic neck adjustments alone were the ONLY cause of your phrenic nerve damage/diaphragm paralysis. Based on my chain of events, the most probable conclusion of my paralysis, was that the phrenic nerves were initially damaged by the chiropractic neck manipulations, but without immediate affect on my breathing. I never left there feeling worse in any way. HOWEVER, AFTER having PTTD ankle surgery and then breathing problems two days post op, especially while lying down, I was diagnosed with atelectasis (anesthesia induced pneumonia). While that was true, the breathing did not improve much at all and tests concluded my diaphragm was paralyzed. The deductive reasoning conclusion was that the neck cracking stsrted the damage, but then the anesthesia lowered my metabolism to such a point, that the phrenic nerves stopped conducting synapses to the diaphragm, causing it to paralyze. THIS WAS A TWO,STEP PROCESS and from what I can tell based on your situation, I would say the exact same thing may have happened to you! Dr. Kaufman said there is NOT any way to prove this, but it made a lot of sense to me and he performed a nerve graft, which has greatly improved my quality of life, as I am slowly healing. I highly encourage you to see him out and NOT WAIT. My surgery did not happen until 16 after my ankle surgery, as he wanted me to have PT to improve my breathing and to exercise as much as I was able and to hope for some nerve regeneration, which happens very slowly overtime. I’ve been told phrenic nerves regenerate about 1 cm per month. Phrenic nerves are about 25 cm in length. However, that being said, Dr. K. said best post op results show up at about 33 months post op. If you haven’t already had these tests: EMG/Nerve Conduction Tesf, sniff test (X-ray) and a full PFT (pulmonary function test) he will ask you to have them done before he can make any recommendations. DO NOT LET ANY DOCTOR TALK,YOU INTO HAVING YOUR DIAPHRAGM PLICATED (TIED DOWN) to take pressure off of your lung(s). If you do, a phrenic nerve graft cannot be performed, which is a much better fix, because your diaphragm should begin moving again, as opposed to being tied down! Please respond with any questions, but certainly review the website! I feel very fortunate for finding Dr. Kaufman!

          • Hi RC,

            PLICATION or NOT?

            Super post thank you. I have a dilemma, or gamble take. I am in a tough situation here and would appreciate your view based on your consultations with Kaufman. My right phrenic was damaged in June 2017, diaphragm paralysis showed up in June. I lost 24% Vital lung function. So it’s been 4-5 months of lower lobe in my right lung, and the right hemi-diaphragm lying stagnant, atrophy taking place. YES?

            Determining the cause of nerve damage is at this point idiopathic, either occurred in a wear and tear C5 nerve root injury this year (MRI shows damaged, herniated C5 disc), or a viral chest infection I picked up around the same time (viral infections are extremely unlikely to cause PNI, but not unheard of). I will be going to a neurologist to do nerve conduction tests in a few days. The Neurologist is likely to tell me that Cervical Phrenic nerve injuries (compression related) are highly unlikely to recover, unlike post Cardiac Surgery and Ablation procedures where PNI have over a 50% + chance of recovery in 3-12 months

            So the gamble is : do I wait for the possible recovery of my Phrenic nerve which take another 6-12 months, (I’ve researched that if the PNI does’t recover within 18 months it’s basically toast)? Note that during this time both the hemi-diaphragm and my lower lung lobe have suffered severe and possibly irreversible atrophy. So even if my phrenic comes online miraculously, it’s going to fire up such low strength Diaphragm Muscle Contractions (CMAP’s) to an almost collapsed lower lobe in the lung. What’s the rule of thumb increment in lung function in this case ? 2-3% – know one ever seems to talk about these two key muscle/lung atrophy issues. The Diaphragm, unfortunately is not like retraining your bicep, there is a permanent proportion of loss of muscle contraction strength.

            Or do I opt for Plication (which you seem to disagree with), which if done early, at least has proven to add back between 9% to 11% of lung function by taking the pressure of the lower lobe, allowing lung expansion, eliminating paradoxical diaphragm movement which restores a good degree of abdominal cavity pressure, improves oxygen diffusion and thereby saves that lower lobe from atrophy.

            I’m not against what Kaufman is doing, in fact it’s brilliant, but I find it annoying that the message given is that a Phrenic Nerve graft, if successful, will “put you back in business” like before taking no account of the percentages of lung improvement versus the time of initial diagnosis.

            What do you say?

  • I’m a 58 year old nonsmoking healthy male that had neck pain. After going to the immediate care and getting no relief I decided to see a chiropractor. Since then I have been seeing a cardiologist and pulmonary doctor because I have a paralyzed diaphragm on one side. The pulmonologist Said that happens for only one of two reasons trauma or neck surgery.. The only reason I could have would be the chiropractor

    • Steven , I’ve had almost the exact complications since having a trapped nerve in my left shoulder since visiting my local chiropractor , the sensation of breathlessness has followed since , I’ve now been to a respiratory specialist done breathing test etc, for almost 3 months ,
      Conclusion is my phrenic nerve is paralysed on my left side so my diaphragm is raised not allowing my lung to inflate correctly
      After doing some research I’m aware of a hospital in my area who have a new procedures of operating to correct this ,
      If anyone reading this has anymore info please feel free to email me
      Kind regards Andrew

      • From two years of research diaphragmic plication seems to be the surgery of choice. I chose NOT to do this. It is not reversible. And the sew up your diaphragm through a very invasive surgery. And I have read about a 50/50 benefit rate. There is a doctor in New Jersey and UCLA that do a phrenic nerve graft. A small pool of people have undergone it, but early results seem to present quite high success rate.

      • Andrew,

        Dr. Kaufman in Shrewsbury NJ? http://www.AdvancedReconstruction.com

        If you haven’t seen him, don’t wait to call! He’ll most likely want you to wait and have therapy and tests before he even sees you.

        He’s the best! I had a nerve graft in Sept. 2015 and doing much better, though it’s a slow healing process.

  • Hi i have a condition called HNA, historically i was diagnosed with brachial neuitis. This effected both my arms as well as my neck. This has left me with bilateral paralysis of the diaphragm. The thought orthe idea that manipulation may have caused a bilateral paralysis for me is a long shot. Yes there have been cases during surgery and possibly during manipulation but for bilateral paralysis to occur durring manipulation….. . For me it’s a very long shot, I live with this condition and have researched beyond belief to find a cure as well as unearthing the little known about HNA or NA that can cause BDP. ( I now have the time)

    Look for the underlying cause of the pain first and foremost, there is alot to rule out as the cause before looking at the possibility of any manipulation that may be the cause. BN, HNA and NA are sudden and very painful conditions that have very rare but know causes of Diaphramic Paralysis. Initially I thought it was the morphine that was causing my breathing issues but this was only coincidental. Just food for thought from a patient and an ex engineer.

  • Would an inflamed phrenic nerve cause burning in head? I also have throat closing at night and sudden gasping for air.

  • I believe that a specific manipulation might have caused my phrenic nerve damage; but when I ask doctors, they will never say that it’s a possibility….the specific thing was a wooden stand placed under my upper neck near the base of my skull and the doctor then proceeded to push down repeatedly on my forehead. He said this was to improve the “curve of life” the shape the neck should be. After the treatment, for about two days, I had pretty bad, burning pain. I should have gone to ER, but didn’t. About 2 years passed and I was always short of breath, so went for check up and that’s when the doctor said she thought I had phrenic nerve damage and I did all the testing and it was confirmed. Number one question diagnosing doctor asked was if I was in an accident. I did fall and felt a sharp pain on my right side, thinking a broke a rib (didn’t, though)….I wonder if this might have been the cause; this happened a few months before diagnosis, but about two years after neck manipulation. Yes, I think I lived with this for a while, not realizing it….. Doctors don’t seem to want to say either of these two things could have caused it, instead saying it’s probably just idiopathic.

  • March 3, 2017: I just wrote a lengthy story about my personal experience with neck adjustments and damaged phrenic nerves/diaphragm paralysis, I am now waiting for approval for it to post. I couldn’t agree more with Dr. Ernst! I hope this referral can help someone get their phrenic nerve repaired for at least partial restoration of not a FULL recovery! The only known surgeon in the world to perform phrenic nerve grafts at this time.
    SEE: http://www.AdvancedReconstruction.com. Dr. Matthew Kaufman, Shrewsbury, NJ and UCLA Medical Center, Los Angeles, CA.

    • RC I have a paralyzed diaphragm. In Jan. Of 2001 I was admitted to the hospital. I thought I had CHF.
      I had difficulty breathing, especially in the supine position. A couple of years later I went to the. MAYO Clinic in Scottdale. The pulmonolgist. Told me, in 20 years I. Was his first patient who had this problem.
      After many tests, they couldn’T rectify the problem.

      I also went to UCLA, the Drs. There informed me that I had primary H (sorry I can’t remember the word) I went to a hospital in San Diego, the Drs. There said I didn’t have PH.

      BY Sher luck I discovered a Dr. @ Yale University who worked with a Dr. Who developed the Phrenic Pacemaker. I too, looked for help on the Web, I wore and still use a Bi-PAP The main reason to breathe when I go to bed, also have sleep Apnea.

      I found out about Dr. Kaufman, he put in 2 pacemakers for each Phoenician nerve. Prior to that I went to the Kessler Ins. Where the late Christopher Reeve (Superman) had been.
      Anyway Dr Kaufman did the operation on Aug. 20 2010 Avert a medical device company gave me a machine which I wore for just short of a year.
      The following year in went to Yale and saw Dr. John Glenns colleague. After more tests he sat down with myself and my wife and came right out and said it wasn’t worth it. His office contacted Dr.Kaufman, sure enough his office contacts me almost a year later after the operation. I was resting my wife answered the phone she wasn’T pleased at all.

      I remember asking him “How many operatons have you done re this procedure” He replied 3 or 4 times. ADDENDUM Christopher Reeve had a phrenic pacemaker put in at the Cleveland Clinic it was successful I was happy for him because it worked and got him off the ventilator. I fell off a roof/ Ladder while fighting a fire. Feel free to contact me @ rosejuneus@yahoo.com
      WarmesT regards Joe

  • I am sure you will find similar problems caused by the so called visceral osteopathic manipulation with the fingers of the osteopath pressing into the abdomen. I know about two cases with internal bleedings caused by osteopaths who manipulated the kidneys. The techniques are very dangerous without any evidence.

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