अपनी भाषा का चयन करें / ਆਪਣੀ ਭਾਸ਼ਾ ਚੁਣੋ

ORTHOPEDIC DISORDERS

Musculoskeletal Condition of Cervical

Neuromuscular Disorders of Cervical

Para spinal Muscular Conditions

Spinal Disorders/Deformities

Brachial plexus injuries

Cervical syndrome

Pain in the neck and its associated complication is a regular feature to anyorthopedic clinic. The causes and pathology of neck pain are complicated . however, the major contributory factor is bad postural habits.

Causes of pain

1.Ischaemia:The origin of ischaemia is in the soft tissues. Increase in the intra – muscular pressure constricts the blood vessels, stops the internal circulation and thereby stagnation of the waste products results in ischaemic of pain.

2.Inflammation:Acute inflammation occurs in the superficial layers of the posterior longitudinal ligament and capsules of the apophyseal and inter body joints . It subsequently leads to chronic hyperplasia resulting in narrowing of the intervertebral cannels.

3.Haemorrhage:Acute traumatic bleeding can also lead to narrowing and compression of the nerve roots.

4.Ligamentous and capsular instabilty: After in jury the process of repair is extremely slow due to the precarious blood supply to the ligaments . the repair may occur by the formation of scar tissue , with reduced tensile and elastic properties, resulting in stiffness.

5.Disc lessions:The incidence of cervical disc extrusion is less common as compared to the lumbar disc lesions due to the presence of lateral inter body joints.

6.Degenerative changes:These are common in the areas of maximum stress. This leads to joint pain and limitation of movements. The actual subluxation of the involved vertebrae is minimal . However thickening and fibrosis of the ligamentous and capsular structures further narrows the intervertebral canal precipitating rhe symptoms.

7.Repeated musucular strains:Certain muscle groups are exposed to repeated strain by performing one particular movement more often than the others. Sudden or jerky movement may also result in this type.

8.Bad Postural habits:Sustained, bad occupational posture or habitual wrong posture of the neck in relation to the thoracic spine and shoulder joints results in stretching of the soft tissues on one side and elongation or lengthening of the ones on the opposite side. this can cause irritation and strain of the ligaments, muscles or joints precipitating cervical pain.

9.Characteristics of pain:The pain originating from the ligamentous or musucular lesion could either be localised or radiating. The radiation however is diffused and without any precise trajectory . the neural pain results in a radicular pain which radiates to precise trajectory .

10.Neurovasscular symptoms may be associated with neck pain as joints cervical spine.

Physical therapy management

To plan the appropriate therapeutic measures, a thorough physical examination of the neck, scapulae and arm is conducted. It consists of:

  • Observation
  • Active movements
  • Passive movements
  • Resisted movements
  • Neurological examination of the upper extremity
  • Neurological examination of the lower limbs.

Treatment

Data thus rrecorded are correlated with the subjective symptoms and other clinical observations. Diagnosis is ascertained and a therapeutic plan drawn which could include any or a combination of the following:

  • Physical agents and massage
  • Exercises
  • Cervical traction
  • Manipulation
  • Cervical collar and Postural and ergonomic advice.

Multicentre trial has shown better relief of the symptoms wit the combination therapy than with single modality (Brewerton,1966). (Physical agents and massage) Various physical agents are routinely used mainly to:

  • Control inflammation
  • Control pain and muscle spasm
  • Control stiffness of soft tissuses and joints
  • Assist mobility
  • Increase blood supply and to relieve ischaemia.

Ankylosis of c-spine

Preganglionic injury

Spasmodic torticollis

Typical torticollis posture with acute muscle spasm and pain. Malalignment of the neck posture at night is the predisposing cause of acute inflammation. It could also be hysterical in origin . the inflammatory process can be controlled with appropriate drugs, thermo therapy and exercise . Soothing superficial or deep heating modality may be used as an adjunct.

  • Relaxed passive movement of head in the opposite direction of spasmodic muscles gradually altered to active movement is the best form of the exercise.
  • Controlled manipulation is beneficial.
  • The movements of rotation and side flexion are repeated in the painless direction under traction.
  • Other relaxed slow full range movements are helpful.
  • A temporary soft collar is useful during working and sleep to maintain proper posture till acute pain subsides.

Cervical ribs

It is fibrous or bony over-development of the costal process of the seventh cervical vertebra.

seventh cervical vertebra. It may be unilateral or bilateral. It is congenital and generally asymptomatic in the early years . during sadult life, a person with this anomaly develops depressed and round shoulders. Neurological and vascular symptoms may also appear .

Neurological Symptoms

  • There may be comlete sensory anaesthesia in the fores arm and hand over the area supplied by the lowest trunk of brachial plexus.
  • Pain and paraesthesia may be prey changing the present on the ulnar aspect of the forearm and hand occasionally relieved by changing the position of hand.
  • Weakness of the finer movements of hand may be present.
  • Atrophy may be present in the interossesi, and the muscles of thenar and hypothenar eminence at a later stage.

Vascular symptoms

  • Absence or feeble radial pulse.
  • Dusky cyanosis of the forearm.

Differential diagnosis

It is important to rule out peripheral vasvular diseases like Raynaud’s disease . certain other conditions like syringomyelia , motor neurone disease poliomyelitis and muscular dystrophy should also be kept in mind

Treatment. Surgery is indicated in patients with established progressive vascular and neurological signs. It consists of removal of the pressure causing elements i.e cervical rib and the associated fibrous band and occasionally dividing the scaleneii group of muscles.

Physiotherapy management

The choice of therapeutic method depends upon the symptoms.

  • Postural guidance.
  • Thermotherapy modality for pain relief.
  • Exercises to improve distal circulation of hand and fingers.
  • Exercises to improve tone power and endurance of the whole arm in general and small muscles of the hand in particular.

Post ganglionic injury

Wry neck(Idiopathic Torticolis)

This is a common condition encountered in our daily routine. The condition is precipitated by mal positioning of the head during sleep. However, it could also be inflammatory or psychological in origin.

The neck movement are limited and painful due to local muscular spasm. The is held fixed and tilted to one side as seen in congenital torticollis. Total relief is attained as the basic inflammatory conditions settles.

Relaxed movements following heat or cold application or even gentle traction offer relief. A conventional collar at work and specially at night with proper pillow adjustment also provides relief.

Torticollis(congenital)

Earb’s palcy

Cervical Disc proleps

The disc rupture may occur as a result of intrinsic changes in the disc substance or as a result of an injury . a part of gelatinous nucleus pulposus extrudes through a rent in the annulus fibrosis at the weakest part of the cervical spine. The c5-c6 or c6 inter vertebral levels are the common sites of disc protrusion.

The protrusion may be:

  • Mild –causing compression of the posterior longitudinal ligament and localised pain
  • Moderate- when it herniates through the posterior ligament and presses laterally on the emerging nerve root, causing lateral prolapsed of the disc.
  • Serve –central protrusion compresses over the spinal cord.
  • The symptoms may be present in the neck and upper limb.
  • A clinical and neurological examination with emphasis on the movements of neck ,arm muscle bulk, sensory status and reflexes will provide information regarding the extent ,site and nature of the pathology .

Treatment

It depends upon the severity of the condition. However, it is claimed that in disc prolapsed there is a tendency for spontaneous recovery.

  • Mild symptoms can usually be controlled with rest in a conventional cervical collar, postural guidance and drug therapy.
  • In severe cases there is stiff and painful neck with positive neurological signs. Immobilisation of the neck in a moulded or POP collar may be necessary for 6 weeks or continuous cervical traction may be given till signs reduce or disappear.
  • Disc lesion with rupture of annulus may be treated by manipulation.
  • Traction is suited best for irreducible nucleus pulposus.

Physiotherapy management

During immobilization

  • Check the traction (positioning line of pull and the magnitude)
  • Postural guidance with immonbilisation.
  • Full ROM exercises for the shoulder joints.
  • Maximum use fo upper extremities.
  • Scapular protraction-retraction and other shoulder girdle movements with sustained holds.
  • Deep breathing and cycling motions without straining the neck.
  • Sometrics to cervical muscles with mild tension.

Mobilization

  • Checking and training in the application of cervical collar.
  • Relaxing thermotherapy modality.
  • Stronger but pain free isometric exercises.
  • Intermittent cervical traction.
  • Relaxed passive mobilization of neck.
  • Gradually increasing ROM and strengthening exercises.
  • Postural guidance to avoid excessive flexion attitudes. To wear collar during working and conventional soft collar at night.

Short neck(klipple-Feil syndrome)

Claw hand(klumpke’s palcy)

Cervical spine

Osteoarthritis of the Cervical spine

Commonly known as cervical spondylosis, spondylitis, spondylarthritis or spondylarthrosis begins as a deess at the generative process in the central intervertelbral joints. Subsequently it affects the posteroior intervertebral.

Pain and stiffness at the neck are the primary sympgtoms. Often there may be reffed symptoms to the upper limb.

There occurs degeneration and narrowing of the disc with bone reaction at the periphery resulting in osteophytes with wear and tear of the articular cartilage. Osteophytes may press on the cervical nerve root at the intervertebral foramina, leading to compression symptoms. Osteophytes may encroach upom the cord and cause pressure over the spinal cord in rare cases . the symptoms vary with the degree and site of compression.

Repetitive movements or postural strains may give rise to pain on the posterior aspect of neck over the trapezios. Stiffness and grating may also be present on movement.

Radiation of pain from shoulder to digits along the course of the nerve indicates nerve root compression. paraesthesia in the form of tingling, pins and needles may be present in the hand . muscular weakness or sensory impairment is rare.

Prolapsed cervical disc

The disc rupture may occur as a result of intrinsic hanges in the disc substance or as a result of an injury. A part of gelatinous nucleus pulposus extrudes through a rent in the annrlus fibrosus at the weakest part of the cervical spine. The c5-c6 or c6 intervertebal levels are the common sites of disc protrusion.

The protrusion may be:

  • Mild –causing compression of the posterior longitudinal ligament and localised pain
  • Mild –causing compression of the posterior longitudinal ligament and localised pain
  • Moderate- when it herniates through the posterior ligament and presses laterally on the emerging nerve root, causing lateral prolapsed of the disc.
  • Serve –central protrusion compresses uver the spinal cord.
  • The symptoms may be present in the neck and upper limb.
  • A clinical and neurological exeamination with emphasis on the movements of neck ,arm muscle bulk, sensory starus and reflexes will procide information regarding thr extent ,site aamd nature of the pathology .

Treatment

It depends upon the severity of the condition. However, it is claimed that in disc prolapsed there is a tendency for spontaneous recovery.

  • Mild symptoms can usually be controlled with rest in a conventional cervical collar, postural guidance and drug therapy.
  • In severe cases there is stiff and painful neck with positive neurological signs. Immobilisation of the neck in a moulded or POP collar may be necessary for 6 weeks or continuous cervical traction may be given till signs reduce or disappear.
  • Disc lesion with rupture of annulus may be treated by manipulation.
  • Traction is suited best for irredulcible nnucleus pulposus.

Physiotherapy management

During immobilization

  • Check the traction ( positioning line of pull and the magnitude)
  • Postural guidance with immonbilisation.
  • Full ROM exercises for the shoulder joints.
  • Maximum use fo upper extremities.
  • Scapular protraction-retraction and other shoulder girdle movements with sustained holds.
  • Deep breathing and cycling motions without straining the neck.
  • Isometrics to cervical muscles with mild tension.

Mobilization

  • Checking and training in the application of cervical collar.
  • Relaxing hermotherapy modality.
  • Stronger but painfree isometric exercises.
  • Intermittent cervical traction.
  • Relaxed passive mobilization of neck.
  • Gradually increasing ROM and strengthening exercises.
  • Postural guidance to avoid excessive flexion attitudes. To wear collar during working and conventional soft collar at night.

Spondylolisthesis

Motor & sensory Loss in upper limbs

Vertebro basilar syndrome

Two posterior cerebral arteries, which originate from the basilar artery, supply the temporal lobes and visual vortex in the brain. The vertebra-basilar artery passes through thr foramina in the lateral masses of the cervical vertebrae. Osteophytes may cause pressure on the vertebral artery. Particularly during thr movements of extension and rotation of the meck. This , in turn,causes transient ischaemia of these areas of the brain. This results in vertigo.

Test for vertigo

A patient stands with arms stretched out horizontally in front with the eyes closed. He is asked to rotate the head fully to one side and stay for a minute. Then he is asked to turn his head to the other side . any straying of the arms away from thr horizontal is suggestive of cerebral ischaemia.

Management

  • Postural guidance to avoid sudden extension or rotation of the head and graduated slow changing of posture, all with eyes open.
  • Use of collar during working.
  • Strong isometric exercises to neck muscles.
  • Synchronization of eye ball movements with movements of the head.
  • Decompression of the vertebral artery.

Cervical spine stenosis

Shoulder pain radiating distally to the arm

Thoracic outlet syndrome

Thoracic Outlet Syndrome

The classical feature of the thoracic outlet syndrome is the nocturnal appearance of pins and needles in the fingers which disappear when the patient changes position or sits up. The symptoms reappear on elevation of the arms overhead or on elevating the scapulae . Pressure on the lower trunk of brachial plexus results due to drooping of the pectoral girdle . When the space between clavicle and first rib is reduced these symptoms occur.

Conservative treatment

Postural guidance and strengthening exercises to the shoulder girdle muscles. Weight carrying, cycling, driving and swimming to be avoided.

Surgical treatment

The indications of surgical treatment in cervical rib syndrome are:
  • Evidence of neuro and vascular disturbances.
  • Severe symptoms incapacitating the patient.

The surgical treatment consists of removal of cervical rib and the fibrous band which are causing abnormal pressure on the subclavian vessels and brachial plexus.

Occasionally, abnormal insertion of the scalene muscles is responsible for the abnormal pressure and thereby the symptoms. In such cases the insertion of these muscles is released to relieve the pressure.

Postoperatively, a small dressing id maintained for about 2 weeks.

Physiotherapy Following Surgery

Routine measures to control pain and inflammation are taken following surgery. Shoulder movements can be initiated after 8-10 days as relaxed passive or assisted active movements.

Active mobilization is begun after 2 weeks and in tensified gradually along with functional re-education. Full function is restarted by 4-6 weeks.

Cervical spondylosis/spondylitis/spondyloarthritis

Deltoid pain

Scelenus syndrome

It is a neurological manifestation of the cervical rib due to compression of the lowest trunk of the brachial plexus between the first rib and the clavicle. This costo-clavicular compression occurs as results of the presence of tough fibrous band in the body of scalenus medius muscle.

The management proceeds on he same lines as described for the “cervical rib”.

High cervical pain

The pain may be felt over the occipital area and may occasionally radiate to the temporal region in the form of headache. The pain will aggravate with the movement of the high cervical spine. The sire of emergence of the occipital nerves will be tender.

Test to identify the lesion at the cervico occipital junction: head id bent forward at the cervico occipital junction keeping the rest of the neck straight head to right and left preventing rotation of the in pain on rotation confirms the origin pain at the cervico occipital junction.

Treatment

  • Rest in a soft cervical collar and analgesics or anti inflammatory drugs.
  • Pain reducing electrotherapy modality.
  • Relaxed passive mobilisation.
  • Graded mobilization avoiding sudden movements.
  • Manipulation.

Levator scapulae syndrome

Certain repetitive movements, e.g. typing with a bad posture, sustained wrong posture of the neck or even psychological tension can give rise to this syndrome. On examination, contraction of the muscles inserted at the supero medial angle of scapula and at the superior portion of cervical spine are noticed, in unilateral involvement , a clearcut disparity is seen at the scapular level . on palpationm tender nodules may often be felt.

Treatment

  • Anti – inflammatory drugs.
  • Local infiltration by lidocaine or steroids.
  • Ultrasound and friction massage to the contracted soft tissues.
  • Gentle mobilization of the neck shoulder girdle and arms.
  • Posture training.

Cervical disc lesion symptoms

  • Unilateral or alternating scapular pain.
  • Bilateral neck pain.
  • Headache by extra segmental dural reference.
  • Unilateral scapula brachial pain with or without nerve root palsy.
  • Pain in the upper limbs and paraesthetic hands as a result of bilateral protrusion.
  • Paraesthesia in hands and feet as a result of central protrusion
  • Spinal cord compression with one or more root palsies in one or both upper limbs with spastic paresis in the lower limbs.

Osteophytic compression symptoms

  • Pressure on one or more nerve roots, respective root symptoms.
  • Compression of the spinal cord may cause paraesthesia of hands and feet.
  • Compression of the anterior spinal artery may cause paraplegia.
  • Kinking of the vertebral artery by an osteophyte on the superior articular process may cause impairment of basilar circulation and vertebra basilar symptoms.
  • Upper cervical pain or headache when there is involvement of the upper two cervical joints.
  • However osteophyte formation at the vertebral body or foramen as well as narrowing of one or more disc spaces could be symptomless. There fore, it is important to plan therapeutic measures on the basis of clinical examination to identify the internal derangement rather than excessive reliance on radiography.

Whiplash injuries

A whiplash neck sprain is common after a road traffic accident. Symptoms usually ease and go without any specific treatment. It is best to keep the neck active and moving. If required, painkillers can ease pain.

What is a whiplash neck sprain?

A whiplash neck sprain occurs when your head is suddenly jolted backwards and forwards (or forwards then backwards) in a whip-like movement, or is suddenly forcibly rotated. This can cause some neck muscles and ligaments to stretch more than normal (sprain)

.

The common cause is when you are in a vehicle that is hit from behind by another vehicle. Being in a vehicle hit from the side or front can also cause a whiplash sprain.

Damage to the spine or spinal cord sometimes occurs from a severe whiplash accident. This is uncommon and is not dealt with in this article. This article deals only with the common whiplash sprain to neck muscles and ligaments. It assumes that you have been assessed by a doctor and serious neck injury has been ruled out

.

Who gets a whiplash neck sprain?

Whiplash neck sprains are common. Many people involved in road traffic accidents develop neck pain (with or without other injuries). Women are more prone to a whiplash sprain than men as their neck muscles are less strong.

Some people are surprised at having symptoms after a minor road traffic accident. Even slow vehicle bumps may cause enough jerking of the neck to cause symptoms.

Less commonly, a whiplash neck sprain can occur after a sporting injury, or even with everyday activities such as jolting the neck when you trip or fall.

What are the symptoms of a whiplash neck sprain?

  • Pain and stiffness in the neck. It may take several hours after the accident for symptoms to appear. The pain and stiffness often become worse on the day after the accident. In about half of cases, the pain first develops the day after the accident.
  • Turning or bending the neck may be difficult.
  • You may also feel pain or stiffness in the shoulders or down the arms.
  • There may be pain and stiffness in the upper and lower part of the back.
  • Headache is a common symptom.
  • Dizziness, blurred vision, pain in the jaw or pain on swallowing, unusual sensations of the facial skin may occur for a short while, but soon go. Tell a doctor if any of these persist.
  • Some people feel tired and irritable for a few days and find it difficult to concentrate.

How is a whiplash neck sprain diagnosed?

Your doctor will usually be able to diagnose a whiplash neck sprain from the description of the way the accident occurred, the typical symptoms, and by examining you. An examination of your neck and arms can check that there are no signs of damage to the vertebrae or spinal nerves or spinal cord. If these are suspected then further tests may be recommended.

What are the treatments for a whiplash neck sprain?

Exercise your neck and keep active

Aim to keep your neck moving as normally as possible. At first the pain may be bad, and you may need to rest the neck for a day or so. However, gently exercise the neck as soon as you are able. You should not let it 'stiffen up'.

Gradually try to increase the range of neck movements. Every few hours gently move the neck in each direction. Do this several times a day. As far as possible, continue with normal activities. You will not cause damage to your neck by moving it.

Medicines

Painkillers are often helpful and may be recommended by your doctor.

  • Paracetamol at full strength is often sufficient. For an adult this is two 500 mg tablets, four times a day.
  • Anti-inflammatory painkillers. These may be used alone or at the same time as paracetamol. They include ibuprofen which you can buy at pharmacies or get on prescription. Other types such as diclofenac or naproxen need a prescription. Some people with stomach ulcers, asthma, high blood pressure, kidney failure, or heart failure may not be able to take anti-inflammatory painkillers.
  • A stronger painkiller such as codeine is an option if anti-inflammatories do not suit or do not work well. Codeine is often taken in addition to paracetamol.
  • A muscle relaxant such as diazepam is occasionally prescribed for a few days if your neck muscles become very tense and make the pain worse.

Other treatments

Some other treatments which may be advised include:

A good posture may help. Check that your sitting position at work or at the computer is not poor. (That is, not with your head flexed forward with a stooped back.) Sit upright. Yoga, pilates, and the Alexander Technique all improve neck posture, but their value in treating neck pain is uncertain.

A firm supporting pillow seems to help some people when sleeping. Try not to use more than one pillow.

Physiotherapy.

  • Various treatments may be advised by a physiotherapist if the pain is not settling. These include traction, heat, manipulation, etc. However, what is often most helpful is the advice a physiotherapist can give on exercises to do at home.
  • A common situation is for a doctor to advise on painkillers and gentle neck exercises. If symptoms do not begin to settle over a week or so, you may then be referred to a physiotherapist to help with pain relief and for advice on specific neck exercises.
  • If the pain becomes worse.
  • If the pain persists beyond 4-6 weeks.
  • If other symptoms develop such as loss of feeling (numbers), weakness, or persistent pins and needles in part of an arm or hand. These may indicate irritation to or pressure on a nerve emerging from the spinal cord.

Other pain-relieving techniques may be tried if the pain becomes chronic (persistent). Chronic neck pain is also sometimes associated with anxiety and depression which may also need to be treated.

What is the outlook (prognosis) after a whiplash neck sprain?

This will depend on the severity of the sprain, but the outlook is good in most cases. Symptoms often begin to improve after a few days. Most people make a full recovery within a few weeks. However, in a small number of people, some symptoms persist long-term.

Can whiplash neck sprains be prevented?

Modern vehicles are increasingly designed to minimise the impact of collisions on the neck. However, all vehicles include head restraints on vehicle seats which may prevent some whiplash sprains. The head restraint should be as high as the top of the head. This may stop the head from jolting backwards in a road traffic accident.

However, up to 3 in 4 head restraints are not correctly adjusted. Head restraints may make a journey less comfortable when they are correctly adjusted as they will not allow your head to lie back. However, if you have had a whiplash neck sprain, you may be more particular about correctly adjusting the head restraint for yourself and for other passengers.

Thoracic/ ribs cage

Costochondritis

Costochondritis….

Costochondritis is a painful condition of the chest wall. It is caused by inflammation in the joints between the cartilages that join the ribs to the breastbone (sternum). Although painful, it is not a serious condition. Usually it has no obvious cause and settles over time. Painkillers and anti-inflammatory medication can be used for relief of symptoms.

What is costochondritis?

Costochondritis is a painful condition of the chest wall. It causes chest pain. Fortunately, it is not a serious condition.

To understand costochondritis, you need to know a bit about the anatomy of the rib cage. The rib cage is a bony structure that protects the lungs. Bones are hard and solid, and they don't tend to bend or move. However, our lungs need to move, so we can breathe.

When we take a deep breath in, the diaphragm acts as a bellows. The diaphragm moves down and this sucks air through our mouth and nose, and into our lungs. Our rib cage expands too. In order for the ribs to expand, the ribs need something to allow movement. Cartilage allows this. Cartilage is a softer, flexible (but very strong) material found in joints around the body.

Cartilages attach the ribs to the breastbone (sternum) and the sternum to the collarbones (clavicles). The joints between the ribs and the cartilages are called the costochondral joints. Those between the cartilages and the breastbone are called costosternal joints. Those between the sternum and the clavicles are called the sternoclavicular joints.

The prefix 'costo' simply means related to the ribs. 'Chondr-' means related to the cartilage and '-itis' is the medical ending (suffix) that means inflammation.

In costochondritis, there is inflammation in either the costochondral, costosternal or sternoclavicular joints (or a combination). This causes pain and tenderness, that tends to be worse with movement and pressure.

Tietze's syndrome is similar to costochondritis. The two conditions are often (incorrectly) used interchangeably. Tietze's syndrome is, however, a different condition. It causes similar symptoms, is still due to inflammation, but tends to cause swelling at the costochondral, costosternal or sternoclavicular joints.

Bornholm disease is another similar condition. However, it is caused by a viral illness and leads to muscle aches and pains, as well as chest pain. Coxsackievirus B is the usual cause of Bornholm disease (although echovirus and Coxsackievirus A can be responsible). See separate leaflet called Bornholm Disease.

Important information regarding chest pain

There are many causes of chest pain. Chest pain is a symptom that you should discuss with your GP to try to establish the cause.

Note: chest pain can have serious causes. Any new, severe or persisting chest pain should be discussed with a doctor. This is particularly important if you are an adult and have a history of heart or lung disease. If the pain is particularly severe, especially if radiating to your arms or jaw, and you feel sick, sweaty or breathless, call 999 for an emergency ambulance. These can be symptoms of a heart attack.

If you are young, and generally healthy then non-serious chest wall pain is common. Costochondritis is an example of a condition that can cause chest wall pain that is not serious. Because the pain caused by costochondritis can be quite severe at times, many people with it become very anxious and worried that it may be due to something more serious.

What causes costochondritis?

Costochondritis is often idiopathic. This is a medical term, meaning 'of unknown cause'. So, in many cases, no cause is found.

Sometimes costochondritis can follow repeated minor chest injury or activities that one is unused to - perhaps decorating or moving furniture.

Who develops costochondritis?

There is no particular person more at risk of costochondritis than another. It does tend to affect younger people, especially teenagers and young adults. It can affect children. People performing repetitive movements that strain the chest wall, particularly if they are not used to it, might be considered more at risk of getting this condition. Some studies suggest women tend to be affected more commonly than men.

People with fibromyalgia tend to develop costochondritis more often than others. Fibromyalgia is a long-term (chronic) condition that causes widespread body pains and fatigue. (See separate leaflet called Fibromyalgia for more information.)

How common is costochondritis?

It is difficult to be precise about how many people develop costochondritis. It is a relatively common problem. Probably, many people with it do not report their symptoms to a doctor. And, as the condition is often short-lived, and settles on its own (spontaneously), the numbers are not known.

Some studies have estimated that between 1 and 3 in 10 people with chest pain have a musculoskeletal cause. This means the chest pain is related to the muscles or the ribs. Costochondritis is one cause of musculoskeletal chest pain.

What are the symptoms of costochondritis?

Costochondritis causes chest pain, felt at the front of the chest. Typically, it is sharp and stabbing in nature and can be quite severe. The pain is worse with movement, exertion and deep breathing. Pressure over the affected area also causes sharp pain. Some people may feel an aching pain. The pain is usually confined (localised) to a small area but it can spread (radiate) to a wider area. The pain tends to wax and wane, and can settle with a change of position and quiet, shallow breathing.

The most common sites of pain are close to the sternum, at the level of the 4th, 5th and 6th ribs.

Note: without tenderness, the cause of the chest pain is unlikely to be costochondritis. Remember to seek medical advice if you are unsure of the cause of your symptoms (see 'Important information regarding chest pain', above).

How is costochondritis diagnosed?

Costochondritis is usually diagnosed based on your symptoms and examination. It is important that other causes of chest pain should be ruled out.

Do I need any tests (investigations)?

No tests (investigations) are needed to confirm costochondritis. However, tests may be performed to rule out other causes of chest pain if the cause of the pain is unclear. Examples of such tests would include a heart trace (electrocardiogram, or ECG) or a chest X-ray.

What is the treatment for costochondritis?

The treatments for costochondritis are painkillers (analgesics) and anti-inflammatory medications. Often, only simple analgesics such as paracetamol or codeine are needed.

Ibuprofen is an anti-inflammatory medication (also called a non-steroidal anti-inflammatory drug, or NSAID) that is often effective for costochondritis. Other NSAIDs are available on prescription. NSAIDs should not be taken on an empty stomach; neither should they be used by people taking anticoagulant medication (such as warfarin), nor by people with asthma (unless under supervision by a doctor). If you have a history of a stomach ulcer, or suffer regular indigestion or acid reflux, you should avoid NSAIDs. If you develop tummy (abdominal) pains, indigestion or being sick (vomiting) whilst taking NSAID medications such as ibuprofen:

You should stop them immediately and seek medical advice.

For severe cases of costochondritis, not responding to painkillers and anti-inflammatory medication, injections of steroids or local anaesthetic medicines may be used.

In extreme cases, an intercostal nerve block can be performed (usually by a doctor specialising in acute pain and/or anaesthetics). This involves injection of a local anaesthetic medicine around the painful ribs, to block the nearby intercostal nerve. The intercostal nerves transmit the painful sensation in costochondritis. This sort of injection temporarily disrupts nerve impulses to stop the pain. Nerve blocks can last several weeks or months. In repeated (recurrent), severe cases of costochondritis, a series of these injections can be given to permanently destroy the nerve causing the pain.

Non-medicinal measures can be tried for relief of pain in costochondritis. Examples of such techniques include:

  • Heat pads
  • Ice application
  • Transcutaneous electrical nerve stimulation (TENS)
  • Acupuncture
  • Gentle stretching exercises
  • Avoidance of sports or activities that worsen the pain

What is the outlook (prognosis) for costochondritis?

The outlook (prognosis) for costochondritis is generally very good. Most cases are mild, short-lived (commonly no more than 6-8 weeks) and get better on their own. This happens with or without simple medications. In nearly all cases, the condition has completely gone within six months. However, in a very small number of cases it lasts longer. Costochondritis may return, but this is unlikely.

Thoracic spine

Thoraco;umber spine

Kyphosis

Kyphosis or kyposis –arcuata or round back is the exaggeration of the posterior spinal curve and is generally localized to the dorsal spine . the back id rounded the head is carried forward and the chest is flattened . this results in typical round shoulders with excessive protrusion of the scapulae.

Habitual bad posture at the school is the common cause . it could develop as a result of undetected defects of vision or hearing. Mental or physical fatigue could also precipitate such habitual postural tendencies.

In old adolescent age it may be the result of previous bad posture , muscular weakness degeneration and diseases of vertrbral bodies and discs.

The deformity may be divided into three degrees according to its severity :

  • First degree;
  • Second degree
  • Third degree.

Progress of the deformity from first to third degree . A bad habitual posture is the precipitating factor . inititally there is no imbalance in the muscles. If not corrected at this stage, it progresses to the second degree.

  • The pectoral muscles become short, thereby restricting the chest expansion resulting in reduced respiratory function.
  • Longitudinal back muscles rhomboids and the middle trapezius are unduly stretched and weakened with loss of tone.
  • Posterior ligaments are lengthened with corresponding shortening of the anterior structures. This gives rise to increased posterior laxity and a typical kyphotic deformity.
  • During the adolescent stage of growth period wedging of the vertebral stage of growth period wedging of the vertebral bodies may occur. The deformity gets organised , which is a difficult syndrome .

Kyphosis can also occur due to tuberculosis ankylosing spondylitis , scheuermann’s diseases or congetital anomalies. Total assessment of the hyphotic deformity is to be done on the same lines as described for scoliosis.

Physiotherapy management

As in scoliosis early detection by screening forms an important part of its prevention. Other methods as described under scoliosis should be adopted physiotherapy management basically depends upon the stage of the condition and its ill-effects.

First degree kyphosis
  • Relaxation of the body especially the upper back.
  • Repeated stretching sessions of shortened anterior structures by bracing the shoulders and maintaining the position .
  • Posture of head neck and shoulder during activity or rest in optimal position should be trained and checked.
  • Mobilization of the whole spine particularly neck scapulae and shoulders .
  • Diaphragmatic and costal breathing with emphasis on inspiration.
  • When precise mobility is attained specific resistive exercises can be added to the weak longitudinal and transverse back muscles. These will be helpful in the natural maintenance of the corrected postures.
  • Controlled pelvic tilt may lead to lordosis or even kyphoscoliosis or sway back.
  • Efficiency of home management programme is vital for good results . therefore it needs to ne emphasized and checked regularly.

Second and third degree kyphosis

As wrong adaptation of the soft tissues are in the advanced stage, active correction and maintenance of the correction is difficult . the milwaukee brace is prescribed with pads applied on the posterior uprights.

Pectus excavatum (funnel chest)

This is thought to be caused by an abnormality of connective tissue, which results in depression of the sternum. It is sometimes associated with Marfan's syndrome and Ehlers-Danlos syndrome. Most cases are recognised at birth or within the first two years of life. Epidemiology[1] Pectus excavatum is a congenital anomaly. It is the most common deformity of the anterior chest in children and is present in between 1 in 300-400 live births. There is a 3:1 male to female ratio. It is thought to be an inherited condition.

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Investigations[1]

  • Radio-imaging with CXR is the first-line investigation.
  • Two new clinical methods have recently been developed:[2]
  • Chest cytometry involves measuring the circumference of the chest in the region of the distal third of the sternum or at the site of greatest deformity with the patient in the orthostatic position and inspiring deeply.
  • Calculation of the anthropomorphic index - this involves taking two measurements. Firstly, the maximum anteroposterior measurement in the region of greatest deformity or of the distal third of the sternum (A) is assessed. Secondly, the greatest depth of the defect is measured with the highest point of the anterior costal wall and the lowest point of the pre-sternal region at the site of greatest deformity being used as reference (B). The index is calculated as B/A.
  • Standardised cardiopulmonary function tests may be useful, particularly in assessing whether patients would benefit from surgery. CT chest scanning may be indicated to assess the degree of sternal deformity, the severity of lung compression and the presence of mediastinal displacement.
  • An MRI technique has been developed due to concerns about the radiation dose obtained from CT scans.[3]
  • Echocardiography may be clinically indicated in patients with dyspnoea to evaluate cardiac compression. 20-60% of patients have mitral valve prolapse. Atrial compression and cardiac displacement are frequently seen.
  • Pulmonary function tests may be required to assess lung capacity.[4]

Management[1]

  • Mild cases may not require treatment as the deformity can be hidden under clothing.
  • The treatment to correct functional disability has for many years been the Ravitch operation in which the anterior chest wall is exposed, skin and muscle flaps are created, the affected cartilages are excised and sternal osteotomy is performed.
  • A newer minimally invasive procedure called the Nuss technique has been developed which involves the insertion of a retrosternal metal bar via two incisions, using a thorascope. The bar is removed 2-3 years later.[5] It is mainly used in 12-14 year-olds but can be performed in younger children and in adults, in whom two bars may be required.[6] The technique may lower the threshold for surgical treatment which was previously hampered by the high incidence of keloid formation of the anterior chest wall which bedevilled the Ravitch procedure. The Nuss technique has also been shown to reduce the length of hospital stay.[7] A higher rate of complications has been reported compared with the Ravitch procedure but no more than would be expected of any recently introduced technique.[8]
  • Autologous fat transplantation has been reported[9] as has polyethylene implant for patients with mild deformity who required aesthetic improvement.[10]
  • A survey of patients who have had surgery showed considerable improvement in body image and function.[

Pectus carinatum (pigeon chest)

In this condition, the sternum is raised (carina = keel). It used to be associated with rickets. Nowadays there is usually an associated history of severe asthma in childhood, sometimes with aventricular septal defect (VSD). 20% of patients have an associated scoliosis. Pectus carinatum complicating surgical treatment for pectus excavatum has been reported.[13]

Two main types have been identified - chondrogladiolar (90%, keel chest, prominent middle and lower sternum) and chondromanubrial (pouter pigeon breast, prominent upper sternum). Some authorities also identify a lateral type.

The large forces needed for inspiration lead to an in-drawing of the lower portion of the ribs giving a Harrison's sulcus.

Most cases were thought to be asymptomatic. However, recent studies suggest that some patients develop a rigid chest wall resulting in reduced vital capacity and symptoms of dyspnoea, exertional tachypnoea and reduced endurance.

Epidemiology[12]

This is much less common than pectus excavatum. The prevalence in the USA has been assessed at 0.06% with one third of patients having a positive family history. Associated diseases are Marfan's syndrome and congenital heart disease. The patient or their parents will often be aware of the condition from early childhood but typically present to health professionals between the ages of 11-15.

Investigations[8][12]

  • Pulmonary function tests should be performed if reduced lung capacity is suspected.
  • Electrocardiography and echocardiography may be needed to rule out cardiac abnormalities and assess cardiac function.
  • Chest radiography should be carried out; CT scanning may be helpful.
  • A scoliosis series should be arranged if this condition is suspected.

Management[12]

  • Many patients have a mild deformity with no associated morbidity requiring treatment.
  • Various physical methods of correcting the deformity have been tried, including casting, bracing and chest compressors.
  • Endoscopic resection of costal cartilage and sternal osteotomy is available for patients who require cosmetic correction but this procedure does nothing to correct any functional disability.
  • Rarely, if there is significant pulmonary and/or cardiac dysfunction, open surgical repair is performed. Various techniques have been tried.

SPINE(Back)Low back

Acquired/Postural spine problems

Spinal canal stenosis(Congenital)

Sciatica

Kyphosis

Kyphosis or kyposis –arcuata or round back is the exaggeration of the posterior spinal curve and is generally localized to the dorsal spine . the back id rounded the head is carried forward and the chest is flattened . this results in typical round shoulders with excessive protrusion of the scapulae.

Habitual bad posture at the school is the common cause . it could develop as a result of undetected defects of vision or hearing. Mental or physical fatigue could also precipitate such habitual postural tendencies.

In old adolescent age it may be the result of previous bad posture , muscular weakness degeneration and diseases of vertrbral bodies and discs.

The deformity may be divided into three degrees according to its severity :

  • First degree;
  • Second degree
  • Third degree.

Progress of the deformity from first to third degree . A bad habitual posture is the precipitating factor . inititally there is no imbalance in the muscles. If not corrected at this stage, it progresses to the second degree.

  • The pectoral muscles become short, thereby restricting the chest expansion resulting in reduced respiratory function.
  • Longitudinal back muscles rhomboids and the middle trapezius are unduly stretched and weakened with loss of tone.
  • Posterior ligaments are lengthened with corresponding shortening of the anterior structures. This gives rise to increased posterior laxity and a typical kyphotic deformity.
  • During the adolescent stage of growth period wedging of the vertebral stage of growth period wedging of the vertebral bodies may occur. The deformity gets organised , which is a difficult syndrome .

Kyphosis can also occur due to tuberculosis ankylosing spondylitis , scheuermann’s diseases or congetital anomalies. Total assessment of the hyphotic deformity is to be done on the same lines as described for scoliosis.

Physiotherapy management

As in scoliosis early detection by screening forms an important part of its prevention. Other methods as described under scoliosis should be adopted physiotherapy management basically depends upon the stage of the condition and its ill-effects.

First degree kyphosis

  • Relaxation of the body especially the upper back.
  • Repeated stretching sessions of shortened anterior structures by bracing the shoulders and maintaining the position .
  • Posture of head neck and shoulder during activity or rest in optimal position should be trained and checked.
  • Mobilization of the whole spine particularly neck scapulae and shoulders .
  • Diaphragmatic and costal breathing with emphasis on inspiration.
  • When precise mobility is attained specific resistive exercises can be added to the weak longitudinal and transverse back muscles. These will be helpful in the natural maintenance of the corrected postures.
  • Controlled pelvic tilt may lead to lordosis or even kyphoscoliosis or sway back.
  • Efficiency of home management programme is vital for good results . therefore it needs to ne emphasized and checked regularly.

Second and third degree kyphosis

As wrong adaptation of the soft tissues are in the advanced stage, active correction and maintenance of the correction is difficult . the milwaukee brace is prescribed with pads applied on the posterior uprights.

Lumber spondylolisthesis

Discogenic or radiating pain in to legs

Lordosis

Lordosis is the exaggeration of the anterior curve of the spine. Common sites of the lordosis are cervical and the lumbar spine. The causes are ;

  • Hip flexion contracture due to diseases of the hip joint like congenital dislocation and tuberculosis
  • Positional or habitual tightness of hip flexors due to paralysis of abdominals or the flexors of lumbar spine
  • It could be adaptive when it is developed to compensate for altered balance e.g. pseudo hypertrophic muscular dystrophy ankylosing spondylitis fixed flexiondeformities at the hip or the knee
  • Congenital or acquired spinal deformities like spondylolisthesis
  • It could be because of habitual posture
  • Obesity with protruding abdomen.

The forward tilting of pelvis produces compensatory exaggerated lumbar lordosis. This leads to stretching of the abdominal muscles and the anterior spinal ligaments. There is reciprocal shortening of the posterior ligaments and muscles. It may be associated with weakness of the glutei and lengthening of the hamstrings.

Treatment

  • Mobilisation of the lumbar spine
  • Anterior stretching of the lumbar spine by concentrating on exercises to achieve posterior tilt of the pelvis.
  • Strengthening of the abdominals glutei and hamstrings.
  • Training in graded correction of the pelvic tilt has to be emphasised . active backward or posterior pelvic tilting by contracting abdominals and glutei in supine is initiated. It is progressed to sitting and standing. Maintenance of the corrected posture is vital . postures like “make yourself as tall as you can” or toe-touching in long sitting or forward bending sitting are simple procedures. To be effective they should be repeated often.

Thorecolumber scoliosis

Priformis syndrome

Flat back & LCS Lumber canal stenosis

This is a spinal deformity which is reverse of lumbar lordosis . the pelvis is tilted backwards with associated shortening of the hamstrings. There is flattening of the normal lumbar lordosis.

The aim of treatment here is to increase the lumbar lordosis, which results in forward tilting of the pelvis.

Maintenance of the arch by active holding and also passive support in sitting are effective in maintaining lordosis.

Mobility exercises and strengthening exercises are important.

CAUTION

While treating spinal deformities certain precautions should be observed such as:

  • The holding or the maintenance of the corrected position should not be continued beyond the point of muscle fatigue.
  • The patient should be taught to localise the corrective exercises. Careful monitoring of the effects of exercise on the deformity is necessary.
  • Necessary compensations or appropriate braces are necessary to square the pelvis.
  • Breathing capacity needs careful monitoring in the thoracic curves.

Fracture of lumber spine

Scheuermonn’s disease

Low back pain

Low back pain is a common ailment that affects most people at least once in their lives. The spine is designed to hold the body upright and serve as its primary support. The low back, which includes the lumbar curvature of the spine, is made up of bones, muscles, nerves, ligaments, tendons and intervertebral discs.

This part of the anatomy has so many complex moving part, it’s no wonder that it requires special cars . The best ways to prevent back pain and maintain a healthy back are by keeping muscles strong and flexible, practicing proper lifting techniques and maintaining a healthy body weight.

TYPES OF LOW BACK PAIN

Back pain is classified as acute or chronic Acute back pain is usually the result of an injury or a sudden jolt and can last from a few days to few weeks; it is generally resolved within 6 to 12 weeks. Back pain becomes chronic when it persists for 3 to 6 Months beyond the expected healing time. About 15 % of low back pain cases progress from acute to chronic.

There are 3 Main types of back pain

  • Non-specific low back pain is not associated with a single known cause and accounts for about 85 %of back pain cases. The pain is commonly due to sports injuries and sudden strenuous physical activities; for example, gardening or home improvement activities on the weekend after being sedentary during the week.
  • Back pain caused by various spinal conditions such as sciatica, bulging disc (also called protruding, Herniated or ruptured disc), spinal stenosis, arthritis, Fibromyalgia, skeletal irregularities and osteoporosis,
  • Back pain resulting from a specific trauma; for example, a car accident or cancer.

CAUSES AND RISK FACTOR

  • Age –As people age, bone strength lessens, as do muscle elasticity and tone. The discs in between the vertebrae lose fluid and flexibility which decrease their ability to cushion spinal compression.
  • Physically strenuous work-back sprains, strains, spasms, or disc rupture can be caused by lifting items that are too heavy or by using improper lifting techniques.
  • Overstretching.
  • Poor phy6sical condition- Due to factors such as sedentary life style or unhealthy amount of exercise (either too little or too much).

Other contributing factors related to non-specific back pain include:

  • Obesity
  • Inappropriate posture
  • Poor sleeping position
  • Weight gain during pregnancy
  • Smoking
  • Stress
  • Anxiety and/or depression
  • Build up of scar tissue from repeat injuries

SIGNS AND SYMPTOMS

Common symptoms of low back pain include:

  • Muscle ache
  • Shooting or stabbing pain
  • Limited flexibility or range of motion
  • Inability to stand straight

When ongoing pain is not relieved, chronic pain sufferers may experiences:

  • Poor sleep quality and lack of concentration
  • Inability to perform tasks well at home or work
  • Irritability
  • Depression

Back pain can indicate a serious condition and can be accompanied by other symptoms such as unintentional weight loss, pain that worsens at night and does not resolve with rest, bladder or bowel incontinence, and weakness in the hands and/or feet. It is important for patients to tell their health care professional about all occurring symptoms.

TREATMENT AND MANAGEMENT

The goal of treatments for low back pain is to reduce pain and restore function, strength, and prevent injury reoccurrence. A combination of treatment may be recommended by your health care professional. In a few serious cases, surgery may be performed to relieve low back pain.

Some common treatments include:

  • Ice and heat
  • Physical activity; staying in bed can make back pain worse and weaken muscles
  • Medications
  • -Nonsteroidal anti-inflammatory drugs (NASDIAS) or acetaminophen
  • - Opioids (to help manage pain)
  • -Muscle relaxants
  • -Medications for sleep and depression

Alternative approaches include:

  • Physical therapy
  • Spinal manipulation/chiropractic care
  • Acupuncture
  • Massage therapy
  • Biofeedback
  • Yoga and relaxation techniques
  • Cognitive behavioral therapy

PREVENTION

Maintaining a healthy back is very important in preventing low back pain. Some techniques include: Focus on physical and metal well being:

Exercise regularly with low-impact aerobic activities such as walking and swimming Strengthen abdominal and back muscles with core-conditioning exercises Practice yoga for strength and flexibility and stretch well after exercising

  • Eat a proper diet
  • Maintain a healthy weight
  • Quit smoking
  • Manage stress levels
  • Exercise proper body mechanics:
  • Practice proper lifting techniques-lift with your knees, keeping your back straight and stomach muscles contracted. Do not lift anything excessively heavy.
  • Utilize ergonomically-designed products, as well as work and living spaces.
  • Maintain proper posture when sitting or standing
  • Wear comfortable low-heeled shoes
  • Sleep on a firm surface and on your side to reduce curving of the spine.

Spondylosis or degenarative

Archenoditis

Low back pain of thorecic origin

Spina bifida/ oculta

Ankylosing spondylitis

Psoriatic arthritis

Reiter’s disease

Pott’s disease

Kyphosis

Lordosis

Flat back

ORTHOPEDIC DISORDERS

Musculoskeletal Condition of Shoulder

Bone & joints related condition at shoulder joints

Neuromuscular Disorders of Shoulder

Painful arc syndrome

Shoulder dislocation

Earb palcy

Frozen shoulder

Fractures around shoulder joint

Klumpke palcy

Lesion of the rotator cuff

Shoulder impinchment

Supraspinatus tendinitis

Infraspinatus tendinitis

Subscapularis tendinitis

Long head of biceps

brachii tendinitis

Subacromial bursitis

ORTHOPEDIC DISORDERS

Musculoskeletal Condition of Elbow

Neuromuscular Disorders of Elbow

Elbow

Bone &joint

Neuromusclo

PeripheralV

Tennis elbow

Dislocation of elbow joint

Ulner nerve injury result in Claw hand.

Volkmann’s

Golfer’s elbow

Osteoarthritis of elbow joint.

Median nerve injury result in Monkey hand.

Ischemic contracture(VIC)

Olecranon bursitiss

Myositis ossification

Radial nerve injury result in Wrist drop

Reptured biceps tendon

Malunion

Posterior interosseous nerve syndrome

Cubital tunnal syndrome

Fractures around elbow joint

Interosseous nerve syndrome

Thumb web pain

ORTHOPEDIC DISORDERS

Musculoskeletal Condition of Forearm & wrist

Neuromuscular Disorders of Forearm & wrist

Wrist sprain

Fractures

Cubital tunnel compression due to ulner nerve

Tenovaginitis De Quervain’s disease

CTS carpal tunnel syndrome

Tenosynovitis

Radial nerve palcy Wrist drop

Median nerve palcy Monkey hand

Ulner nerve palcy Claw hand

ORTHOPEDIC DISORDERS

Hands/ Fingers

Ulner deviation

Bannett’s fracture/ dislocation

Reynaud’s phenomenon(RP)

Fracture of fingers

Reflex sympethetic dystrophy.(RSD)

Mallet finger (swan neck deformity)

Trigger finger

Boutonniere deformity

ORTHOPEDIC DISORDERS

Pelvic/Hip joints

Iliotibial tract syndrome

Total hip replacement

Priformis syndrome

DHS(physiotherapy management)

Coxa vera

Coxa velga

Perthes disease

Avescular necrosis

ORTHOPEDIC DISORDERS

Ligaments injuries

Total knee replacement

Traumatic effusion

Arthroscopy

Knock knee

Bow knee

Genu recurvatum Chondromalacia

Chondromalacia Patellae

Popliteal cysts

Baker’s cyst

Osteochondritis dissecans

Osteoarthritis

ORTHOPEDIC DISORDERS

Ankle sprain/strain

Volkmann’s ischemic contracture(VIC)

Planter facitis

Calcaneal spur

Metatarsalgia

Tendo-achilles injuries

Tenosynovitis

Pace planus

Pace caves

High arch of foot

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