Kindle; 2012:292. Hardworking 19-year-old was misdiagnosed with a torn ligament after suffering with 'horrendous' knee pain, fatigue and sleepless nights. Best results are with hypermobile or subluxation patients and not those with normal movement. It often happens repeatedly during the second trimester. Abdominal cramping. Awwad WM, Saadeddin M, Alsager JN, AlRashed FM. Overall, 3 had an excellent result, 2 had a good result, and 1 was not improved. Referred pain into the buttock, thigh, hamstring, and feet. 2001 Dec;15(6):474-83. doi: 10.1007/s004820100035. This new concept could improve the treatment of chronic pain and could lead to an important enhancement of current anatomical knowledge and therapies." (Ramin, A., 2016). [4] Inferiorly, the tendon of the iliococcygeus muscle inserts onto the tip of the coccyx. Spasm of the muscles of the pelvic floor, 3. Chronic proctalgia and chronic pelvic pain syndromes: new etiologic insights and treatment options, Comparison of three manual coccydynia treatments: a pilot study, Coccygodynia and pain in the superior gluteal region: and down the back of the thigh: causation by tonic spasm of the levator ani, coccygeus and piriformis muscles and relief by massage of these muscles, Diagnosis and treatment of pain of vertebral origin, Chiropractic treatment of coccygodynia via instrumental adjusting procedures using activator methods chiropractic technique, Effect of stretching of piriformis and iliopsoas in coccydynia, The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled study, Nonoperative Management of Coccydynia: A Comparative Study Comparing Three Methods, The effects of extracorporeal shock wave therapy in patients with coccydynia: a randomized controlled trial, Extracorporeal shock wave therapy relieved pain in patients with coccydynia: a report of two cases, Effects of extracorporeal shock wave therapy on pain in patients with chronic refractory coccydynia: A quasi-experimental study, https://www.physio-pedia.com/index.php?title=Coccygodynia_(Coccydynia,_Coccalgia,_Tailbone_Pain)&oldid=306878. My passion and specialization are in the evaluation and treatment of cervical disc, facet, ligament and nerve pain, including the non-surgical treatment of Craniocervical instability (CCI). Practice Essentials. Whereas conventional radiofrequency ablation has become a standard treatment for joint pain , its reported use in the literature for coccygeal pain has been infrequent. Several findings seen at cross-sectional imaging can point to a source of pain that may be subtle and easily overlooked. The coccyx is your tailbone. This surgery may prove an alternative to coccygectomy. World J Gastroenterol. Coccygectomy for chronic refractory coccygodynia: clinical case series and literature review. The sacrum is a large wedge-shaped bone at the base of the spine. National Library of Medicine Why do we then have this chronic pain problem? Cryptoglandular Disease - Most Common. Epub 2017 Apr 6. It functions to restrain movement in the lumbosacral and sacroiliac joints (2) In doing so, the iliolumbar ligament is a major stabilizer of the low back and sacroiliac joint (3). Chiropractic Technique-Principals and Procedures. [Relevance of nerve blocks in treating and diagnosing low back pain--is the quality decisive?]. They cannot attend a movie nor a concert. 1982;136(4):372-4. Using loose fitted clothing that wont place pressure on the area around the tailbone is advised. Non-surgical methods include medicines like non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen pain killers, minimal sitting, stool softeners, a tailbone cushion, as well as additional postural changes intended for unloading, ice at first and then moist heat following a few days, ultrasound therapies and also manual treatment such as massage, stretches, and also joint mobilization. Five to twenty five degrees of rotation is normal, so hypermobility is greater than twenty five degrees. Whether patients are referred to us or already have a Cleveland Clinic ob/gyn, we work closely with them to offer treatment recommendations and follow-up care to help you receive the best outcome. [1][3][4] The coccyx should also be palpated to detect the presence of swelling, bone spicules or fragments, and coccygeal masses. The anococcygeal nerve of the coccygeal plexus has a variable description of supply 4. Naeim F, Froetscher L, Hirschberg GG. When considering the effects of other modalities, Lin and Colleagues (2015)[27] reported that IFC and shortwave diathermy were able to decrease pain scores but not to the same extent as ESWT. When refering to evidence in academic writing, you should always try to reference the primary (original) source. The sacrotuberous ligament (STL) is a stabiliser of the sacroiliac joint and connects the bony pelvis to the vertebral column [1]. The coccygeal vessels on each side are ligated or cauterized. Even those without a musculoskeletal education can carry out this infiltration therapy. See Treatment and Medication.) At the midline, the muscles blend together posterior to the vagina in women and around the anal aperture in both sexes. Don't try to work or play through the pain. As every pain in the motor system has a reason, why can the coccyx be so painful in some patients? | Investigation and diagnosis | Treatment | Coping with coccyx pain | Find a doctor or specialist, Medical papers | Personal experiences | Links to other sites | Support groups | Site map. [1] For example, over-extension of the levator ani muscle can shift the coccyx into an abnormal position. [2][3] The first coccygeal segment might not fuse together with the second coccygeal segment. PRP is rich in growth factors that can increase blood flow and accelerate healing. Less commonly, a tumor may cause bone pain. Anococcygeal Ligament has 3 layers: You have already completed the quiz before. Ligaments that become overstretched or torn are technically "sprained.". 3rd ed. com/u/29411067/Coccygodynia)[Accessed December 15 2010] Search Google Scholar Export Citation. [7][11], Although not a hallmark sign of coccygodynia, low back pain may still arise in individuals with coccygodynia due to the morphological variations in the shape of the coccyx and its forward curvature. New York: Churchill Livingston Inc. 803p. Stress to this ligament occurs most often when leaning forward or getting out of a chair. People who have normal coccyx movement respond better to these types of therapies. Ombregt L, Bisschop P, ter Veer JH. This area is also known as the coccyx. This nerve supplies the sacrotuberous ligament as well as the skin over the tailbone. Ligament injuries are poorly understood and oftentimes missed. Radiographs may be taken to look for fracture or obvious displacement or subluxation. Driving a car for any length of time may be hell. Coccygeal muscle. Posterior cruciate ligament (PCL). The gluteus maximus attaches to the coccyx, as does the levator ani muscle, which is a key component of the pelvic floor. These include infection, neoplasm, crystal deposition, and cystic formations such as pilonidal cyst. If you have questions, give us a call. [1][2], Patients will usually exhibit a guarding seated posture, whereby one buttock will be elevated to take weight off of the coccyx. Clinically, its anatomy is not well known. I have had experience in treating tailbone pain with conservative methods. Tailbone pain due to these causes usually is not permanent, but if the inflammation and symptoms are not managed, the pain may become chronic. The fracture is an acute pain problem. [4] In an anterior (front) to posterior (back) direction, the lateral border of the coccyx serves as an insertion point for the coccygeal muscles, the sacrospinous ligament, the sacrotuberous ligament and the gluteus maximus. Perineal body. Schmerz. While not common, the force may result in a fracture of the coccyx. doi: 10.1097/MD.0000000000005010. These options may be used in those individuals with advanced degeneration with coccyx instability (e.g., subluxation or hypermobility) and are successful between 60 91 percent. Mennell JB. [13] Although commonly recommended, the therapeutic outcomes of these conservative recommendations have not been evaluated in the literature. 8600 Rockville Pike [1][6] With rapid weight loss, the cushioning around the coccyx may be lost,[4] and the coccyx is at an increased risk for anterior subluxation (displacement forward). In the old anatomists tradition of naming parts according to similarities in nature, coccyx comes from Greek 'kokkoux' (cuckoo), as the human tailbone resembles the shape of a cuckoo's beak. PLoS ONE. Disclaimer. Williams & Wilkins; 1993. Activities that put prolonged pressure on the tailbone, such as horseback riding and sitting on hard surface for long periods of time may cause the onset of pain. Stem cells are natural powerhouses of healing. The anococcygeal ligament is a fibroelastic construct connective tissue coat of the anorcctum to the coccyx and presacral fascia and extending via the external anal sphincter. 2000;22:163168. Attaching anococcygeal ligament and coccygeal muscle; . The https:// ensures that you are connecting to the What type of treatment is available after so many years of suffering? It can persist over years. He said we sit from 38 years to 72 years. The anus by reinforcing and elevating its posterior attachment to the coccyx is supported by the attachment of iliococcygeus to the anococcygeal ligament. Most of the time, the pain will get worse when sitting. . Rather than consider coccygectomy when the traditional nonoperative treatment of coccydynia fails, resection of the ACN might be considered. coccygeus muscle spasm (77.8% vs. 17.2%, p < .001), anococcygeal ligament pain (63.5% vs. 9.4%, p < .001), external anal sphincter pain/spasm . The coccyx is the last part of the spinal column and is a small bone that is just below the sacrum bone. The site is secure. An iliolumbar ligament injection under x-ray is illustrated in the picture to the right. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). It commonly occurs from an injury, but there are instances where it can occur spontaneously. If the pain persists, other treatments may be applied. The fracture finally heals, but the fracture of the coccyx seldom occurs. Available at: Kerr EE, Benson D, Schrot RJ. [but see note at end]. Round ligament pain occurs almost exclusively in pregnancy. Sacrococcygeal pain can arise from the sacrococcygeal joint, from contiguous structures sharing the same innervation, or from distant sites. Order JointAdvance #2 - Biogetica JointsFormula, 77 points out of 100. Superficial external pudendal artery. [1][2][4] This articulation creates a symphysis or synovial joint, which forms one of the borders of the foramen for the dorsal branch of the fifth sacral nerve route (S5). sharing sensitive information, make sure youre on a federal [13], Physiotherapists may also recommend the use of cushions. The artery which supplies blood to the major erectile body in both the male and female is the: Artery of the bulb. This site needs JavaScript to work properly. We serve patients from all across the Sunshine State, in Orlando FL, Conway FL, Edgewood FL, Jensen Beach FL, Ocean Breeze FL, Rio FL, Palm Bay FL, Malabar FL, Melbourne Village FL, Atlantis FL, Palm Springs FL, Boynton Beach FL, Fort Pierce FL, Fort Pierce South FL, White City FL, Plantation / Ft. Lauderdale FL, Pine Island Ridge FL . Rarely, pain can happen from bursitis, arthritis, infection or a tumor. [27] Patients who received ESWT reported greater subjective satisfaction scores following treatment, with ~ 70% reporting good to excellent satisfaction. The tailbone or coccyx mainly functions as a structure that bears the body's weight as well as a point of attachment for many muscles, tendons, ligaments, and nerves. Its never too late to address tailbone pain, regardless of how old the injury is or how severe symptoms are. . Taping or bracing of the SI joints can be helpful. Others may report relief of their pain when they sit on their legs or on one buttock. Pain may also be present with intercourse. MeSH Iliococcygeus forms the midline raphe after it meets the fibers from the opposite side, which is continuous with the anococcygeal ligament and provides a secure anchoring point for the pelvic floor. sharing sensitive information, make sure youre on a federal He also injected the anterior aspect of the tailbone. 33-50% Will Develop Fistula-In-Ano. Anococcygeal Ligament is situated between the coccyx and anorectal boundary, it is a complicated musculotendinous structure. The anococcygeal raphe is a thin, linear structure running from the coccyx to the anal canal measuring approximately 1-2 cm in length and 2-5 mm in . Round ligament pain is a common, normal pregnancy symptom. The anococcygeal nerve arises from the coccygeal plexus. Copyright 2021 Wolters Kluwer Health, Inc. All rights reserved. The .gov means its official. Each one is about 10 to 12 centimeters long. To better understand how ligaments respond to PRP and stem cells please watch the video below. Hirschberg GG, Froetscher L, Naeim F. Iliolumbar syndrome as a common cause of low back pain: diagnosis and prognosis. We do not endorse non-Cleveland Clinic products or services. The pudendal nerve is one of the major nerves that innervates the pelvic floor muscles, external urethral sphincter, and anal sphincter. Obese people mostly have posterior subluxation, while individuals having normal weight suffer mostly hypermobility and thin individuals usually have forward or anterior subluxations. One of its best known properties is its ability to increase absorption of nutritional compounds. Most horse riders who fall off a horse fall onto their back or pelvis, but some may have the impact direct to the tailbone. [15][20], A study by Maigne and Chatellier (2001)[15], who compared the effectiveness of various massage, mobilization and manipulation techniques, reported that manual treatments were helpful for ~ 26% of cases with coccygodynia at 6 months and ~ 24% of the cases of coccygodynia at 2 years post treatment. In: StatPearls [Internet]. When your tailbone hurts, simple actions like going from sit to stand, sitting on the floor, engaging in sexual activities, or even having a bowel movement can be excruciating. [13][14] A proper sitting posture ensures weight is taken off the coccyx and is instead loaded onto the ischial tuberosities and the thighs. Pubovesical ligament. [3] Most cases will resolve within a few weeks to months, however for some patients the pain can become chronic, having negative impacts on quality of life. Because of this, the pelvic ligaments can be injured. Pennekamp PH, Kraft CN, Sttz A, Wallny T, Schmitt O, Diedrich O. Maigne R. Douleurs dorigine vertbrale et traitements par manipulations, medicine orthopdique des derangements intervertbraux mineurs, 2e editie, p. 473-476. 2. a double layer of peritoneum extending from one visceral organ to another. Sacrococcygeal pain syndromes: diagnosis and treatment Orthopedics. Behnke R. Kinetic Anatomy: Human Kinetics. We also learned that anatomically the tailbone consists of four or five bony connected rudiments of vertebrae. [27] In this study, 2000 shots of ESWT were applied to the coccyx area per session for 4 sessions at 5 Hz and a pressure of 3-4 bar. Coccygectomy: surgical technique. However, imaging can aid in determining potential causes of pain to help . This stretching can cause spasms in the round ligaments, leading to the pain. Simpson JY. While it might seem awkward initially, the pain relief that follows is well worth getting through the treatment according to our patients. . Sitting is far too important of a daily task to suffer severe pain that limits sitting. Methods: [2] Patients may also report pain with defecation or the frequent need to defecate. It stretches between the sacrum and the Sitz bone (ischial spine). Corticosteroid injections reduce inflammation and pain and may be combined with local anesthetic to make them even more effective. Would you like email updates of new search results? Abdominal pain can be a symptom of other conditions, whether youre pregnant or not. You can even try to sleep using a body pillow or cushion in between the knees. J Anat. [1][2] The pain is typically localized to the sacrococcygeal joint[2] and is described as a pulling or cutting sensation. When the ACN is described in anatomy textbooks, it is with varying distributions of innervated skin territory and nerve root composition. https://www.statpearls.com/ArticleLibrary/viewarticle/114587. [1][2][3][4] Non-operative treatments may range from the recommendation of non-steroidal anti-inflammatory drugs (NSAIDs), activity modification, ergonomic adjustments, and physical therapy. A Randomized Clinical Trial on the Effect of Biofeedback on Pain and Quality of Life of Patients With Chronic Coccydynia. 2016 Sep;95(39):e5010. Careers. [23], The technique chosen will vary depending on what the originating cause of the coccygodynia is. In some cases there is a clear-cut, decades-old history. [1][5] Postacchini and Massobrio (1983)[5] stated that individuals with coccygodynia are more likely than the general population to have a configuration of Type II,III and IV. Med Times Gazette. It functions to prevent rotation of the ilium. These forces can be significant. The coccygeal plexus gives rise to the anococcygeal nerve. Division of the anococcygeal ligament and discharge of purulent fluid will confirm entry into this space. Generally, surgery consists of removal of a hypermobile segment or complete removal (coccygectomy). Its a growing pain thats common and normal during pregnancy. But for some it is hell, and sometimes for years. A review of traditional anatomy textbooks was used to establish classical thoughts about the ACN. Healing Anal Fissures with Pelvic Rehab. Last reviewed by a Cleveland Clinic medical professional on 07/20/2021. Fractures do occur and can be very painful, especially when the fracture parts are dislocated. This is made worse by the dismissive glances of your doctor. Additionally, it may help by wearing flat, comfortable footwear. It is composed of fibers of the levator ani muscle that unite with the muscle of the opposite side, muscle fibres from external anal sphincter . The ligament, located in the back of the knee, that controls backward movement of the tibia (shin bone). Conflicts of interest and sources of funding: The authors declare that they have no conflict of interest. [1][2][3][4] Surgery is usually only considered when patients continue to complain of coccygeal pain after the use of conservative treatments. Nausea or vomiting. It usually lasts only a few seconds, but it can last hours. Background: This will help lessen the stress on the uterus and round ligaments. After subdermal infiltration at two sites anterior and posterior of the anal ring, the anococcygeal ligament is deeply infiltrated with 5 ml; 8 - 10 ml are injected into both ischioanal spaces while withdrawing the needle to anaesthetise the deep nerve endings. [3] Individuals will commonly report tenderness on palpation of the coccyx. This therapy applied repeatedly may have the same relaxation effect as manipulation. During the FIMM Conference in Brisbane last year a specialist for manual medicine, Dr. Leo van Deursen, spoke about ';homo sedens' in our century, meaning ';the seated man'. Although it doesn't produce movement, it can shorten and tighten in response to the activities of the muscles and fascia around it. The iliolumbar ligament: its influence on stability of the sacroiliac joint. Coccygeal adjustment may shift the coccyx back to its correct placement and relieve pain. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). [13] Individuals should be taught to correct their sitting posture by sitting more erectly on a firm chair. A method for defining the anatomic basis for sacrococcygeal pain is presented as well as a discussion of the relevant anatomy and differential diagnosis of sacrococcygeal pain. Ho H.C. Leong J.C.Y. The anococcygeal body ( anococcygeal ligament, or anococcygeal raphe) is a fibrous median raphe in the floor of the pelvis, which extends between the coccyx and the margin of the anus. 2001;199(Pt 4):457-63.3. Treatments may include core and pelvic floor strengthening. This can be done by working near the gluteal muscles, or buttocks, and just to the sides of the tailbone. Most patients will react to pressure on these soft tissues with a report that this is exactly where their tailbone pain is located. If you have ongoing low back, buttock or pelvic pain that can not be explained schedule a telemedicine consultation with a board-certified, fellowship-trained physician. One structure that is a common cause of tailbone pain is the anococcygeal ligament. It spans between the tip of the 4 and 5th transverse process of the spine to the waist bone (iliac crest). The results were seldom good and mostly as disappointing as in other areas with similar conditions, such as the calcaneal spur. [2] Single-position radiographs are usually not used for diagnosis as they are unable to identify any morphological differences between individuals with and without coccygodynia. The ligaments connect the uterus to the pelvis and hold the uterus in place. [23]In this study, stretching was performed for 2 minutes on each side of the hip, 5 times per week. Eur J Orthop Surg Traumatol. The science and Art of Joint Manipulation. After receiving 2 weeks of ultrasound and 2 weeks of shortwave diathermy, only 16% of patients in the study report relief in their symptoms. Ligament stability is poorly understood by most physicians and oftentimes missed. It is a thin triangular band and about 3.8-4.6cm in length. True coccygodynia consists of pain arising from the sacrococcygeal joint, whereas pseudococcygodynia consists of pain referred to but not arising from the coccyx. [3][4] Post-traumatic coccygodynia is usually a result of internal or external trauma. Consultant for musculoskeletal medicine. This anatomy is well depicted at imaging, and management is often dictated by what structures are involved. 2.. Pool-Goudzwaard AL, Kleinrensink GJ, Snijders CJ, Entius C, Stoeckart R. The sacroiliac part of the iliolumbar ligament. Before Disclaimer. When we talk about the tailbone, we are referring to the part of the body that attaches to the sacrum, or the very tip of the lower spine. Pelvic floor and prostate pain; Treatment Options for Pelvic Ligament Injuries and Pain. Please enable it to take advantage of the complete set of features! [4]The use of cushions can be recommended over a 6-8 week period. [1] Posteriorly, the sacrotuberous ligament passes behind the sacrospinous ligament. Posterior labial/scrotal artery. FOIA It may take weeks or even months of conventional therapy before substantial pain relief is experienced. Ligament stability is poorly understood by most physicians and oftentimes missed. But patients with a chronic dysfunction in the tailbone cannot sit. 2011 Oct 28;17(40):4447-55. doi: 10.3748/wjg.v17.i40.4447. More aggressive approaches such as removing the tailbone dont guarantee the pain will be better. However, low back pain is known to be higher in individuals with tailbone pain compared to the general population, particularly those with a coccyx that is curved forward with the end pointed straightforward. blockade of the ganglion impar are primarily treatment of pelvic and perineal pain with a substantial sympathetic component.2-4 The block has been administered through different approaches, including the transsacrococcygeal ligament approach, transsacrococcygeal joint approach, paramedial approach via anococcygeal ligament, and paracoccygeal Ligament, tendon, and muscle injuries occur in similar ways or types, but generally have different names, causes, and outcomes for patients. Professor Hans Tilscher from Vienna, in his book about infiltration therapy, describes meticulously, the technique of injecting lignocaine in M gluteus maximus, M levator ani and M coccygeus (a part of the sacro-tuberal ligament). What are the Pelvic Ligaments? This could be a sign of endometriosis, when the uterine lining grows outside the uterus. Ahadi T, Raissi GR, Hosseini M, Sajadi S, Ebadi S, Mansoori K. Basic Clin Neurosci. Its easy to injure this part of the body through a fall such as on the stairs, on slippery surfaces, when participating in sporting activities, or even during during childbirth. 1979;60(9):415-9. Scemama et al. Ask your doctor if yoga for pregnant women is right for you. As a result, they are susceptible to injury. The ACN can be evaluated with a diagnostic nerve block, can be identified at surgery, and can be resected, and its proximal end can be implanted into the coccygeus muscle. Trampoline springers who hit the bar know how painful this is. The superficial anococcygeal ligament is a loose bundle of elastic fibers, and it connects between the external sphincter and the CX (Muro et al., 2014; Jin et al., 2015). People with coccydynia most often complain of pain in and around the coccyx without significant low back pain, pain radiation or referral of pain to other areas. The ligament that gives stability to the inner knee. Modified wedge-shaped cushions (coccygeal cushions), which can be purchased over the counter, help to relieve the pressure placed on the coccyx during sitting. Structure. 4-31% Will Recur. [1][2] Other complaints may include pain with coughing or increased pain during menstruation in females. Coccydynia or tailbone pain. adj., adj ligamentous. The iliolumbar ligament: a study of its anatomy, development and clinical significance.J Bone Joint Surg (Br). The medical term for tailbone pain is coccydynia, referring to the tailbone or coccyx (pronounced coc-six) and refers to pain symptoms in the area of the tailbone. Anococcygeal Ligament pulls vagina and rectum forward to preserve urinary and fecal continence. Sacrococcygeal pain can arise from the sacrococcygeal joint, from contiguous structures sharing the same innervation, or from distant sites. Localized injections into tailbone region is a possible means of therapy when non-operative measures fail. Act now and regain your passion and joy! Levator Scapulae Massage: Options When It Doesnt Work, Interstitial Cystitis Natural Treatment: A New Novel Treatment Option, See if you're a Candidate for Regenexx Procedures, Iliolumbar ligament syndrome with pain localized to either the right or left waist bone (iliac crest) (4), Sacroiliac joint pain due to instability(5), Vaginal pain due to irritation of the pudendal nerve (6). Such treatment is usually given by an intimate partner, chiropractor, osteopath or physical therapist. Cleveland Clinics Ob/Gyn & Womens Health Institute is committed to providing world-class care for women of all ages. Patients may also have connective tissue disorders that affect the overall quality of the ligaments such as EDS. Attachments. [4], In addition to being an insertion site, the coccyx, in conjunction with the ischial tuberosities, provides weight-bearing support to an individual in a seated position. Groin Pain after Hip Replacement: What Is Being Missed? The 5th nerve can exit through the tailbone, that also functions to attach the gluteus maximus and coccygeal muscles, as well as the anococcygeal ligament. Bookshelf These ligaments are important stabilizers. 3.Pool-Goudzwaard A, Hoek van Dijke G, Mulder P, Spoor C, Snijders C, Stoeckart R. The iliolumbar ligament: its influence on stability of the sacroiliac joint. Moreover, JointAdvance contains Bioperene. Coccygodnia can usually be distinguished from pseudococcygodynia by physical examination with the diagnosis being confirmed by injection of local anesthetic into the sacrococcygeal joint. The surgeon should work toward and just distal to the coccyx to guide the appropriate dissection. 2015;10(3):e0119542. Too many people are living their life with untreated tailbone pain, and fortunately, its one of the easiest conditions for us to treat in pelvic health. In Phase two repair cells are laying down new tissue. 2017 Oct;27(7):961-965. doi: 10.1007/s00590-017-1947-3.
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