Painful Conditions Of The Upper Back

Dorn Spinal Therapy

Spine Healing Therapy

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MIDDLE AND UPPER BACK PAIN FROM OSTEOPOROSIS

Thoracic kyphosis is a primary deformity in osteoporosis, usually accompanied by compensatory extension of the cervical spine. Complaints of upper middle and low back pain are common and can best be treated by gentle efforts to reduce the postural deformity and prevent further progression before the faulty posture becomes a fixed structural fault. If a support can be tolerated, encourage the patient to use one to help maintain the best possible alignment. As tolerated, exercises should be done to help maintain functional range of motion and develop strength.

For patients (usually older people) with a fixed kypho-sis of the spine, little correction can be obtained. Some correction of the forward shoulders may be possible, but the basic faults cannot be altered. A Taylor-type brace (see p. 226) may be used to prevent progression of the deformity and to give some relief from painful symptoms.

For some women, the weight of heavy breasts that are not adequately supported contributes to the faulty position of the upper back, neck and shoulders. (See page 343.)

Subjects with a round upper back often develop symptoms in the posterior neck. As the thoracic spine flexes into a kyphosis, the head is carried forward, the eyes seek eye level to preserve the erect position of the head, and the cervical spine is extended (see pp. 152 and 153). Symptoms associated with this problem are described under Tightness of Posterior Neck Muscles on page 159.

The subject pictured here exhibits a posture typical of osteoporosis—thoracic kyphosis, posterior pelvic tilt with protruding abdomen, and compensatory neck hyperextension. Because the deformity was still somewhat flexible, correction was achieved by connecting an upper back support with posterior stays to a panty brief by using soft strapping and Velcro. This provides support to the thoracic spine in standing and sitting, with improved head and neck alignment

A vest-type upper back posture support can also be effective in improving alignment.

Localized or radiating pain in the arm often is the result of faulty alignment that causes compression or tension on nerves, blood vessels, or supporting soft tissues. The faulty alignment may be primarily in the neck, upper back or shoulder girdle. More often, however, all three areas are involved, and treatment must be directed toward overall correction.

Under normal conditions and through normal range of motion, it may be presumed that a muscle will not irritate a nerve that lies in close proximity to or pierces the muscle. A muscle that is drawn taut, however, becomes firm and has the potential for exerting a force of compression or friction. A muscle that has developed adaptive shortness moves through less range and becomes taut before reaching normal length; a stretched muscle moves through more than normal range before becoming taut. A taut muscle, especially a weight-bearing muscle, can cause friction on a nerve during repetitive movements.

In mild cases, the symptoms may be discomfort and dull ache rather than sharp pain when the muscles contract or elongate. Sharp pain may be elicited by vigorous movements. More often, however, it tends to be intermittent, because the subject finds ways to avoid the painful movements.

Recognizing this phenomenon during the early stages can increase the likelihood of finding ways to counteract or prevent the more painful or disabling problems that develop later. Physical therapists who deal with stretching and strengthening exercises have the opportunity to observe early signs of impingement among their patients. Examples of such impingement include:

Teres major with the axillary nerve Supinator with the radial nerve (14, 25) Pronator with the median nerve (11, 14, 25) Flexor carpi ulnaris with the ulnar nerve (26) Lateral head of the triceps with the radial nerve

Trapezius with the greater occipital nerve (26) Scalenus medius with C5 and C6 root of the plexus and the long thoracic nerve (26) Coracobrachialis with the musculocutaneous (11, 14)

THORACIC OUTLET SYNDROME

Thoracic outlet syndrome results from compression of either the subclavian artery or the brachial plexus within the channel bordered by the scalenus anterior and posterior muscles of the first rib. The diagnosis is often puzzling and controversial. It encompasses numerous similar clinical entities, including scalenus anticus, hyperabduction, costoclavicular, costodorsal outlet, pec-toralis minor and cervical rib syndromes.

Symptoms are varied and may be neurogenic or vascular in origin. Parasthesia and diffuse "aching" pain over the whole arm are common. The condition is aggravated by carrying, lifting, or engaging in activities such as playing a musical instrument.

When present, muscle atrophy usually affects all the intrinsic muscles of the hand. Tendon reflexes are not altered. Arterial compression is a less common cause than was once thought, but symptoms such as coldness, aching in the muscles, and loss o/strength with continued use can reflect vascular compromise. As Dawson et al., state, "The proper diagnostic test should be the production of the neurologic symptoms of arm abduction, whether or not there is a change in the pulse or the appearance of a bruit" (14).

Unless symptoms are severe and clearly defined, conservative treatment should emphasize increasing the space of the thoracic outlet by improving the posture, correcting the muscle imbalance, and modifying the occupational, recreational, and sleeping habits that adversely affect the posture of the head, neck and upper back. Cooperation by the patient is essential to success. The patient should be taught self-stretching exercises to relieve tightness in the scaleni, sternocleidomastoid, pectoral muscles and neck extensors. (See p. 116 and exercise sheets, p. 357.) Learning to do diaphragmatic breathing will lessen involvement of the accessory respiratory muscles, some of which are in need of stretching. Sleeping in a prone position should be avoided, and activities that involve raising the arms overhead should be kept to a minimum. Research has shown that "with conservative therapy [and] . . . exercises designed to correct slumping shoulder posture, ... at least two out of three patients improve to a satisfactory degree" (14)

CORACOID PRESSURE SYNDROME

Coracoid pressure syndrome (see Classic Kendall on this page) is a condition of arm pain that involves compression of the brachial plexus. It is associated with muscle imbalance and faulty postural alignment (27).

At the level of attachment of the pectoralis minor to the coracoid process of the scapula, the three cords of the plexus and the axillary artery and vein pass between these structures and the rib cage. (See figure, opposite.) In normal alignment of the shoulder girdle, there should be no compression on the nerves or blood vessels. Forward depression of the coracoid process, which occurs in some types of faulty postural alignment, tends to narrow this space.

The coracoid process may be tilted downward and forward either because of tightness in certain muscles or because weakness of other muscles allows it to ride into that position. The painful arm conditions are more often found when the tightness factor predominates.

The muscle that acts to depress the coracoid process anteriorly is chiefly the pectoralis minor. The upward pull of the rhomboids and levator scapulae posteriorly aid in the upward shift of the scapula that goes along with the anterior tilt. Tightness of the latissimus dorsi affects the position indirectly through its action to depress the head of the humerus. Tightness of the sternal part of the pectoralis major acts in a similar manner. In some instances, tightness of the biceps and coracobrachial, which originate on the coracoid process along with the pectoralis minor, appears to be a factor. Muscle tightness may be ascertained by the shoulder adductor and internal rotator length tests. (See pp. 309, 310.)

Weakness of the lower trapezius contributes to the faulty shoulder position. Stretch weakness of this muscle allows the scapula to ride upward and tilt down anteriorly, and it favors an adaptive shortening of the pec-toralis minor.

In the acute stage, moderate or even slight pressure over the coracoid process usually elicits pain down the arm. Soreness is acute in that spot and in the area described by the pectoralis minor muscle along the chest wall.

The pain down the arm may be generalized or predominantly of lateral or medial cord distribution. There may be tingling, numbness or weakness. The patient often complains of loss of grip in the hand. Evidence of circulatory congestion, with puffiness of the hand and engorgement of the blood vessels, may be present. In cases of marked disturbance, the hand may be somewhat cyan-otic in appearance. The patient will complain of increased

Scalenus ant. Scalenus med.

Scalenus ant. Scalenus med.

pain when wearing a heavy overcoat, trying to lift a heavy weight, or carrying a suitcase with that arm. Pressure can also be caused by a backpack or a shoulder bag.

Frequently, the area extending from the occiput to the acromion process, which corresponds to the upper trapezius muscle, is sensitive and painful. This muscle is in a state of "protective spasm" in an effort to lift the weight of the shoulder girdle and thus relieve pressure on the plexus. The muscle tends to remain in a state of contraction unless effective treatment is instituted.

CLASSIC KENDALL

"The Coracoid Pressure" syndrome was reported by the Kendalls in 1942. It was presented at a Joint Meeting of the Baltimore and Philadelphia Orthopedic Society, March 17, 1947, by E. David Weinberg, M.D., and was later referred to in an article by Dr. Irvin Stein (28).

Treatment in the acute stage consists first of applying a sling (see p. 345, Figure B) that supports the weight of the arm and shoulder girdle, relieving pressure on the plexus and taking the workload off the upper trapezius. Heat and massage may be applied to the upper trapezius and other muscles that exhibit tightness. Massage should be gentle and relaxing, progressing after a few treatments to gentle kneading and stretching (See p. 162.) Slow, passive stretching of the pectoralis minor can be initiated (see below). If tightness is also present in the pectoralis major, latissimus, or both, the involved arm should be placed carefully overhead, if tolerated, to place the muscles on a slight stretch. Gentle traction is applied with one hand while massage is applied with the other (See p. 344.) A shoulder support (see p. 339) usually is needed to help maintain the correction of alignment and to relieve strain on the lower trapezius muscle during the recovery period.

Certain exercises to stretch the pectoralis minor are contraindicated. Head and shoulder raising from a back-lying position, as in trunk curls, should be avoided, because this movement rounds the upper back and depresses the coracoid anteriorly, increasing compression in the anterior shoulder region.

AVOID forceful shoulder-extension exercises involving rhomboid, pectoralis minor and latissimus actions that depress the head of the humerus and coracoid process and exaggerate the existing faults. (See photo above.)

Pectoralis Minor Length Test

STRETCH OF PECTORALIS MINOR

To stretch the pectoralis minor, place the subject in a supine position, and press the shoulder backward and downward. One hand should be "cupped" just medial to the glenoids, avoiding direct pressure on the shoulder joints using firm, uniform pressure that helps to rotate the shoulder girdle back.

After strain has been relieved by support and by stretching of the tight opposing muscles, specific exercises are indicated for the middle and lower trapezius. (See exercise sheets, pp. 116 and 357.) If the overall posture is faulty, general postural correction is needed.

Note: Among women with very large breasts, the faulty alignment may be accentuated by pressure from brassiere straps. In addition, the weight of the breasts pulling forward and downward can contribute to upper and middle back discomfort. A "posture bra " that is readily available in stores can provide effective support for the breasts and relieve bra strap pressure."

ES

y

Bra—inadequate support

Regular posture bra

{front view)

M

1

M

Long-line posture bra Regular posture bra

(back view)

TERES SYNDROME (QUADRILATERAL SPACE SYNDROME)

The quadrilateral (or quadrangular) space in the axilla is bounded by the teres major, teres minor, long head of the triceps and humerus. The axillary nerve emerges through this space to supply the deltoid and teres minor. The area of sensory distribution of the cutaneous branch of the axillary nerve is shown on page 256.

This syndrome is characterized by shoulder pain and limitation of shoulder joint motion, particularly rotation and abduction. Pain extends into the area of cutaneous distribution of the sensory branch of the axillary nerve. Tenderness may be elicited by palpation of the quadrilateral space between the teres major and teres minor. A slight or moderate pressure over the space may elicit sharp pain radiating into the area of the deltoid muscle.

The teres major, which is a medial rotator, is usually tight and holds the humerus in internal rotation. In standing, the arm tends to hang at the side, in a position of internal rotation (i.e., the palm of the hand faces more toward die back than toward the side of the body) (see p. 75). An element of tension exists on the posterior cord

CLASSIC KENDALL

'Teres syndrome" was described in Posture and Pain in 1952 (27). A book published in 1980 contains a very interesting discussion of this syndrome in which it is called "Quadrilateral Space Syndrome" (29).

and axillary branch, produced by the position of the arm. Pain that is more marked during active motion indicates friction on the axillary nerve by the teres muscle in movement. Internal or external rotation, whether done actively or passively, is painful. With limitation of external rotation, abduction movements are also painful, because the humerus does not rotate outward as it normally should during abduction. When stretching a tight teres major, a patient may complain of a shooting pain in the area of cutaneous sensory distribution of the axillary nerve. The assumption is that the axillary nerve is being compressed or stretched against the tight teres major. The pain that results from direct irritation to the nerve is in contrast to the discomfort that is often associated with the usual stretching of tight muscles, and is not unlike the encountered in cases of subdeltoid bursitis.

Treatment consists of heat and massage to the areas of muscle tightness and active, assisted exercises to stretch the medial rotators and the adductors of the humerus. Stretching of the arm overhead in flexion or abduction and in external rotation is done very gradually.

With tightness in the teres major, the scapula is pulled in abduction as the arm is raised in flexion or abduction and externally rotated. To insure that stretching is localized to the teres, it is necessary to press against the axillary border of the scapula when raising the arm to restrict excessive abduction of the scapula. If the scapula moves excessively in the direction of abduction, the teres, which is a scapulohumeral muscle, will not be stretched, and the rhomboids, which attach the scapula to the vertebral column, will stretch too much.

ASSISTED STRETCH OF TERES MAJOR AND LATISSIMUS DORSI

Assisted stretch of the teres major and latissimus dorsi is performed with the patient in a supine position, with the hips and knees flexed, the feet flat on table, and the low back flat. Hold the scapula to prevent excessive abduction to localize stretch to the shoulder joint adductors and to prevent excessive stretch of the rhomboids. The therapist provides traction on the arm while stretching the arm overhead.

PAIN FROM SHOULDER SUBLUXATION

Shoulder pain resulting from traction on the shoulder joint because of loss of tone and malalignment of the joint requires special treatment considerations. The cause may be paresis secondary to stroke, trauma to the brachial plexus, or a lesion of the axillary nerve. Effective management requires maintaining joint approximation during rest as well as during treatment to restore motion and to improve motor control.

A special sling, called a shoulder-arm support, helps to provide joint approximation and support to protect the subluxed shoulder when the patient is sitting or standing (30). When used to hold the humerus in the glenoid, the shoulder girdle carries the weight of the arm, and the sling does not hang on the neck (See Figure A.) Careful measurements should be taken for the sling to provide the best approximation of the joint and to prevent further stretch, instability, and pain in the weakened upper extremity. Measurements are taken with the elbow bent at a right angle. A tape measure is held at the top of the shoulder, looped down around the forearm, and then back up to the shoulder. The number of inches determines the size of the sling.

The patient should be taught how to protect the shoulder when not wearing the sling. Proper alignment and approximation can be maintained when sitting in an armchair by having the affected arm supported on the arm rest. In this position, the patient can use die opposite hand to press downward on top of the shoulder, making the humerus feel snug in the glenoid cavity. Teach the patient to relax the arm in this position on the arm rest and to avoid shrugging the shoulder. Shoulder joint approximation must be maintained during active, assisted exercises to restore joint motion and function (31). In other words, do not let the joint be subluxed at any time.

The weight of die arm is carried by the neck and opposite shoulder.

TIGHT SHOULDER EXTERNAL ROTATORS

There may be significant differences in range of motion depending on a person's occupation. According to one source, "major league pitchers have different ranges of motion for each shoulder. In the pitching arm, with the shoulder in abduction, there are 11 degrees less extension, 15 degrees less internal rotation, and 9 degrees more external rotation" (32).

ASSISTED STRETCH OF SHOULDER EXTERNAL ROTATORS

Assisted stretch of the shoulder external rotators is performed with the patient in a supine position, with the hips and knees flexed, the feet flat on the table, the low back flat, and the arm at shoulder level. Starting with the elbow bent at a right angle and the forearm in a vertical position, have subject hold down the right shoulder with firm pressure from the left hand to prevent shoulder-girdle motion. The therapist provides traction on the arm and helps the subject to rotate the shoulder medially.

CERVICAL RIB

A cervical rib is a rare, congenital, bony abnormality that may—or may not—give rise to symptoms of nerve irritation.

A painful arm condition appearing in a young or middle-aged adult is occasionally related to the presence of a cervical rib. The posture of the individual with a cervical rib often determines whether painful symptoms will occur. The appearance of symptoms only after the person has reached adulthood may be explained by the fact that the posture of the individual has gradually become more faulty in alignment, thus causing the relationship of the rib and the adjacent nerve trunks to change unfavorably.

The faulty alignment most likely to cause irritation is the type characterized by a round upper back and a forward head. Care of a patient with painful symptoms resulting from a cervical rib requires postural correction of the upper back and neck. This treatment may relieve the symptoms completely and obviate the need for a surgical procedure.

346 SPINAL NERVE AND MUSCLE CHARTS

USE OF CHARTS FOR DIFFERENTIAL DIAGNOSIS

Muscle strength grades are recorded in the column to the left of the muscle names. The grades may be in numeral or letter symbols. Either system may be used and grades can be translated as indicated on the Key to Grading Symbols, p. 23.

After the grades have been recorded, the nerve involvement is plotted, when applicable, by circling the dot(s) under peripheral supply and the number(s) under the spinal segment distribution that corresponds with each involved muscle.

The involvement of peripheral nerves and or parts of the plexus is ascertained from the encircled dots by following the vertical lines upward to the top of the chart, or the horizontal lines to the left margin. Where there is evidence of involvement at spinal segment level, the level of lesion may be indicated by a heavy black line drawn vertically to separate the involved from the uninvolved spinal segments.

As a rule, muscles graded good (8) and above may be considered as not being involved from a neurological standpoint. This degree of weakness may be the result of such factors as inactivity, stretch weakness, or lack of fixation by other muscles. It should be borne in mind, however, that a grade of good might indicate a deficit of a spinal segment that minimally innervates the muscle.

Weakness with grades of fair or less may occur as a result of inactivity, disuse atrophy, immobilization, or from neurological problems. Faulty posture of upper back and shoulders, may cause weakness of middle and lower trapezius.

It is not uncommon to find bilateral weakness of these muscles with grades as low as fair—. It is unlikely that there is a neurological problem with involvement of the spinal accessory nerve in cases of isolated weakness of these muscles unless there is involvement of the upper trapezius also.

The use of the Spinal Nerve and Muscle Charts is illustrated by the case studies that follow.

The six cases that follow are examples of different neu-romuscular problems.

The subjects were referred for manual muscle testing to aid in establishing a diagnosis. They were not seen for follow-up treatment.

The results of the manual muscle testing, recorded on the Spinal Nerve and Muscle Chart, became an important aid in determining the extent and level of lesion.

NECK, DIAPHRAGM AND UPPER EXTREMITY

Name

Dale fit&HT

MUSCLE

HEAD S NECK EXTENSORS

PERIPHERAL NERVES

INFRAHYOID MUSCLES

RECTUS CAP ANT i LAT

LONG US CAPITIS

LONGUS COLLI

LEVATOR SCAPULAE

STERNOCLEIDOMASTOID

TRAPEZIUS (U M L)

DIAPHRAGM

SERBATUS ANTERIOR

RHOMBOIDS MAJ A MIN

SUBCLAVIUS

SUPRA SPINA TUS

INFRASPINATUS

SU BSC APULA RIS

LAT1SSIMUS OORSI

TERES MAJOH

PECTORALIS MAJ IUPPER)

PECTORALIS MAJ [LOWER)

PECTORALIS MINOR

TERES MINOR

DELTOID

- Dorsal Prim. Bimis

- PKhjs Roof

- SufliPWf Trunk

- Medal Cord

SPINAL SEGMENT

583SS8Ü3

SENSORY

Case 1: Radial nerve lesion below the level of the branches to the triceps following a fracture of the humerus. Initially, the triceps was weak, but recovery was complete.

TERES MINOR

DELTOID

11 Í 3

CORACOBRACHIAL^

6

7

BICEPS

s

6

BRACH IALIS

5

6

TRICEPS

6

7

S

i

101

ANCONEUS

*

7

9

= 2

BRACHIALIS (SMALL PART)

5

6

0

BRACMIORAOIALIS

r

5

S

n

EKT CARPI RAD L

<*

5

6

7

8

C tL

n

EXT CARPI RAD B

(m

S

7

18

o

SUPINATOR

5

6

m

n

EXT DIGrTORUM

A

6

7

e

o

EXT DIGITI MINIMI

(i

fi

T

a

Q

EXT CARPI ULNARIS

<i

6

7

a

0

ABDPOLLICIS LONGUS

ft

S

7

s

0

EXT POLUCIS BREVIS

£

6

7

8

o

EXT POLLJCIS LONGUS

if

s

7

e

0

EXTiNDICIS

i?

6

7

e

IO

PRONATOR TERES

6

7

tO

FLEX CARPI RADIALIS

S

7

fi

(Q

PALMARIS LONGUS

16)

7 7

a a

1 i

10

FLEX DIGIT SUPERFICIALIS

Í I

c <

10

FLEX DIGIT PROF 11 II

7

a

1

i<?

FLEX POLIICIS LONGUS

*

«1

7

s

i

IQ

PRONATOR QUADRATHS

«

7

8

1

IO

ABD POLLICIS BREVIS

6

7

8

i

to

OPPONENS POLLICIS

6

7

e

i

ÍQ

FLEX POLL BREV (SUP H|

6

7

fi

t

*

LUMBRiCALES 1 a ll

«)

7

a

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10

FLEX CARPI ULNARIS

7

a

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FLEX DIGIT PROF. Ill & IV

7

a

i

PAL MARIS BREVIS

<7)

a

i

to

ABD DIGITI MINIMI

(7)

9

1

IQ

OPPONENS DIGITI MINIMI

PI

8

i

to

FLEX DIGITI MINIMI

(7)

B 1

!Q

PALMAR INTEROSSEI

8

1

to

OORSAL INTEROSSEI

B

i !

LUMBRICALES Uli IV

(7)

e

i

10

ADDUCTOR POLUCIS

a

t

'Q

FLEX POLL BREV [DEEP H.)

a

i

Abd Poll BrevisAbd Poll Brevis

D*fmjuorr»i radrïwrt Irpm KP4Q4J1 jnfl GwTcrt vaj Rae KB 409 O' 19« Curwtous D-grfejton or pwfMrir narval igúwm lipffl GrayZ Anjj&n* ot it* rtvnjr QctJy ¿(Hh

D*fmjuorr»i radrïwrt Irpm KP4Q4J1 jnfl GwTcrt vaj Rae KB 409 O' 19« Curwtous D-grfejton or pwfMrir narval igúwm lipffl GrayZ Anjj&n* ot it* rtvnjr QctJy ¿(Hh

NECK, DIAPHRAGM AND UPPER EXTREMITY

Name

Dale

Ltrr

HEAD a HECK EXTENSORS

PERIPHERAL NERVES

INFRAHYOID MUSCLES

RECTUS CAP ANT SLAT

LONGUS CAPmS

LONG US COLD

LEVATOR SCAPULAE

STERNOCLEIDOMASTOID

TRAPEZIUS |U M 14

DIAPHRAGM

SERRA TUS ANTERIOR

RHOMBOIDS MAJ i MIN

SUPRASPINATUS

INFRASPINATUS

SUBSCAPULARS

LAT1SSIMUS OOflSl

TERES MAJOR

PECT ORALIS MAJ (UPPER I

PECTORALIS MAJ (LOWER!

PECT ORALIS MINOR

TERES MINOR

DELTOID

— CORACOBRACHIAL^

BICEPS

BRACH IAL!S

TRICEPS

BRACHIAL IS I SMALL PARTi

BRACHIORADIALIS

EXT CARPI RAD L

EXT CARPI RAD B

EXT OtGITOBUM

EXT DIGITI MINIMI

EXT CARPI ULNARIS

ABO POLUCIS LONGUS

EXT PQLUCIS e REVIS

EXT POLUCIS LONGUS

EXT NDICIS

PRONATOR TERES

FLEX CARPI RADIALIS

PALMARIS LONGUS

FLEX DIGIT SUPERFICIALIS

FLEX POUJCIS LONGUS

PRONATOR OUADRATUS

ABD POUJCIS BREVIS

OPPONENS POUJCIS

FLEX POU BREV |SUP H|

LUMBRICALESI & II

FLEX CARPI ULNAR IS

flex DiGrr prof ill * iv

PALMARIS BREVIS

ASD DIGITI MINIMI

OPPONENS DKjm MINIMI

Fl£X OIGm MINIMI

PALMAR 1NTEROSSEI

DORSAL INTE ROSS El

LUMBRICALES III & IV

ADDUCTOR POUJCIS

FLEX POLL BREV (DEEP H )

- Dorsal Prim. Ramus

• Superior Trunk

• Posterior Coffl

SPINAL SEGMENT

Abd Poll Brevis

Case 2: The radial, median and ulnar nerves are all involved al approximately the same level of the forearm, just below the elbow. (Refer to Spinal Nvne anil Motor Point Chart, opposite.) This type of ¡n_ volvement may be caused by pressure from a tourniquet. bandage, or a east. The etiology is not clear-cut in this particular instance, but the history indicates that bandaging may have been a factor.

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