Introduction

Ligamentous hyperlaxity, also known as joint hypermobility syndrome, is a condition characterized by excessive flexibility of the joints and ligaments. This hypermobility can affect various parts of the body, including the fingers, elbows, knees, shoulders and spine. Although some people may benefit from this increased flexibility in areas such as dancing or gymnastics, it may also be associated with symptoms and complications that affect the quality of daily life.

Ligamentous hyperlaxity can be caused by genetic or hereditary factors or be idiopathic, that is to say without any apparent cause. Affected individuals often have a range of joint motion beyond normal, which may manifest as excessive flexibility, easy stretching, and unusual joint positions.

The most common symptoms associated with ligamentous hyperlaxity include joint pain, recurrent sprains, tired muscles, and stability issues. Due to laxity in ligaments, joints may be less supported, increasing the risk of sustaining injuries, especially in situations where stability is crucial.

This condition may also be associated with other clinical manifestations, such as chronic fatigue, gastrointestinal problems, and skin disorders, although these symptoms can vary greatly from person to person. Some individuals may live with mild hyperlaxity and be largely asymptomatic, while others may experience more severe symptoms that affect their daily quality of life.

Diagnosis of ligamentous hyperlaxity is often based on a thorough clinical evaluation, including specific tests to measure joint range of motion and joint stability. In some cases, additional tests such as medical imaging can be used to assess the condition of the joints.

Management of ligamentous hyperlaxity generally focuses on relieving symptoms and preventing complications. Non-pharmacological approaches include osteopathy to strengthen muscles and stabilize joints, as well as specific exercises aimed at improving proprioception and coordination.

In some cases, orthopedic devices such as splints or orthotics may be recommended to support the joints. Pain management strategies may also be implemented, including the use of analgesic or anti-inflammatory medications depending on individual needs.

It is important to emphasize that although ligamentous hyperlaxity can cause discomfort and challenges, it can also be managed effectively with appropriate management. Sufferers can lead active, fulfilling lives by working closely with healthcare professionals to develop a personalized treatment plan tailored to their specific needs. Continuing research in this area aims to better understand the underlying mechanisms of ligamentous hyperlaxity and to develop innovative therapeutic approaches to improve the quality of life of affected individuals.

Causes

Ligamentous hyperlaxity has varied origins, and several factors can contribute to this condition. The main causes include:

List of causes
  1. Genetic Factors: A genetic predisposition plays an important role in ligamentous hyperlaxity. Some individuals inherit genes that affect the structure and composition of connective tissues, making ligaments more flexible and joints more mobile. This form of hyperlaxity is often called hereditary joint hypermobility syndrome.
  2. Abnormalities in Collagen Production: Collagen is a crucial structural protein found in connective tissues, including ligaments. Abnormalities in collagen production, often linked to specific genes, can lead to ligament laxity.
  3. Hormones: Hormones, particularly female sex hormones such as estrogen, can influence the flexibility of ligaments. This is why ligamentous hyperlaxity is more common in women and can vary during different stages of life, such as puberty, pregnancy and menopause.
  4. Connective Tissue Disorders: Some connective tissue disorders, such as Ehlers-Danlos syndrome, are associated with ligamentous hyperlaxity. These disorders are often hereditary and characterized by abnormalities in collagen synthesis.
  5. Intense or Specific Physical Activity: Certain physical activities, including dancing, gymnastics or other sports that require great flexibility, can contribute to the development of ligamentous hyperlaxity. Overuse or repetitive movements can stretch ligaments over time.
  6. Neurological Alterations: Neurological alterations can also play a role in ligament laxity. Problems in the central or peripheral nervous system can affect the coordination of muscles and ligaments, leading to joint instability.
  7. Environmental Factors: Environmental factors such as repetitive trauma, accidents or injuries can also contribute to loosening ligaments.
  8. Age: Ligamentous hyperlaxity can progress with age. Children may have some natural flexibility, but this tends to decrease with growth. However, in some people this flexibility persists or becomes more pronounced into adulthood.
  9. Physical Activity Level: Individuals engaged in sporting or physically demanding activities may develop ligamentous hyperlaxity due to repetitive movements or constant stretching of the ligaments. This may be more common in professional athletes or those engaged in activities requiring a lot of flexibility.
  10. Obesity: Excess weight can put extra pressure on joints, which can contribute to ligament laxity. Obesity can also influence inflammatory processes in the body, indirectly affecting connective tissues.
  11. Muscular Disorders: Muscle strength plays an important role in joint stability. Weak muscles or muscle imbalance can contribute to ligament laxity by not providing adequate support.
  12. Metabolic Disorders: Certain metabolic disorders, such as metabolic syndrome, may be associated with connective tissue problems, which could contribute to ligamentous hyperlaxity.
  13. Psychosocial Factors: Stress, anxiety, and other psychosocial factors can influence pain perception and muscle tension, possibly contributing to ligament laxity.
  14. Posture and Body Alignment: Problems with posture or body alignment can also play a role in the development of ligamentous hyperlaxity. Poor posture can cause additional stress on the ligaments.
  15. Expanded Genetics: In addition to genetic mutations directly linked to collagen proteins, other genetic variations may also contribute to excessive ligament flexibility. Studies continue to explore the influence of different genes on ligament laxity.
  16. Recreational or Artistic Activities: Certain recreational, artistic, or occupational activities that involve extensive use of joint flexibility, such as advanced yoga, contemporary dance, or artistic gymnastics, may contribute to ligamentous hyperlaxity, especially if performed in a manner intensive or inappropriate.
  17. Chronic Inflammation: Medical conditions characterized by chronic inflammation, such as certain autoimmune diseases, can impact joint stability and contribute to ligament laxity.
  18. Previous Trauma: Previous injuries, particularly those affecting the ligaments, can leave after-effects that compromise long-term joint stability, potentially contributing to hyperlaxity.
  19. Associated Collagenopathies: In addition to Ehlers-Danlos syndrome, other genetic or acquired disorders that affect collagen production or connective tissue structure may be associated with ligamentous hyperlaxity.
  20. General Hypermobility: Some individuals may have a general constitution characterized by hypermobility, affecting multiple musculoskeletal systems. This can manifest as generalized ligamentous hyperlaxity.
  21. Orthopedic Conditions: Underlying orthopedic conditions, such as hip dysplasia, can influence joint stability and contribute to ligamentous laxity.
  22. Neurological Conditions: Neurological disorders that affect motor control or sensory perception may also play a role in ligament laxity, as they can influence muscle coordination.
  23. Nutrition and Hydration: A diet deficient in essential nutrients, particularly those related to connective tissue health such as vitamin C, vitamin D and zinc, can potentially influence ligament laxity. Likewise, adequate hydration is crucial to maintaining tissue suppleness.
  24. Psychological Factors: Psychological factors such as stress, anxiety and emotional tension can contribute to ligament laxity. Chronic stress can cause a release of chemicals in the body that affect muscle tension and joint stability.
  25. Medications: Certain medications, such as corticosteroids used long term, can have effects on connective tissues, potentially influencing ligament laxity.
  26. Lifestyle Habits: Lifestyle habits, such as lack of physical activity, poor posture or inadequate repetitive movements, can contribute to ligament laxity by affecting muscle strength and joint stability.
  27. Related Medical Conditions: Other medical conditions, such as Marfan syndrome or Loeys-Dietz syndrome, which affect the structure of connective tissues, may be associated with ligamentous hyperlaxity.
  28. Defects in Ligament Formation: Genetic or acquired abnormalities in the embryonic development of ligaments may also be contributing factors.
  29. Environmental Factors: The environment in which a person operates, including factors such as climate, exposure to toxins and other environmental influences, can have effects on ligament laxity.
  30. Thyroid Hormones: Abnormalities in thyroid function can affect the health of connective tissues, including ligaments, and contribute to hyperlaxity.
  31. Comorbidities: The presence of concomitant illnesses or medical conditions, such as autoimmune disorders, may have implications for ligamentous laxity.
  32. Central Nervous System Disorders: Conditions that affect the central nervous system, such as cerebral palsy, can influence muscle tone and coordination, contributing to ligamentous laxity.
  33. Professional Activities: Certain professions can expose individuals to repetitive movements or prolonged postures which can contribute to ligamentous hyperlaxity. For example, awkward working positions can put additional pressure on joints.
  34. Temporary Hypermobility: In some people, joint hyperlaxity may be temporary and related to factors such as injuries, periods of prolonged inactivity, or temporary hormonal changes.
  35. Non-Classical Genetic Influences: In addition to genes directly related to collagen proteins, other genes involved in metabolism, immune response or other cellular processes may also play a role in ligament laxity.
  36. General Nutritional Status: General nutritional status, including diet quality, consumption of essential nutrients, and weight management, can influence connective tissue health and contribute to hyperlaxity.
  37. Genetic Predisposition to Pain: Studies suggest a correlation between ligamentous hyperlaxity and a genetic predisposition to pain, which may affect an individual’s perception of joint flexibility.
  38. Past Traumatic Events: Previous trauma, such as car accidents, serious falls or sports injuries, can leave scars on ligaments, potentially contributing to laxity.
  39. Immune Response and Inflammation: Inappropriate immune responses or chronic inflammatory conditions can influence ligament laxity by altering the structure and function of connective tissues.
  40. Socio-Economic Factors: Socio-economic conditions, including education level, socio-economic status and living conditions, may also play an indirect role in overall health and, therefore, ligament laxity.
  41. Mechanical Influences: Certain types of physical activities or repetitive movements can place excessive forces on joints, contributing to hyperlaxity.

Symptoms

List of symptoms
  1. Joint Hypermobility: Joints may have a greater range of motion than normal. This can manifest as excessive flexibility in the fingers, elbows, knees, shoulders, spine, and other joints.
  2. Joint Instability: Due to the increased flexibility of ligaments, joints may be less stable. This can lead to a feeling of “laxity” or instability, increasing the risk of injuries and sprains.
  3. Joint Pain: People with ligamentous hyperlaxity may experience joint pain, particularly after physical exertion, strenuous activity or prolonged standing. This pain can be localized to the affected joints.
  4. Muscle Fatigue: The need for muscles to compensate for ligamentous laxity can lead to increased muscle fatigue. Muscles may have to work harder to maintain joint stability.
  5. Frequent Sprains: Due to the increased fragility of ligaments, people with hyperlaxity may be more likely to experience sprains, even during light activities.
  6. Postural Stability Issues: Some individuals may experience difficulty maintaining a stable posture, particularly during prolonged standing. This can influence motor coordination and balance.
  7. Body Deformities: In some people, ligamentous hyperlaxity can contribute to body deformities, such as flat feet, excessive lumbar lordosis, or hyperextension of the knees.
  8. Gastrointestinal Symptoms: Some individuals may experience gastrointestinal symptoms, such as irritable bowel syndrome, which may be associated with ligamentous hyperlaxity.
  9. Cardiovascular Symptoms: In some cases, cardiovascular symptoms such as palpitation or orthostatic hypotension may be observed, although these symptoms are more associated with certain connective tissue disorders.
  10. Associated Neurological Disorders: Neurological symptoms, such as headache or dizziness, can sometimes be linked to complications of ligamentous hyperlaxity, particularly when associated with connective tissue disorders.
  11. Dermatological Problems: In some people, ligamentous hyperlaxity may be accompanied by skin disorders, such as skin fragility, abnormal healing, or velvety, fragile skin.
  12. Respiratory Problems: In some cases, chest wall abnormalities may be associated with ligamentous hyperlaxity, leading to excessive mobility of the rib cage. This can potentially contribute to breathing problems, although it is less common.
  13. Gynecological Disorders: In women, ligamentous hyperlaxity may be linked to gynecological symptoms such as pelvic pain or pelvic stability problems.
  14. Oro-Facial Sphere Disorders: Some individuals may experience ligamentous hyperlaxity in the jaw, which can contribute to problems such as joint cracking, headaches or temporomandibular joint (TMJ) disorders.
  15. Vision Disorders: Abnormalities in the structure of connective tissues can also affect the eyes, sometimes leading to vision problems such as myopia or astigmatism.
  16. Hearing Disorders: In some cases, ligamentous hyperlaxity may be associated with abnormalities in the structure of the inner ear, contributing to hearing problems.
  17. Cardiovascular Complications: In some people, ligamentous hyperlaxity may be associated with cardiovascular complications, such as heart valve abnormalities or blood vessel dilations.
  18. Growth Problems: In children with ligamentous hyperlaxity, growth delays may sometimes be observed, although this depends on the severity of the condition and its impact on bone structure.
  19. Anxiety Symptoms: Some individuals with ligamentous hyperlaxity may exhibit anxiety symptoms related to fear of injury, perceived joint instability, or uncertainty about tissue strength.
  20. Neurological Symptoms: Neurological symptoms such as sensations of tingling, numbness, or muscle weakness can sometimes accompany ligamentous hyperlaxity, although this is less common.
  21. Sleep Problems: Some people with ligamentous hyperlaxity may experience sleep problems, such as insomnia. This may be related to joint pain, discomfort, or other factors associated with the condition.
  22. Swallowing Problems: In some individuals, ligamentous hyperlaxity in the throat can contribute to swallowing difficulties, sometimes called dysphagia.
  23. Sensitivity to Weather Conditions: Some people report sensitivity to changes in weather, with an increase in painful symptoms or an exacerbation of joint instability in response to specific weather conditions.
  24. Urological Problems: Although less common, ligamentous hyperlaxity can sometimes be associated with urological problems, such as bladder disorders or urinary control problems.
  25. Immune Issues: Research suggests that alterations in the immune system may be seen in some people with ligamentous hyperlaxity, although the precise nature of this relationship requires more study.
  26. Responses to Physical Exertion: Symptoms associated with ligamentous hyperlaxity can vary depending on physical exertion. Some individuals may experience worsening symptoms after strenuous activities, while others may experience problems during lighter activities.
  27. Impacts on Quality of Life: The combination of symptoms of ligamentous hyperlaxity can have significant impacts on quality of life, including limitations in daily, professional and social activities.
  28. Emotional Responses: Managing emotions related to the condition, such as frustration, anxiety, or depression, may be an important aspect of the overall management of ligamentous hyperlaxity.

Pathophysiology

The pathophysiology of ligamentous hyperlaxity is complex and involves various mechanisms in connective tissues, joints, and other anatomical components. Although the exact details may vary from person to person, here is a general overview of the pathophysiology associated with this condition:

  1. Collagen Alterations: Collagen is a crucial structural protein found in connective tissues, including ligaments. In ligamentous hyperlaxity, there may be alterations in the production or structure of collagen. These alterations can be genetic, resulting from mutations in the genes responsible for collagen synthesis, or can be acquired over time.
  2. Decreased Ligament Strength: Normal ligaments are responsible for the stability of joints by limiting their range of motion. In ligamentous hyperlaxity, ligaments have reduced strength due to changes in their composition or structure. This leads to greater joint flexibility.
  3. Abnormalities in Elastic Fibers: In addition to collagen, elastic fibers contribute to the resilience of connective tissues. Abnormalities in these elastic fibers can be seen in people with ligamentous hyperlaxity, which can increase tissue flexibility.
  4. Defects in Structural Protein Synthesis: Structural proteins other than collagen, such as proteoglycans, also play a role in the structure of connective tissues. Defects in the synthesis of these proteins can contribute to ligament fragility.
  5. Joint Instability: Due to ligamentous laxity, joints can become unstable, which can lead to excessive movement and abnormal movement. This increases the risk of injury and may contribute to painful symptoms.
  6. Inflammatory Response: Inflammatory processes can be activated in response to ligamentous laxity. This can lead to a release of inflammatory mediators, contributing to joint pain and other associated symptoms.
  7. Genetic and Environmental Interactions: In some people, ligamentous hyperlaxity may result from genetic factors, while in others, environmental influences such as trauma or repetitive physical activities may play a role.
  8. Interactions with Other Connective Tissues: Ligamentous hyperlaxity can also influence other connective tissues in the body, such as the skin, blood vessels, and internal organs. This may contribute to the variability of symptoms observed.
  9. Neurological Alterations: Alterations in the nervous system, particularly in the regulation of muscle tone and coordination, can also contribute to ligamentous hyperlaxity.

Myofascial knot formation

Joint hypermobility can also contribute to the activation of trigger points, also called myofascial nodes. These points are tender, tight areas in the muscles, often associated with muscle and joint pain.

Hypermobility can lead to overuse or increased stress on certain muscles, which can lead to the development of trigger points. These points can cause local pain, but they can also lead to referred pain, where pain is felt in other parts of the body than where the trigger point is located.

Thus, trigger point activation may be a consequence of hypermobility, adding an additional dimension to the muscular impacts associated with this condition. Consulting an osteopath represents a wise option for treating trigger points, thus aiming to reduce muscle tension and improve functionality.

Effect of hypermobility on muscle

  1. Muscle Weakness: Muscles may struggle to maintain joint stability under conditions of hypermobility, which can lead to muscle weakness. Muscles can be overworked to compensate for ligament laxity and maintain joint stability.
  2. Early Muscle Fatigue: Due to the increased need for stabilization, muscles can fatigue more quickly during hypermobility. This can lead to early muscle fatigue, especially during prolonged or demanding activities.
  3. Muscle Imbalance: Certain muscle groups may be overused to compensate for ligament laxity, while others may be less used. This can lead to muscle imbalance, with some muscle groups overloaded and others weakened.
  4. Stress on Adjacent Muscles: When ligaments do not provide adequate stability, surrounding muscles may be placed under increased stress to maintain joint function. This can increase the risk of muscle strains and injuries.
  5. Compensatory Muscular Hyperactivity: Certain muscles may become overactive in response to hypermobility in an attempt to stabilize joints. This can lead to increased muscle tension and contribute to fatigue.
  6. Muscle Contractures: Certain muscles may be more susceptible to developing contractures, which are involuntary shortening of muscle fibers. This can affect flexibility and joint mobility.
  7. Motor Coordination Problems: Hypermobility can affect muscle coordination, especially during complex movements or tasks requiring precise control. This may cause difficulty in carrying out certain activities.
  8. Muscle Pain: Muscles overworked to compensate for hypermobility can develop excessive tension, leading to muscle pain. This may contribute to symptoms of discomfort associated with hypermobility.
  9. Impacts on Proprioception: Proprioception, which is the body’s ability to perceive its position in space, can be impaired due to hypermobility. This can influence the ability to maintain balance and execute coordinated movements.
  10. Influence on Posture: Hypermobility can affect posture by changing the way muscles support the body. This can lead to suboptimal postures, which can contribute to musculoskeletal problems.

How to correct ligamentous hyperlaxity

Correction of ligamentous hyperlaxity depends on the severity of the condition and associated symptoms. It is important to note that ligamentous hyperlaxity can be influenced by genetic factors, meaning it can be difficult to eliminate completely. However, several approaches can help manage symptoms and strengthen joint stability. Here are some commonly recommended strategies:

  1. Muscle Strengthening: A muscle strengthening exercise program targeting the muscles around the joints can help compensate for ligamentous laxity by providing additional support.
  2. Osteopathy: Osteopathy can play a crucial role in the management of ligamentous hyperlaxity. An osteopath can design a personalized exercise program to strengthen muscles, improve joint stability and reduce the risk of injury.
  3. Exercise Therapy: Specific exercises, such as joint stabilization, proprioception and balance exercises, can help improve muscle coordination and strengthen joints.
  4. Orthotics: Using orthotics, such as ankle braces or knee braces, can provide additional support to the joints and reduce the risk of injury.
  5. Education: An essential part of managing ligamentous hyperlaxity is educating the patient about their condition. This may include advice on activities to avoid, proper posture techniques, and daily coping strategies.
  6. Postural Rehabilitation: Particular attention to posture and body biomechanics can be beneficial. Postural adjustments can help reduce pressure on joints.
  7. Trigger Point Treatment: For those who develop trigger points, techniques such as myofascial release can help relieve muscle tension.
  8. Stress Management: Stress can worsen the symptoms of ligamentous hyperlaxity. Stress management techniques, such as meditation and relaxation, may be beneficial.
  9. Speech therapy (for orofacial problems): For those who have ligamentous hyperlaxity in the jaw, an evaluation by a speech therapist can be useful to manage orofacial problems.
  10. Nutrition and Supplements: Certain nutrients, such as vitamin C, vitamin D, zinc, and essential amino acids, are essential for connective tissue health. A balanced diet and, if necessary, supplements can contribute to overall tissue health.

Specific Tests

Screening for ligamentous hyperlaxity may include several specific tests that assess joint flexibility and ligamentous laxity. Some of these tests are commonly used by healthcare professionals. It is important to note that these tests should be carried out by qualified professionals. Here are some of these tests:

  1. Beighton Test: The Beighton Test is a frequently used test to evaluate ligament laxity. It includes five specific joint movements, and the maximum score is 9 points. A high score may indicate ligamentous hyperlaxity. Movements included in the Beighton Test include flexion of the thumbs toward the forearms, extension of the elbows beyond the midline, extension of the knees beyond 10 degrees, flexion of the trunk toward the forward with straight legs, and flexion of the wrists beyond 90 degrees.
  2. Hand to Floor Test: The patient stands with legs straight and attempts to touch the ground with the palms of the hands. Excessive flexibility may indicate ligamentous hyperlaxity.
  3. Seated Hip Test: The patient sits on the floor with their legs extended in front of them and attempts to bring their knees to the floor. A large gap between the ground and the knees may indicate ligament laxity.
  4. Patella Test: In a seated position, the patient extends the legs and the practitioner assesses the ability of the kneecaps to move laterally. Excessive movement may suggest ligamentous hyperlaxity.
  5. Ankle Test: Lateral tilt of the ankle can be assessed by asking the patient to stand on one leg and tilt in and out. Excessive tilting may indicate ligamentous laxity.
  6. Wrist Test: The patient is asked to extend the wrist with the fingers pointing toward the floor. Significant extension may indicate ligamentous hyperlaxity.
  7. Jaw Test: The assessment of ligamentous laxity in the jaw can be done by measuring the amplitude of the mouth opening.

Calculation of the Beighton score to determine Ligamentous hyperlaxity

The Beighton score is a simple system used to assess joint hypermobility or ligamentous laxity in individuals. It involves a series of five tests, and each test is scored on a scale from 0 to 1, with a maximum total score of 9. A higher Beighton score indicates greater joint hypermobility. Here are the tests and scoring:

  1. Passive dorsiflexion of the little fingers while keeping the wrists extended backward (score 1 point for each side).
  2. Passive apposition of the thumbs to the flexor aspects of the forearm (score 1 point for each thumb).
  3. Hyperextension of the elbows beyond 10 degrees (score 1 point for each elbow).
  4. Hyperextension of the knee beyond 10 degrees (score 1 point for each knee).
  5. Ability to place the palms flat on the floor with the knees fully extended (score 1 point).

To calculate the Beighton score, add up the points obtained from each of the five tests. The maximum possible score is 9, with each test contributing a maximum of 2 points (except for the fifth test, which contributes a maximum of 1 point). The scoring is as follows:

  • Test 1: 0 or 1 point for each side (maximum 2 points)
  • Test 2: 0 or 1 point for each thumb (maximum 2 points)
  • Test 3: 0 or 1 point for each elbow (maximum 2 points)
  • Test 4: 0 or 1 point for each knee (maximum 2 points)
  • Test 5: 0 or 1 point (maximum 1 point)

For example, if an individual has hyperextended knees (2 points), hyperextended elbows (2 points), and can place palms on the floor with knees extended (1 point), the Beighton score would be 5 (2 + 2 + 1).

It’s important to note that joint hypermobility can vary between individuals, and the Beighton score is just one component of a broader assessment for conditions like Ehlers-Danlos syndrome or joint hypermobility syndrome. Interpretation of the Beighton score should be done in the context of a comprehensive clinical evaluation.

Conclusion

In conclusion, ligamentous hyperlaxity is a condition characterized by excessive joint flexibility due to laxity of the ligaments. Screening for this condition can be done using specific tests, such as the Beighton Test, which evaluates the flexibility of the body’s major joints. This test, consisting of five movements and a fifth finger extension, awards points based on the success of each movement.

It is important to note that the Beighton Test is only a screening tool and is not a definitive diagnosis. A high score may indicate ligamentous hyperlaxity, but a thorough evaluation by medical professionals is necessary to confirm the diagnosis. This evaluation may include physical examinations, a detailed medical history, genetic testing, and imaging studies.

Management of ligamentous hyperlaxity can involve varied approaches, including muscle strengthening, osteopathy, educational counseling, and sometimes medical interventions. Each individual may experience different symptoms, requiring a personalized approach to optimize quality of life and minimize the risk of complications related to ligament laxity.

If there is suspicion of ligamentous hyperlaxity or associated symptoms, it is strongly recommended to consult a healthcare professional for a precise assessment and appropriate advice. A multidisciplinary approach involving rheumatologists, osteopaths and other specialists may be necessary to develop an optimal management plan.

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