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574� September/October 2008, Volume 62, Number 5
Relationship Between Performance-Based and Self-Reported Assessment of Hand Function
KEY WORDS• evaluation• limitation of activities• rehabilitation• task performance
Celina R. Rallon, MA, OTR/L, CHT, ICLM, SIPT-C, is Occupational Therapy Specialist, Department of Rehabilitation Medicine, Staten Island University Hospital, Staten Island, NY.
Christine C. Chen, ScD, OTR/L, FAOTA, is Associate Professor, Programs in Occupational Therapy, College of Physicians and Surgeons, Columbia University, 710 West 168th St., 8th Floor, New York, NY 10032; [email protected]
OBJECTIVE. To examine the relationships between self-reported and performance-based hand function.
METHOD. Thirty participants with hand function limitations completed the Manual Ability Measure (MAM–36) and the Upper Extremity Performance Test for the Elderly (TEMPA). Participants were categorized into two groups: (1) Dominant Hand Affected and (2) Nondominant Hand Affected. Correlations between the two assessments were examined. The speed of task execution and TEMPA scores were compared between the two groups.
RESULTS. A significant correlation was found between the MAM–36 and TEMPA Total Functional Rating (r = 0.79, p < .05). Significant differences were found in the speed of execution of unilateral tasks and the Unilateral Functional Ratings between the two groups.
CONCLUSION. The MAM–36 is a promising assessment tool for measuring a client’s perceived hand function. However, a performance-based assessment can supplement information about the quality and speed of hand-task performance.
Rallon, C. R., & Chen, C. C. (2008). Relationship between performance-based and self-reported assessment of hand func-tion. American Journal of Occupational Therapy, 62, 574–579.
Celina R. Rallon, Christine C. Chen
In� evaluating� and� treating� clients�with�hand� function�problems,� occupational�therapists�are�faced�with�deciding�which�assessment�tool�to�use.�Among�the�cur-
rently�available�tools,�one�type�is�standardized,�performance�based,�and�administered�by� the� therapist,�whereas� another� is� self-report.�Performance-based� assessments�provide�the�therapist�with�objective�and�firsthand�(or�observed)�information�about�the�client’s�hand�function�but�are�more�time�consuming.�Questionnaires�are�filled�out�by�clients�to�show�their�own�rating�of�their�hand�use;�they�are�usually�quicker�to�administer�but�provide�the�occupational�therapist�with�only�subjective�informa-tion�about�the�client’s�perception.�Several�studies�demonstrate�the�importance�of�using�either�standardized�assessments�or�questionnaires.�However,�only�minimal�study�has�been�done�to�show�the�correlation�between�findings�from�a�standardized�test�and�a�client’s� self-report�of�hand�function.�The�purpose�of� this�exploratory�research�was�to�examine�the�extent�to�which�a�client’s�self-report�relates�to�or�agrees�with�the�occupational�therapist’s�evaluation�of�hand�use.
Literature Review
Standardized Assessments
The�use�of�standardized�tests�has�been�well�recognized�in�evaluating�clients�with�upper-extremity�or�hand�impairments�because�standardized�tests�provide�accurate�and�objective�information�that�can�be�used�for�treatment�planning�and�determining�treatment�effectiveness�(Rudman�&�Hannah,�1998).�In�many�clinical�settings,�for�
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The American Journal of Occupational Therapy� 575
example,�dexterity�tests�are�used�to�evaluate�upper-extremity�function� (Desrosiers,� Hebert,� Bravo,� &� Dutil,� 1995).�Common�standardized�assessments�include�the�Nine�Hole�Peg�Test�(Mathiowetz,�Weber,�Kashman,�&�Volland,�1985),�the�Box�and�Block�Test�(Mathiowetz,�Volland,�Kashman,�&�Weber,�1985),�and�the�Purdue�Pegboard�(Tiffin,�1968).�All�of� these�assessments�use� speed�of�manipulation�as� the�surrogate�of�hand�function�(O’Neill,�1995).�The�Nine�Hole�Peg�Test�has�a�high�interrater�reliability�(intraclass�correlation�[ICC]�=�.98�to�.99;�Oxford�Grice�et�al.,�2003).�The�Box�and�Block�Test�has�a�high�test–retest�reliability�(ICC�=�.89�to�.97;�Desrosiers,�Bravo,�Hebert,�Dutil,�&�Mercier,�1994).�The�Purdue�Pegboard�also�has�a�high�test–retest�reliability�(ICC�=� .85� to� .90;�Gallus�&�Mathiowetz,�2003).�These�assess-ments,�however,�do�not�consider�the�following:�(1)�the�func-tion�of�the�entire�upper�extremity,�(2)�how�the�measurement�of�components�of�hand�function�(i.e.,�speed)�translates�into�use�of�the�extremity�in�daily�life,�and�(3)�the�effect�of�artificial�setting�in�which�the�testing�occurs.
Questionnaires
Questionnaires�are�a�part�of�the�evaluation�of�upper-extrem-ity�and�hand�conditions�and�allow�us�to�better�understand�what�clients�experience�(Schuind�et�al.,�2003).�Questionnaires�are� also� easier� to� administer� than�physical� testing:�They�require�no�special�equipment,�are�less�time�consuming,�and�can�be� self-administered� and� therefore� eliminate�observer�bias�(Amadio,�2001).�Amadio�(2001),�however,�pointed�out�that�questionnaires�are�not�the�best�tool�to�measure�anatomic�or�physiologic�impairments.�Even�with�an�increase�in�the�use�of�client�self-report�outcome�measures�by�clinicians,�some�practitioners�hesitate� to�use� them�as�part�of� their�practice�(Michener�&�Leggin,�2001).�According�to�Michener�and�Leggin� (2001),� there� is� a�belief� among�practitioners� that�information�gathered�through�self-report�is�subjective,�less�reliable,�and�less�accurate�than�information�obtained�through�standardized�assessments.�They�concluded,�however,�that�if�a�questionnaire�is�well�designed�and�validated,�the�informa-tion�collected�from�clients�through�this�method�is�also�reli-able�(Michener�&�Leggin,�2001).
Correlation Between Objective and Subjective Assessments
Numerous� studies� demonstrate� the� importance�of� either�standardized�assessments�(Desrosiers�et�al.,�1995;�Pap,�Angst,�Herren,� Schwyzer,� &� Simmen,� 2003;� Richards,� Stoker-Yates,�Pohl,�Wallace,�&�Duncan,�2001;�Rudman�&�Hannah,�1998;�Schuind�et�al.,�2003)�or�client�self-report�assessments�(Amadio,�2001;�Barbier,�Penta,�&�Thonnard,�2003;�Chen,�Granger,�Peimer,�Moy,�&�Wald,�2005;�Michener�&�Leggin,�2001;�Pap�et�al.,�2003;�Schuind�et�al.,�2003).�However,�only�
one�study�correlated�the�findings�between�the�two�types�of�assessments:�O’Connor�and�colleagues�(1999)�attempted�to�correlate�the�findings�from�two�objective�measures�(Sollerman�Hand� Function� Test� [Sollerman� &� Ejeskär,� 1995]� and�Sequential�Occupational�Dexterity�Assessment�[van�Lankveld�et�al.,�1996])�with�two�subjective�measures�(Visual�Analog�Scales� for�Pain� and� the�Upper�Limb�Health�Assessment�Questionnaire�[ULHAQ],�both�of�which�can�be�found�as�components�of�the�Health�Assessment�Questionnaire�[see�Bruce�&�Fries,�2005])�for�clients�with�rheumatoid�arthritis.�This� study� showed� a� strong� relation�between� the� scores;�however,�reliability�and�validity�of�the�ULHAQ�has�not�been�studied,�and�this�study�involved�clients�with�only�one�specific�condition�(rheumatoid�arthritis).�Therefore,�the�purpose�of�the�current�study�is�to�examine�the�relation�between�a�self-reported�hand�function�measure�and�a�performance-based�standardized�test.
Method
Description of Participants
The�participants�consisted�of�30�adults�who�had�hand�func-tional�limitations�caused�by�current�or�past�injuries�or�dis-eases� such� as� fractures,� carpal� tunnel� syndrome,�previous�hand�surgeries,�arthritis,�and�stroke.�The�participants�were�occupational�therapy�clients�who�responded�to�an�advertise-ment� posted� at� the� outpatient� Occupational� Therapy�Department�of�Staten�Island�University�Hospital�in�Staten�Island,�New�York.
Inclusion Criteria
To�be�included�in�the�study,�participants�had�to�be�more�than�18�years�old�and�pass�a�screening�assessment�that�deter-mined�whether�the�participant�had�adequate�cognitive�ability�to�follow�instructions.
Instruments
We�used�the�Manual�Ability�Measure�(MAM–36;�Chen�&�Giustino,� 2007;� Chen,� Kasven,� Karpatkin,� &� Sylvester,�2007)�and�the�Upper�Extremity�Performance�Test�for�the�Elderly�(TEMPA;�Desrosiers,�Hebert,�Dutil,�&�Bravo,�1993)�to�assess�hand�function�among�the�participants.
MAM–36. The�MAM–36,�a�recently�developed,�psycho-metrically�sound�outcome�measurement�tool�that�is�a�task-oriented� and� client-centered�questionnaire,�measures�per-ceived�manual�ability�(Chen�&�Giustino,�2007;�Chen�et�al.,�2007).�It�consists�of�a�list�of�36�discrete�hand�tasks.�A�4-point�rating�system�is�used�for�the�client�to�indicate�how�easy�or�hard�the�task�is�for�him�or�her�to�perform:�4�(easy),�3�(a little hard),�2�(very hard),�and�1�(cannot do).�Chen�and�colleagues�
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576� September/October 2008, Volume 62, Number 5
have�demonstrated�evidence�of�the�reliability�and�validity�of�the�MAM–36:�Rasch�person�reliability�ranged�from�0.83�to�0.94,�and�the�item�reliability�ranged�from�0.85�to�0.98�(Chen�et�al.,�2007;�Chen�&�Giustino,�2007).�They�also�provided�preliminary�evidence�of�criterion-related�validity�(Chen�et�al.,�2005).�A�copy�of�the�MAM–36�can�be�found�at�Chen�et�al.�(2007).
Compared�with�the�Disabilities�of�the�Arm,�Shoulder�and�Hand�assessment�(Beaton�et�al.,�2001),�which�measures�clients� performing� complex� tasks� including� recreational�activities�and�heavy�household�chores,�tasks�in�the�MAM–36�are� simpler�and�more� specific� to� the�construct�of�manual�ability�(Chen�et�al.,�2005).�Unlike�ABILHAND�(Barbier�et�al.,� 2003),� a�questionnaire�developed� to�measure�manual�ability� that�was� administered� to� a� sample�of� clients�with�rheumatoid�arthritis�and�chronic�stroke�only,�the�MAM–36�was� administered� to� a� sample�of� clients�with� a� variety�of�impairments,�such�as�rheumatoid�and�osteoarthritis,�multiple�sclerosis,� cerebral� vascular� accident� (CVA),� carpal� tunnel�syndrome,�tenosynovitis,�and�traumatic� injuries� including�fractures�and�open�wounds�(Chen�et�al.,�2005,�2007;�Chen�&� Giustino,� 2007).� The� MAM–36,� therefore,� has� been�shown� to�be� a�promising�outcome�measurement� tool� to�measure�manual�ability.
TEMPA. The�Upper�Extremity�Performance�Test�for�the�Elderly�(TEMPA;�Desrosiers,�Hebert,�Dutil,�&�Bravo,�1993)�is� a� standardized� assessment� developed� to� assess� upper-extremity�function;�it�includes�both�quantitative�and�qualita-tive� information� (Desrosiers� et� al.,� 1995).� It� has� been�regarded�as�an�assessment�with�adequate�psychometric�prop-erties�and�clinical�utility�(Rudman�&�Hannah,�1998).�The�TEMPA�requires�a�person�to�perform�nine�tasks�related�to�activities�of�daily�living:�five�bilateral�tasks�(open�a�jar�and�remove�a�spoonful�of�coffee,�unlock�a�lock�and�open�a�pill�container,�write�on� an� envelope� and� stick� a� stamp�on� it,�shuffle�and�deal�playing�cards,� and� tie� a� scarf� around� the�neck)�and�four�unilateral�tasks�(pick�up�and�move�a�jar,�pick�up�a�pitcher�and�pour�water�into�a�glass,�handle�coins,�and�pick�up�and�move�small�objects).�Three�parameters�are�mea-sured�for�each�task:�(1)�speed,�(2)�functional�rating,�and�(3)�task�analyses.�The�functional�rating�(FR)�indicates�the�extent�of�independent�completion�of�the�task,�and�there�are�four�scores:� unilateral� functional� ratings� (R–FR�or�L–FR)� for�unilateral�hand�tasks,�bilateral�functional�rating�(B–FR)�for�bilateral�hand�tasks,�and�the�total�or�combined�functional�rating.�If�the�task�is�successfully�completed�without�assistance�or�modification,�a�score�of�0�is�given;�if�the�task�is�completed�with�some�difficulty,�a�score�of�–1�is�given;�if�the�task�could�only�be�partially�completed�or�performed�in�its�entirety�with�major�difficulty,�a�–2�is�given;�if�more�than�25%�of�the�task�cannot�be�performed,�a�–3�is�given.
The�TEMPA�has�been�shown�to�have�excellent� test–retest� reliability� for� its� speed�of� execution� and� functional�rating� components� (Richards� et� al.,� 2001).�According� to�Richards�et�al.�(2001),�ICC�was�.89�for�the�unilateral�tasks�of�the�TEMPA�and�>.97�for�the�functional�rating�compo-nent�of�the�test.�Concurrent�validity�of�the�TEMPA�has�been�established�(Desrosiers,�Hebert,�Dutil,�Bravo,�&�Mercier,�1994).� High� correlations� (.90� to� .95)� exist� between� the�TEMPA’s� four� functional� ratings� and� task� analysis� total�scores�and�the�Action�Research�Arm�Test�(Lyle,�1981).
Procedure
The�Institutional�Review�Boards�of�New�York�University�and�Staten�Island�University�Hospital�approved�this�research.�The�researcher�screened�each�possible�participant�to�deter-mine�whether�he�or�she�was�eligible�as�a�candidate�using�the�screening� assessment.�The�MAM–36� and�TEMPA�were�administered�to�each�participant,�and�after�each�participant�completed�the�two�hand�function�assessments,�he�or�she�was�asked�to�rate�himself�or�herself�on�the�ease�or�difficulty�of�the�TEMPA�activities�as�well.
Data Analysis
Descriptive�statistics�were�calculated�to�determine�the�char-acteristics�of�the�participants.�Ordinal�ratings�of�the�MAM–36�were�first� transformed� into� interval�measures� through�Rasch�Rating�Scale�Analysis� (Wright�&�Masters,� 1982).�Next,�Spearman�correlations�were�conducted� to�examine�the�relationships�between�the�MAM–36�and�the�functional�ratings�of�the�TEMPA.�The�participants�were�categorized�into�two�groups:�(1)�Dominant�Hand�Affected�(participants�whose�dominant�hand�was�also�the�affected�or�symptomatic�hand)�and�(2)�Nondominant�Hand�Affected�(participants�whose�nondominant�hand�was�the�affected�or�symptomatic�hand).�Four�participants�who�had�both�hands�affected�were�assigned�to�a�group�depending�on�which�hand�was�more�symptomatic.�T�tests�were�conducted�to�compare�functional�ratings,�task�performance�speed,�and�MAM–36�measures�of�the�two�groups.
ResultsTwenty�women�and�10�men�(n�=�30)�participated� in�the�study.�The�participants’�ages�ranged�from�34�to�76�(M�=�56.07,�SD�=�11.87).�Most�of�the�participants�had�a�diagnosis�that�fell�under�the�orthopedic�category�involving�the�hand�(26.7%),�such�as�wrist�sprain,�capsulotomy�of�the�metacarpal�joints,�wrist�fracture,�and�tendon�transfer�or�repair;�another�13.3%�had�involvement�of�parts�of�the�arm�other�than�the�hand,�such�as�shoulder�adhesive�capsulitis,�lateral�epicondy-litis,�rotator�cuff�tear,�and�shoulder�bursitis.�An�additional�
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The American Journal of Occupational Therapy� 577
23.3%�had�a�diagnosis�that�fell�under�the�“other”�category,�which�included�brachial�plexopathy,�Charcot�Marie�Tooth�Disease,�diabetic�neuropathy,�reflex�sympathetic�dystrophy,�and�hand�infection.�Twenty�percent�had�a�diagnosis�of�CVA.�Last,�16.7%�had�a�diagnosis�of�spinal�cord�injury,�rheuma-toid�arthritis,�or�osteoarthritis.�Twenty-four�of�the�partici-pants�(80%)�were�right-hand�dominant,�whereas�the�other�six�were�left-hand�dominant.�Eighteen�participants�(60%)�had�their�left�hand�affected,�eight�(26.7%)�had�their�right�hand�affected,�and� the� remaining� four� (13.3%)�had�both�hands�affected.
Significant�correlations�were�noted�between�the�MAM–36�measures� and� the� functional� ratings� on� the� TEMPA�(Table�1).�The�Dominant�Hand�Affected�group�consisted�of�12�participants,�and�the�Nondominant�Hand�Affected�group�had�18�participants.�Eight�participants�(67%)�in�the�Dominant�Hand�Affected�group�were�right-hand�dominant,�whereas�16�participants�(89%)�were�right-hand�dominant�in�the�Nondominant�Hand�Affected�group.�The�t-test�analyses�revealed�a�significant�difference�between�the�two�groups�for�the�TEMPA�functional�ratings�for�the�right-�and�left-handed�unilateral� tasks� (Table�2).�The�Dominant�Hand�Affected�group�had�a�lower�group�mean�(–3.25)�for�the�functional�rating�for�the�right�than�the�Nondominant�Hand�Affected�group�(–1.28).�Conversely,�the�Dominant�Hand�Affected�group�had�a�higher�group�mean�for�the�functional�rating�for�the�left�than�the�Nondominant�Hand�Affected�group.�No�significant�difference�was�noted�for�the�bilateral�and�com-bined�functional�ratings�of�the�TEMPA,�the�MAM–36�mea-sures,�and�task�performance�speed�for�all�five�bilateral�tasks�of� the� TEMPA� between� the� two� groups.� Although� the�MAM–36�measures�did�not� show�a� significant�difference�between�the�two�groups,�it�should�be�noted�that�the�group�mean�was�0.92�logits�for�the�Dominant�Hand�Affected�group�and�1.09�logits�for�the�Nondominant�Hand�Affected�group,�indicating�that�the�manual�ability�was�greater�in�those�who�had�their�nondominant�hand�impaired.�A�significant�differ-ence�was�noted�in�the�task-performance�speed�for�the�follow-ing�unilateral�tasks�of�the�TEMPA:�(1)�picking�up�a�jar�with�the�right�or�the�left,�(2)�pouring�with�a�pitcher�with�the�right,�
(3)�handling�coins�with�the�left,�and�(4)�picking�up�small�objects�with�the�left.
ConclusionThe�findings�of�this�study�showed�a�moderate�correlation�between�a�client’s�self-report�(MAM–36)�and�standardized�assessment�(TEMPA)�of�hand�function.�Moreover,�the�speed�of�execution�and�the�proficiency�of�performance�were�sig-nificantly�compromised�when�clients�performed�unilateral�hand�tasks�with�their�affected�hand.�Last,�the�fact�that�no�between-group�difference�was�found�in�the�MAM–36�or�the�TEMPA�bilateral�or�combined�functional�ratings�suggests�that�the�MAM–36�measured�the�bilateral�or�overall�manual�ability�of�the�clients.
The�MAM–36�is�a�promising�assessment�tool�that�occu-pational�therapists�can�use�as�a�valid�measure�to�quickly�and�adequately�evaluate�a�client’s�hand�function.�This�tool�may�be�helpful�to�many�clinicians�to�better�manage�the�time�spent�with�their�clients.�Self-report�questionnaires�need�to�be�short�enough�for�easy�completion�and�review�and�must�contain�items� that� will� evaluate� a� client’s� functional� limitations�(Michener�&�Leggin,�2001).�When�additional�information�
Table 1. Correlations Between MAM–36 and Functional Ratings of the Upper Extremity Performance Test for the Elderly
MAM FR–R FR–L FR–bilateral
FR–R 0.38*FR–L 0.38* –0.35FR–bilateral 0.68** 0.47** 0.23FR–combined 0.79** 0.54** 0.47** 0.87**
Note. MAM = Manual Ability Measure; FR–R = functional rating of the right hand; FR–L = functional rating of the left hand.
*p < .05. **p < .01.
Table 2. T-test Analyses Comparing the TEMPA Functional Ratings and MAM–36 Measures of the Dominant Hand Affected and Nondominant Hand Affected Groups
M SD T test
Unilateral functional rating for tasks performed with the right hand Dominant hand affected –3.25 2.45 Nondominant hand affected –1.28 2.24 (Range = 12–0) 0.03*Unilateral functional rating for tasks performed with the left hand Dominant hand affected –1.67 3.05 Nondominant hand affected –3.83 2.40 (Range = 12–0) 0.03*Bilateral functional rating Dominant hand affected –5.17 2.12 Nondominant hand affected –4.56 1.75 (Range = 15–0) 0.40Total/combined functional rating Dominant hand affected –10.08 4.75 Nondominant hand affected –9.67 4.89 (Range = 39–0) 0.82Total MAM raw score Dominant hand affected 102.33 18.86 Nondominant hand affected 105.44 21.84 0.69MAM measure (logits) Dominant hand affected 0.92 1.28 Nondominant hand affected 1.09 1.49 0.75
Note. TEMPA = Upper Extremity Performance Test for the Elderly; MAM–36 = Manual Ability Measure–36.
*p < .05.
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578� September/October 2008, Volume 62, Number 5
is�needed�about�a�client’s�quality�of�performance�on�a�given�task�(i.e.,�how�fast�or�coordinated�a�task�is�done),�however,�a�performance-based�assessment�such�as�the�TEMPA�may�be�needed.�These�findings� are� similar� to� the�findings� of�O’Connor�et�al.�(1999),�which�showed�the�need�for�using�a�more�sensitive�assessment�tool�to�determine�the�severity�of�hand�function�limitation�than�a�self-report�measure�alone.
The� current� sample� included�participants�with�hand�impairments�and�functional�limitations.�Many�of�them�have�had�the�condition�for�some�time�and�have�learned�to�adapt.�A�limitation�of�the�current�study�is�that�the�severity�of�the�participants’� hand� impairment�was�not� categorized.�The�participants�were� also�not� categorized� according� to� their�diagnosis.�Additional�data�from�a�larger�sample�size�is�needed�to�clarify�whether�a�stronger�correlation�exists�between�the�two�hand�function�assessments�and�whether�clearer�differ-ences�may�be�found�between�people�with�injuries�to�their�dominant�hand�and�those�whose�symptomatic�hand�is�their�nondominant�hand.
The� information� gained� from� the� MAM–36� and�TEMPA�is�valuable.�Both�measures�offer�information�on�a�client’s�ability�to�function�and�complete�tasks.�At�the�same�time,�the�two�assessments�offer�important�as�well�as�different�additional�information�about�the�client.�The�MAM–36�pro-vides�insight�into�the�client’s�perception�of�his�or�her�ability�to�function,�whereas�the�TEMPA�provides�information�on�the�speed�and�proficiency�of�performance.�The�MAM–36�requires�the�client�to�rate�the�difficulty�of�the�tasks�regardless�of�which�hand� is�used� to�perform� the� tasks,�whereas� the�TEMPA�can�compare�the�performance�of�the�affected�hand�to�that�of�the�nonaffected�hand,�especially�with�unilateral�tasks.�Therefore,�the�use�of�a�performance-based�assessment�complements�that�of�a�self-report,�and�both�may�be�necessary�for�a�thorough�occupational�therapy�evaluation�and�treat-ment�planning.� s
AcknowledgmentsThis�research�was�undertaken�in�partial�fulfillment�of�Celina�R.�Rallon’s�requirements�for�an�advanced�masters�of�occu-pational� therapy�degree� from�New�York�University.�The�research�was�partially�supported�by�a�National�Institutes�of�Health�career�development�grant�awarded�to�Christine�C.�Chen,�ScD�(5K23HD042702).�We�extend�our�thanks�to�the�people�who�participated�in�the�research.
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