http://doi.org/10.33698/NRF0178 – Esha Sharma, Avinash Kaur Rana, Amarjit Singh
Abstract: Dysmenorrhea refers to the painful menstrual cramps of uterine origin. It is a common gynecological condition in women irrespective of age and nationality but most of the women do not seek treatment due to lack of knowledge and social stigma. So there is a need to prove the efficacy of non pharmacological intervention. Present study was conducted with an objective to assess the effectiveness of acupressure at SP 6 point on dysmenorrhea among nursing students of National Institute of Nursing Education, PGIMER, Chandigarh. The study design was pre experimental. Total 78 students were enrolled by total enumeration sampling technique. The study subjects received acupressure for 20 minutes at SP 6 point immediately when they reported moderate to severe pain episode. In this study, pre test pain score was obtained before giving intervention and then intervention ie. acupressure at SP 6 point was given for 20 minutes ( 10 minutes for each leg). The post intervention assessment of the severity of menstrual pain using Numerical Pain Rating Scale was done immediately, 1 hour, 2 hour and 3 hour after intervention. Dysmenorrhea was assessed by using Numerical Pain Rating Scale and Modified Menstrual Distress Questionnaire. Modified Menstrual Distress score was obtained before and 3 hours after the intervention. Analysis of the baseline and post intervention data was done at the end. The data was analyzed using descriptive and inferential statistics. Analysis was carried out with the help of statistical package for social sciences (SPSS-16) program. The findings were interpreted and presented with the help of tables and graphs. The results showed that there was significant difference in the mean pain score of Numerical Pain Rating Scale before intervention, immediately after, at 1 hour, at 2 hour and at 3 hour was 6.05, 4.05, 3.35, 2.68 and 2.24 respectively. Mean score of Modified Menstrual Distress Questionnaire was 24.65 before applying acupressure and after it was reduced to 9.98. The reapeated measure ANOVA was applied in subsequent observations determined statistically significant reduction in the severity of dysmenorrhea (p< 0.001). So, acupressure is an effective way in reducing dysmenorrhea.
Keywords
Dysmenorrhea, Acupressure, SP 6 point.
Correspondence at
Dr. Avinash Kaur Rana
Lecturer,
National Institute of Nursing Education PGIMER, Chandigarh
Introduction
Menstruation is a normal physiological phenomenon for females indicating her capability for procreation. However it is often associated with some degree of sufferings and embarrassment. The menstrual morbidities constitute an important area of unmet need for reproductive health services for women in developing countries. About 25-50% of adult women and roughly three quarters of adolescents experiences some pain with menstruation, with about 5-20% of women reporting severe dysmenorrhea or pain that prevents them from participating in their usual activities.1
Dysmenorrhea is defined as painful menstruation usually beginning during puberty. The term dysmenorrhea is derived from the Greek word dys meaning difficult/painful/abnormal, meno meaning month and rrhea meaning flow. It is also known as menstrual cramps; typically feel like a dull pain in the lower abdomen before or during menstrual periods. The pain sometimes radiates to the low back or thigh area. Other symptoms may include nausea, loose stools, sweating, and dizziness. There are two types of dysmenorrhea: primary and secondary dysmenorrhea. Primary dysmenorrhea, which usually starts after first menstrual period, involves no physical abnormality.2 Another variety of primary d y s m e n o r r h e a i s m e m b r a n e o u s dysmenorrhea where there is casting of big pieces of endometrium. This is said to be run and nervousness. In Korea, 27–40% of girls in their late teen years complaining of dysmenorrhea take analgesics repeatedly. However, these drugs are only temporarily effective in relieving pain and may induce side effects, dependency, and unnecessary medical costs. Furthermore, these drugs need to be taken repeatedly as their concentrations in the blood decrease over time. Complementary and alternative therapies may be adopted as nursing interventions to prevent and/or alleviate dysmenorrhea.5
Recent research focusing on complementary and alternative interventions for dysmenorrhea include the use of muscle relaxation therapy, magnetic therapy, reflexology, hand acupuncture, moxibustion heat therapy, aroma therapy, acupuncture and acupressure. Acupuncture and acupressure are based on traditional Chinese medicine and share the main principle of opening and harmonizing an obstructed meridian by stimulating surrounding acupuncture points.5 in families.3 Secondary dysmenorrhea, on the other hand, has an underlying physical cause, such as endometriosis, pelvic inflammatory disease, uterine fibroids, or uterine polyps.3
D y s m e n o r r h e a c a n d e c r e a s e productivity, creativity, and work performance due to serious daily stress and social and economic loss. In a study, dysmenorrhea accounted for 600 million lost work hours and $2 billion in lost productivity annually.4 Beginning a few hours preceding and immediately after menstruation, dysmenorrhea typically lasts approximately 48–72 hours and includes symptoms such as lower abdominal cramps, back pain, nausea, vomiting, loss of appetite, fatigue,
Experimental studies on acupressure and acupuncture have demonstrated their effectiveness in alleviating discomfort through sedative and analgesic effects. Many studies have shown that acupuncture is effective for pain relief in general and acupuncture of specific sites such as the SP6 point has been reported to alleviate dysmenorrhea. The SP6 acupoint is the junction point of the liver, spleen, and kidney meridians, and it is proposed to strengthen the spleen, resolve and expel dampness, and restore balance to the Yin and blood, liver, and kidneys.6
The merit of utilizing acupressure therapy as a nursing intervention has been proposed in the literature as a non-invasive measure that offers comparable effects to acupuncture therapy. Acupressure for dysmenorrhea may offer women a non- invasive, cost-free, and timely way to manage dysmenorrhea on their own, thereby saving time, cost, and effort.6 Chen and Chen studied to compare between Hegu and Sanyinjiao matched points of acupressure and Hegu, Zusanli single acupressure point on adolescent girls’ menstrual distress, pain and anxiety perception. Hegu and Sanyinjiao(SP6) acupressure points reduced the pain, distress and anxiety typical of dysmenorrhoea. Acupressure at single point Hegu was found, effectively, to reduce menstrual pain during the follow-up period, but no significant difference was found in reducing menstrual distress and anxiety perception.Zusanli acupressure point had no significant effects of reducing menstrual pain, distress and anxiety perception.7
Another study done by Wong C et.al evaluated the effects of Sanyinjiao (SP6) acupressure in reducing the pain level and menstrual distress resulting from dysmenorrhea Results of study shows that there was a statistically significant decrease in pain score for Pain Visual Analogue Scale (p = 0.003) and SF-MPQ (p = 0.02) immediately after the 20 min of SP6 acupressure during the initial intervention session. During self-care periods, participants were taught to perform the technique for them to do twice a day from the first to third days of their menstrual cycle, 3 months subsequent to the first session. Findings showed significant reduction of PVAS (p = 0.008), Short form-McGill Pain Questionnaire (p = 0.012), and Short form- Menstrual Distress Questionnaire (p= 0.024) scores was noted in the third month of post- intervention.8
Chen HM et al assessed the effects of acupressure at the Sanyinjiao point (SP6) on symptoms of primary dysmenorrhea among adolescent girls. Thirty-one (87%) of the 35 experimental participants reported that acupressure was helpful, and 33 (94%) were satisfied with acupressure in terms of its providing pain relief and psychological support during dysmenorrhea.9 Another study by Mirbagher AN et al conducted a randomized controlled pre and post-test design was employed to verify the effects of SP6 acupressure on dysmenorrhea. Results shows significant differences were observed in the scores of dysmenorrhea between the two groups immediately after and 3 h after treatment.10
Gharlloghi S et.al studied to determine the effects of acupressure at Sanyinjiao (SP6) point and DiJi (SP8) point on pain severity of primary dysmenorrhea and the associated systemic symptoms. The findings of study indicate that the severity of dysmenorrhea pain diminished significantly for up to 2 hours following treatment with acupressure at the SP6 and SP8 points (P< 0.001). Furthermore, the severity of associated systemic symptoms reduced significantly after acupressure at the SP6 and SP8 points, except for nausea and vomiting. 11
In recent study (2012) done among students of NINE, PGIMER, Chandigarh, showed the prevalence of dysmenorrhea was 87.5%12. It decreases productivity, creativity, and work performance due to serious daily stress & a common cause of absenteeism in students. The common strategy used is over the counter drugs but these drugs have many adverse effects. Moreover, it is a social stigma for the girls who wish to get medical treatment for dysmenorrhea. So, there is a need to adopt risk free approach or non- medicinal treatment which the girls can use in their homes/hostel. Complementary and Alternative therapies are proving to be very effective in providing natural pain relief during dysmenorrhea. Acupressure is one of them. Evidence need to be created for such therapies and experimental design is a good design for this. There is a need to prove it. So, this study is done for students who had moderate to severe dysmenorrhea
Objectives
To assess the effectiveness of acupressure on SP 6 point on dysmenorrhea among nursing student
Materials and Methods
A pre experimental design was employed to study the effect of acupressure at SP 6 point on dysmenorrhea among B.Sc nursing students. Null hypothesis was acupressure will not be helpful to reduce the intensity of pain among nursing students having dysmenorrhea at 0.05 level of significance. The study was carried out in National Institute of Nursing Education (NINE), PGIMER, Chandigarh. Study subjects were selected from the B.Sc Nursing students residing in hostel. The target population comprised of all the B.Sc Nursing students (18-23 yrs) residing in hostel who had moderate and severe pain and had regular periods between 21 to 35 days during the month of August and September 2013. The permission from the principal was sought for conducting study and hostel warden was informed. Ethical Clearance was taken from Institute Ethical Committee. The study was carried out in four steps: Development of protocol for acupressure and tools to collect data. The tools for data collection were: identification performa, Numerical pain rating scale, modified menstrual distress questionnaire. The tools and protocol were developed through review of relevant literature and validated by experts from field of nursing, Department of Public Health and Department of Obstetrics and Gynecology. After validation of tool pilot study was conducted in NINE, PGIMER, Chandigarh for assessing feasibility of the study. Results of the pilot study indicated that study was feasible.
The researcher was trained in acupressure by professor of traditional Chinese medicine for several sessions over a period of one month, studying the SP6 literature & participating in practicum sessions to identify SP6 acupoint and practice acupressure techniques. After extensive acupressure training, the technique of providing acupressure was checked with repeated manipulations to ensure that it would remain correct throughout the treatment. After that the researcher was certified to perform the acupressure.
Sample was selected by total enumeration technique. Total 254 nursing students were assessed for dysmenorrhea. Out of them 95 students were enrolled having moderate (51) and severe (44) dysmenorrhea by using Numerical rating pain score. Among them 17 subjects dropped and final sample consisted of 78 subjects. Data was collected in the month of July and August 2013. Study subjects were selected on the basis of scoring of Numerical Pain Rating Scale and only those students with moderate and severe dysmenorrhea were included after taking the written informed consent. They were explained about the purpose of the study and were told that data so collected will be kept confidential & will be used only for research purpose. They were given full autonomy to participate in the study. After recruiting the subjects for the study, socio-demographic details were collected. Study subjects were traced & contacted telephonically around the date of their last menstrual period and told to inform the researcher when they had dysmenorrhea.
The subjects were given identification performa, Modified Menstrual Distress questionnaire to obtain pre-test Modified Menstrual Distress score and pre-test pain score was obtained by using Numerical pain rating scale Then intervention i.e. acupressure at SP 6 point was given for 20 minutes ( 10 minutes for each leg). The post intervention assessment of the severity of menstrual pain was done by using Numerical pain rating scale immediately, 1 hour, 2 hour and 3 hour after intervention. Modified Menstrual Distress score was obtained 3 hours after the intervention. Analysis of the baseline and post intervention data was done. The data was analysed using descriptive and inferential statistics. Analysis was carried out with the help of statistical package for social sciences (SPSS-16) program. The findings were interpreted and presented with the help of tables and graphs.
Fig-1:Description of study population
Results
Table 1 showed that one third of the study subjects (30.8%) were 21 years old and 26.9% were 22 years old with the mean age of 20.9 ± 1.26 years and in age range of 18 to 23 years.
Table 1. Distribution of study subjects according to age
Variables | Frequency (%) n=78 |
Age (years) | |
18 years | 03( 3.8) |
19 years | 08(10.3) |
20 years | 15(19.2) |
21 years | 24(30.8) |
22 years | 21(26.9) |
23 years | 07( 9.0) |
*Mean age ± SD, | |
Range: 20.9±1.262, 18-23 |
V a r i a b l e s s h o w i n g m e n s t r u a l characteristics of study subjects
Table 2 depicts that the 70.5% of the subjects attain menarche at the age of 12-14 years with the mean age of 13.7± 1.306 years. Age of attaining monarche ranged from 11 to 16 yrs. Length of menstrual cycle was 26-30 days in 73.1 % of subjects with mean length of 29.1± 1.19days. Length of menstrual cycle ranged from 24-35 days. 75.6% had duration of menstrual cycle of 4-6 days with mean duration of 4.52± 1.19 days and the amount of blood flow was 3-4 pads/day in 60.3% of study subjects with mean amount of blood flow of 4.52± 0.822 pads.
Table 2. Variables showing menstrual characteristics of study subjects
N=78
Variables | Frequency (%) |
Age at Menarche (years) | |
· <12 years | 04 (5.1) |
· 12-14 years | 55 (70.5) |
· >14 years | 19 (24.4) |
*Mean age ± SD, | |
Range:13.7 ± 1.306, 11-16 | |
Length of menstrual cycle | |
· 21-25 days | 06 (7.7) |
· 26-30 days | 57 (73.1) |
· 31-35 days | 15 (19.2) |
*Mean ± SD, | |
Range: 29.1 ± 2.391,24-35 | |
Duration of menstrual cycle | |
· 1-3 days | 14 (17.9) |
· 4-6 days | 59 (75.6) |
· >6 days | 05 (6.4) |
*Mean ± SD, | |
Range: 4.6 ± 1.196, 2-7 | |
Amount of blood flow | |
· 1-2 pads/day | 29(37.2) |
· 3-4 pads/day | 47(60.3) |
· >4 pads/day | 02(2.6) |
*Mean ± SD, | |
Range: 2.8 ± 0.822,1-5 pads |
Variables associated with dysmenorrhea Table 3 shows that 51.3% of the study subjects had menstrual pain that starts with the onset of menstruation and 47.4% had onset of pain before menstruation. Most of them had pain that starts with onset of menstruation and continues upto 48 hrs of menstruation and 42.3% had family history of dysmenorrhea.
Table 3. Variables associated with dysmenorrhea
N=78
Variables | Frequency (%) |
Onset of pain
· Before menstruation · With onset of menstruation · After 24 hrs of menstruation |
37 (47.4) 40 (51.3) 01 (1.3) |
Duration of pain
· Starts before menstruation continues up to 24 hrs of menstruation · Start with onset of menstruation continues up to 48 hours · Start before menstruation and continues throughout the menstruation · Starts after 24 hours and continues throughout |
24(30.8)
40(51.3) 13(16.7)
01(1.3) |
Family history of dysmenorrhea | 33(42.3) |
Practices adopted to manage dysmen- orrhea among subjects
As shown in the figure 1, study subjects use different practices to manage dysmenorrrhea ie. 29.5% took rest and lie on back, 25.6% took over the counter medication, 15.4% use hot water bottle, 9% modified their diet including hot tea, 5.1% used diversional activities to relieve dysmenorrheal and rest ie. 15.4% used combination of two or three therapies simultaneously.
Fig 1: Practices adopted by subjects to manage dysmenorrhea Severity of dysmenorrhea at different time intervals as per Numerical Pain Rating Scale among subjects
Table 4 depicts that before intervention all the subjects had moderate to severe dysmenorrhea ie. 60.3% had moderate and 39.7% had severe dysmenorrhea but immediately after the intervention 1.3% had no pain, 37.2% had mild, 60.3% had moderate and only 1.3% had severe dysmenorrhea. At 1 hour after the intervention, 61.5% had mild and 37.2% had moderate pain where as none of the subject had severe dysmenorrhea. Two hours after the intervention, 9% had no pain, percentage of subjects in mild increases upto 70.5% and only 20.5% had moderate dysmenorrhea. At 3 hour of intervention, 14.1% had no pain, 71.8% had mild, 12.8% had moderate and only 1.3% had severe pain.
Table 4 Severity of dysmenorrhea at different time intervals as per Numerical Pain Rating Scale among subjects
Severity of dysmenorrhea as per Numerical Pain Rating Scale |
Before intervention(%) |
After intervention |
|||
Immidiately
n(%) |
1 hour
n(%) |
2 hours
n(%) |
3 hours
n(%) |
||
No pain ( 0) | — | 1 (1.3) | 1 (1.3) | 7 (9.0) | 11 (14.1) |
Mild pain (1-3) | — | 29 (37.2) | 48 (61.5) | 55 (70.5) | 56 (71.8) |
Moderate pain(4-6) | 47 (60.3) | 47 (60.3) | 29 (37.2) | 16 (20.5) | 10 (12.8) |
Severe pain (7-10) | 31 (39.7) | 1 (1.3) | — | — | 1 (1.3) |
Mean pain score before and immediately, 1hour, 2hours, 3 hours follow up as per Numerical Pain Rating Scale
Figure 2 shows the mean pain scores as per Numerical Pain Rating Scale. Before the intervention the mean pain score was 6.05 but immediately after the intervention it was reduced to 4.05, 3.35 after 1 hour of intervention, 2.68 after 2 hours and 2.24 after 3 hours of the intervention.
Fig 2: Mean pain score before and after intervention according to MMDQ Mean pain score of the subjects among all consecutive observations as per Numerical Pain rating Scale
Table 5 depicts the comparison of mean pain score of numerical Pain Rating Scale of study subjects during subsequent observations. The mean pain score difference between before and immediately after intervention was 2.000 with significant p value of <0.001. Further comparison of pain score immediately after intervention with subsequent observations ie, immediately after, at 1 hour, at 2 hour and at 3 hour shows the mean difference of 2.705, 3.372 and 4.038 respectively with significant p value. Similarly, comparison of pain score immediately after intervention with the pain score at 1 hour, at 2 hour and 3 hour showed significant reduction in the severity of dysmenorrhoea. Also significant difference was observed between the pain score at 1hour with the pain score at 2 hour and 3 hour. So, the comparison of all observation among themselves shows significant reduction of pain after each observation.
Table 5: A repeated measures ANOVA with mean pain score of the subjects among all consecutive observations as per Numerical Pain rating Scale
Pain score | Pain score | Pain score | ||
Mean difference | Std. Error | p** value | ||
Before intervention: | Immeditely after | 2.000 | 0.121 | < 0.001 |
At 1 hour | 2.705 | 0.135 | < 0.001 | |
At 2 hour | 3.372 | 0.154 | < 0.001 | |
At 3 hour | 4.038 | 0.136 | < 0.001 | |
Immediately after: | At 1 hour | 0.705 | 0.097 | < 0.001 |
At 2 hour | 1.372 | 0.117 | < 0.001 | |
At 3 hour | 2.038 | 0.133 | < 0.001 | |
At 1 hour: | At 2 hour | 0.667 | 0.091 | < 0.001 |
At 3 hour | 1.333 | 0.130 | < 0.001 | |
At 2 hour: | At 3 hour | – 0.669 | 0.118 | < 0.001 |
** Repeated Measure ANOVA (post hoc benforrni)
Severity of dysmenorrhea before and after interventionas per Modified Menstrual Distress Questionnaire among subjects
Table 6 depicts the score of Modified Menstrual Distress Questionnaire. Before giving intervention 26.9% had mild, 57.7% had moderate, 14.1% had strong and 1.3% had severe dysmenorrheal. After the intervention ie. acupressure at SP 6 point most of the study subjects, i.e, 89.7% had mild, 9% had moderate, 1.3% had strong and none of subject had severe dysmenorrhea.
Table 6. Severity of dysmenorrhea before and after interventionas per Modified Menstrual Distress Questionnaire among subjects
Modified Menstrual Distress Questionnaire | Before Intervention n (%) | After Intervention n (%) |
Mild dysmenorrhea (1-18) | 21 (26.9) | 70 (24.4) |
Moderate dysmenorrhea (19-36) | 45 (57.7) | 7 (9.0) |
Strong dysmenorrhea (37-54) | 11 (14.1) | 1 (1.3) |
Severe dysmenorrhea (55-72) | 1 (1.3) | 0 (0) |
Comparison of mean scores before and after intervention as per Numerical Pain Rating Scale (NRS) &Modified Menstrual Distress Questionnaire (MMDQ)
Table 7 infers the comparison of mean pain score of before and after intervention. According to Numerical Pain Rating Scale (NRS) pain score before intervention was 6.05±1.23 and after it was reduced to 2.24±1.46. Paired t test showed that there was significant difference in the mean pain score (p < 0.001). The mean score of MMDQ before and after intervention for dysmenorrhea was 24.65± 10.57 and 9.98 ±6.17 respectively. Paired t test showed that there was significant difference in the mean score before intervention and after intervention (p < 0.001).
Table 7. Comparison of mean scores before and after intervention as per Numerical Pain Rating Scale (NRS) &Modified Menstrual Distress Questionnaire (MMDQ)
Pain Score | |||
Before Intervention (Mean ± SD) | After intervention (Mean ± SD) | t-value, df p* value | |
NRS | 6.05± 1.23 | 2.24± 1.46 | 22.36, 77
< 0.001 |
MMDQ | 24.65± 10.57 | 9.99± 6.17 | 16.26, 77
<.0.001 |
* Paired t test Discussion
Acupressure for dysmenorrhea is a natural way to relieve pain. It is safe, non- invasive, economical and cost free pain relieving technique. SP6 acupoint can relieve dysmenorrhea. It can be self- administered by sitting cross-legged and using one’s right hand for the left leg SP6 point and left hand for the right leg SP6 point, administering simultaneous pressure.
A randomised control trail conducted by Chen and Chen (2010), determined that acupressure was effective in reducing severity of dysmenorrhea when it was given for 20 minutes on SP6 point. On the same lines the present study was undertaken in which acupressure was given for 20 minutes when the study subjects reported pain. Moreover, he reported the immediate effect of SP 6 acupressure on reducing dysmenorrhea but present study extends beyond his study by including a series of measurement at different time interval (i.e., immediately after, 1, 2, and 3 h post treatment) in order to assess the long term effect of acupressure.7 Another study conducted by Wong et al (2010) also determined the effectiveness of acupressure by conducting randomised control trial in which acupressure at SP6 was given twice a day for first three days of the menstrual cycle and findings showed statistically significant decrease in pain score using Visual Analogue Scale, McGill pain questionnaire and Modified Menstrual Distress Questionnaire.8 Whereas in present study similar results were obtained using Numerical Pain Rating Scale and Modified Menstrual Distress Questionnaire in which the acupressure was applied immediately when subjects reported dysmenorrhea.
Furthermore, clinical trail conducted by Gharloghi S et al (2011) comparing the acupressure at SP6 and SP8 point in which results showed that the severity of dysmenorrhea diminishes significantly for menstruation and results showed statistically significant reduction in severity of dysmenorrhea. These findings were in accordance to the study conducted by Chang S et al. in which study subjects received acupressure treatment within the first 8 hours of menstruation and similar results were obtained i e, significant reduction in severity of dysmenorrhea13.
Mirbagher M et al (2011) conducted study comparing acupressure at two different points i.e. light touch at SP6 for 20 min in control group and acupressure at SP6 in experimental group. There were significant di fferences in VAS scores between the experimental and control groups immediately, 1, 2, and 3h after intervention10 In present study, reduction in pain score was assessesed at similar time intervals. Results of both studies are comparable. Findings of this study clearly indicates that 20 minutes acupressure is an effective complementary mean for reducing dysmenorrhea without any side effects of drugs.
A c u p r e s s u r e c a n b e r e a d i l y implemented in routine life. It proved to be an effective measure. Moreover it could be used by the women who had complaint of dysmenorrhea in order to improve the quality of life. In contexts where other more effective methods of reducing dysmenorrhea are up to 2 hours following intervention 11 and in available, it can be used as an alternative and present study only one group receiving acupressure at SP6 point was studied that showed similar results but upto 3 hours of intervention.
In present study, acupressure was provided within first two days of complementary therapy. In addition, acupressure is easy to administer and little training of the person who administer the treatment is required. Based on the findings of present study it was concluded that the study group had significant reduction in the severity of dysmenorrhea after giving intervention. So, the null hypothesis was rejected and alternate hypothesis was accepted i.e. acupressure is effective in reducing dysemenorrhea. Acupressure can be used as a convenient self-care method i.e. free of cost and complications and easy-to-learn nursing intervention to reduce the dysmenorrhea. The findings of the study can be used as a guideline for further research on effect of acupressure using combination of different points. However, further studies of efficacy as well as effectiveness are needed to determine the clinical applicability of acupressure for dysmenorrhea. Further investigations are necessary to replicate the beneficial findings of acupressure in a large population and to better elucidate physiologic mechanism underlying pain relief.
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