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Measuring Balance in the Elderly - Validation of an Instrument

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Measuring Balance in the Elderly: Validation of an Instrument
Author(s): Katherine O. Berg, Sharon L. Wood-Dauphinee, J. Ivan Williams and Brian Maki
Source: Canadian Journal of Public Health / Revue Canadienne de Santé Publique, Vol. 83,
SUPPLEMENT 2: Rehabilitation Outcome Measures Conference (JULY / AUGUST 1992), pp.
S7-S11
Published by: Canadian Public Health Association
Stable URL: http://www.jstor.org/stable/41990843
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Measuring Balance in the Elderly:
Validation of an Instrument
Katherine O. Berg, MSc, PT,' Sharon L. Wood-Dauphinee, PhD, PT,2
J. Ivan Williams, PhD,3 Brian Maki, PhD 4
ABSTRACT
This study assessed the validity of the Balance
Scale by examining: how Scale scores related to
clinical judgements and self-perceptions of bal-
ance, laboratory measures of postural sway and
external criteria reflecting balancing ability; if
scores could predict falls in the elderly; and how
they related to motor and functional performance
in stroke patients. Elderly residents (N= 1 1 3) were
assessed for functional performance and balance
regularly over a nine-month period. Occurrence
of falls was monitored for a year. Acute stroke
patients (N=70) were periodically rated for func-
tional independence, motor performance and
balance for over three months. Thirty-one elderly
subjects were assessed by clinical and laboratory
indicators reflecting balancing ability. The Scale
correlated moderately with caregiver ratings, self-
ratings and laboratory measures of sway. Différ-
ences in mean Scale scores were consistent with
the use of mobility aids by elderly residents and
differentiated stroke patients by location of
follow-up. Balance scores predicted the occur-
rence of multiple falls among elderly residents and
werestrongly correlated with functional and motor
performance in stroke patients.
ABRÉGÉ
CetœétudeévaluekvaHditédel'échelled'équilibre
en examinant 1 ) s'il y a un rapport entre les résultats
de cette échelle versus: les évaluations cliniques et en
laboratoire de l'équilibre, les auto- perceptions de
l'équilibre, et les critères externes reflétant les apti-
tudesau titre del'équilibre; 2) si les résultats permettent
de prédire les risques de chute chez les personnes
âgées et s'ils sont reliés à la performance fonctionnelle
et motrice de sujets accidentés cérébraux vasculaires.
La performance fonctionnelle et l'équilibre de
résidents âgés (N= 1 1 3) ont été évalués régulièrement
pendant 9 mois. La survenue des chutes a été suivie
pendant un an. L'indépendance fonctionnelle, la
performance motrice et l'équilibre d'accidentés
cérébraux vasculaires aigus (N=70) ont été évalués
régulièrement pendant trois mois. L'équilibre a été
évalué avec des outils cliniques et en laboratoire chez
3 1 sujets âgés. Une corrélation modérée a été observée
entre l'échelle d'équilibre et les évaluations des
prestateurs desoins, les auto-évaluations et les mesures
de balancement postural telles qu'établies en
laboratoire. Les scores moyens obtenus chez les
résidents âgés diffèrent selon l'utilisation d'appareils
facilitant la marche et chez les sujets accidentés
cérébraux vasculaires, les scores moyens diffèrent
selon l'emplacement du suivi. L'échelle d'équilibre
permet de prédire la survenue de chutes multiples
chez les résidents âgésetd'établirunefortecorrélation
avec la performance fonctionnelle et motrice des
sujets accidentés cérébraux vasculaires.
Improving postural control or balance is a
primary goal in rehabilitation and geriatric
medicine. There is a need for a reliable and
valid instrument, suitable for use in the clinical
setting and in research. In an earlier study we
developed an instrument for rating the ability
of an individual to maintain balance while
performing 14 movements required in every-
day living.1 The content of the Balance Scale
was verified by health care professionals and
elderly individuals who participated in the
study. Preliminary tests demonstrated that it
could be administered with high levels of
inter-rater and intra-rater agreements (both
ICCs=0.98), that it was internally consistent
(a=0.96) and that it correlated strongly with
global ratings of balance made by treating
therapists (r=0.81).
The general goal of the current study was to
accrue further evidence concerning the valid-
ity of the Balance Scale. Specifically the objec-
tives were:
1 . to determine the degree to which scores
of the Balance Scale were related to clini-
cal judgements of balance and laboratory
measures of postural sway (concurrent
criterion validity);
2. to determine if the scores on the Balance
Scale could predict the falls that would
occur among elderly ambulatory indi-
viduals (predictive, criterion validity);
1. School of Physical and Occupational Therapy,
McGill University, Montreal
2. School of Physical and Occupational Therapy;
Department of Epidemiology and Biostatistics,
McGill University, Montreal
3. Clinical Epidemiology Unit, Sunnybrook Health
Science Centre, University of Toronto, Toronto
4. Centre for Studies in Aging, Sunnybrook Health
Science Centre, University of Toronto, Toronto
Correspondence to: Ms. K. Berg, School of Physical and
Occupational Therapy, 3654 DrummondSt., Montreal,
PQ, H3G 1Y5
This research was funded by the National Health Re-
search and Development Program.
3. to assess the degree of association of the
scores on the Balance Scale with indices
of functional and motor performance
during the recovery of stroke patients
(construct validity); and
4. to assess the ability of the Balance Scale to
discriminate among groups known to
differ on defined characteristics (concur-
rent criterion validity).
The research was carried out in three set-
tings; a home for the elderly, acute care hospi-
tals, and a laboratory.
METHODS
Home for the Elderly
One hundred and thirteen individuals from
the McGriffith McConnell Residence, a home
for the elderly in Montreal, agreed to partici-
pate in the study. Research assistants assessed
the subjects' levels of functional independence
with the Barthel Index,2 a well-known and
validated measure of self-care and mobility
skills.3'7 Caregivers rated their global ability to
' balance (good, fair or poor), and the partici-
pants provided similar self-ratings. Indepen-
dent evaluators scored the subjects on the
Balance Scale. The assessments were made at
the beginning of the study, and every three
months for a nine-month period. The occur-
rence of falls amongst the subjects was care-
fully monitored over an entire year.
Of the 113 subjects, 4 died and 16 had
missing information due to illness, injury or
unwillingness to comply with a specific assess-
ment.
Acute Care Hospitals
The second sample consisted of 70 acute
stroke patients admitted to the Montreal Gen-
eral Hospital or the Royal Victoria Hospital/
Montreal Neurological Institute Complex. We
screened 238 patients, but 168 were excluded
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MEASURING BALANCE IN THE ELDERLY
because of inclusion criteria (60%), inability
to obtain consent (1 1%), and death prior to
first assessment (7%). Other patients (22%)
were reached too late or there were missing
data, and we could not establish their eligibil-
ity for the study.
Within 14 days of stroke onset, research
therapists rated the patients on the Barthel
Index and the Fugl-Meyer Scale,8 a validated
measure of motor performance.9'13 An inde-
pendent evaluator scored them on the Balance
Scale. The assessments were repeated at four,
six, and twelve weeks in the locations where
the patients were residing.
During the follow-up period, ten patients
were lost from the study. Eight patients died
and two patients developed other health prob-
lems that prevented further participation.
The Laboratory
The final sample consisted of 31 elderly
individuals who agreed to participate in a
laboratory study at Sunnybrook Health Sci-
ence Centre in Toronto. It represented the
spectrum of ability to balance and incorpo-
rated those who required aids for walking.
Common health problems included rheumatic
diseases (55%), neurological disorders (33%),
cardiovascular diseases (45%), and problems
with vision (52%). Most were taking medica-
tions and 1 3 individuals had at least one fall in
the previous three months.
An independent evaluator administered the
Balance Scale, theTinetti Balance Subscale14'15
and the Timed "Up and Go" Test.16 The
Tinetti Balance Subscale involves rating the
individuals on 13 common tasks, and it has
demonstrated reasonable reliability and valid-
ity i4,i5,i7 Tjmec[ "Up ancl Go" Test pro-
vides a reliable and valid assessment of func-
tional mobility.16
For the laboratory tests, postural sway was
measured while subjects stood still and in
response to pseudo-random perturbations of a
platform.18 The platform consisted of two
force plates, safety rails and an enclosure that
moved with the platform. Postural sway was
quantified in terms of the root mean square
amplitude of the centre of pressure displace-
ment (relative to the mean COP location) and
the average speed of the COP displacement.
The amplitude and speed variables were di-
vided by the length of the feet for the anterior-
posterior tests and the width of the subject's
base of support for the medial-lateral ones. It
TABLE I
Sociodemographic characteristics of the subjects at entry into the study
Stroke Patients Elderly Residents Lab Subjects
N=70 N=1 1 3 N=31
Sociodemographic Mean (SD) Mean (SD) Mean (SD)
Characteristics or Percent or Percent or Percent
Age (years) 71.6 (10.1) 83.5 (5.3) 83.0 (6.9)
Sex
Male 51.4 17.7 29.0
Female 48.6 82.3 71.0
Marital Status
Married 58.6 9.7 16.1
Never Married 12.9 25.7 12.9
Formerly Married 28.6 64.5 71.0
Language
French 40.0 8.8 0.0
English 31.4 90.3 87.1
Other 28.6 0.9 12.9
Usual Living Arrangements
Home 95.7 0.0 3.2
Residence 2.9 100.0 80.7
Institution 1.4 0.0 16.1
Employment Status
Full-Time 5.7 0.0 0.0
Retired 70.0 100.0 100.0
Unemployed 2.9 0.0 0.0
Housewife 18.6 0.0 0.0
Usual Occupation
Professional 15.7 39.8 22.6
Clerical 8.6 27.4 25.8
Sales 5.7 4.4 6.5
Service 7.1 2.7 22.6
Transportation 8.6 1.8 3.2
Production 11.4 2.7 9.7
Labourer 15.7 0.9 0.0
Housewife 27.1 18.6 9.7
None 0.0 1 .8 0.0
Education (years) 8.6(3.5) 12.6(3.0) 10.8(3.5)
is assumed that low values for amplitude and
speed of sway are indicative of good balance.
RESULTS
The demographic characteristics of indi-
viduals in the three studies are displayed in
Table I. The participants had a wide variety of
health, balance and mobility problems charac-
teristic of older persons.
Home for the Elderly
The scores on the Balance Scale range from
0 to 56 points. Based on clinical experience, a
score of 45 seems to be a cut-off point between
those individuals who are safe in independent
ambulation and those requiring investigation
concerning their need for assistive devices or
supervision.
The correlations of the Balance Scale scores
with global ratings of the caregivers ranged
from 0.47 to 0.61 and from 0.39 to 0.41 with
the self-ratings of the participants. The coeffi-
cients were moderate in magnitude, statisti-
cally significant, and in the expected direction
(Table II).
We grouped the residents according to their
use of mobility aids at entry into the study, and
analyzed the mean differences across the groups.
We treated use of aids as an indicator of ability
to balance and tested the concurrent validity
of the Balance Scale by determining how well
it differentiated amongst the known groups.19
The results are displayed in Table III. The
scores for those who used walkers (33.1) and
canes indoors (45.3) were significantly differ-
ent from each other and lower than mean
scores for participants who either walked with-
out aids (49.6) or only used a cane when
outdoors (48.3). The balance scores for the
latter two groups were comparable.
At the end of the 12 months, the partici-
pants were classified as having none or one fall,
or two or more falls. For an initial Balance
Scale score less than 45, the relative risk of
multiple falls over the next 12 months was 2.7
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MEASURING BALANCE IN THE ELDERLY
TABLE II
Mean Balance Scale scores (SD) and Pearson Product Moment correlation
coefficients of Balance Scale scores with caregiver's ratings and patienťs ratings
of global balance for elderly residents at each evaluation point
Entry Three Months Six Months Nine Months
Mean Balance Scale 47.7 (5.5) 47.3 (5.9) 46.9 (7.0) 47.3 (5.4)
Score (SD)
N 93 93 93 93
Balance Scale & .52 .46 .62 .49
Caregiver's Global
Rating
N 93 93 92 91
Balance Scale & .42 .41 .40 .39
Self-rating
N 92 93 92 92
TABLE III
Mean Balance Scale scores (SD) of Griffith McConnell residents by use of
mobility aids at entry to study and associated analysis of variance results
No Aids Cane Cane Walker
(N=49) Outdoors Indoors (N=9)
(N=26) (N=29)
Balance Scores 49.6 48.3 45.3 33.1
(SD) (5.6) (3.2) (3.4) (8.4)
95% CI 47.9-51.1 47.0-49.6 44.0-46.5 26.7-39.6
F = 29.61 ; dt = 3,1 09; p < .0001
TABLE IV
The logistic regression model predicting multiple falls compared to single or no
falls among the elderly residents (N=1 1 3)
Variables Beta Standard Significance Adjusted 95%
Coefficient Error Level Odds Ratio CI
Initial Balance Scale Scores -.1 1 .04 .006 .90 .83 to .97
History of Falls in Past
3 Months 1 .75 .64 .007 5.75 1 .63 to 20.25
Visual Problems 1.03 .50 .039 2.80 1.05 to 7.44
Constant 3.83 1.75 .03
TABLE V
Means and (standard deviations) for Balance Scale, Barthel Index and
Fugl-Meyer Scale scores of stroke patients at each evaluation point (N = 60)
Initial 4-Week 6-Week 12-Week
Evaluation Evaluation Evaluation Evaluation
Balance Scale
0-56 15.5 (16.7) 23.9 (20.1) 26.5 (20.5) 31.7 (20.4)
Barthel Index
0-100 33.8 (30.5) 48.5 (34.1) 55.5 (35.1) 64.4 (34.9)
ADL Subscale
0-53 21.9 (17.6) 29.9 (18.9) 32.6 (18.6) 36.7 (18.2)
Mobility Subscale
0-47 11.9 (14.4) 18.6 (17.1) 22.8 (18.0) 27.7 (17.6)
Fugl-Meyer Scale
0-114 53.9 (38.2) 64.3 (38.1) 69.9 (36.0) 73.5 (35.7)
Arm Subscale
0-66 29.9 (26.2) 35.9 (25.8) 39.1 (24.9) 40.8 (24.4)
Leg Subscale
0-34 17.4 (10.6) 20.8 (10.7) 22.5 (9.7) 23.8 (9.4)
Balance Subscale
0-14 6.6 (3.9) 7.6 (3.6) 8.3 (3.6) 8.9 (3.8)
(95% CI 1.5-4.9). We also used logistic re-
gression to test the predictive validity of the
measure. Sixteen of the patients had fallen
within three months prior to the study, so this
was included as a predictor along with the
initial Balance Scale score. As can be seen in
Table IV, balance scores, visual deficits and
prior falls were significant predictors of falls.
In summary, with the data obtained on the
elderly residents, we tested the Balance Scale
scores against global scores of the caregiver,
self-ratings of the participants, the use of walk-
ing aids, and the prediction of falls over 12
months. All results were statistically signifi-
cant and in the hypothesized direction.
Acute Care Hospitals
We have complete data on 60 stroke pa-
tients. Acute stroke patients are expected to
recover with varying degrees of residual defi-
cits. The task for this part of the study was to
determine the relationships of the Balance
Scale to the Barthel Index and the Fugl-Meyer
Scale over the 1 2-week period, as well as to the
location of the patients at 12 weeks after the
stroke.
The scores for the Balance Scale, the Barthel
Index, and the Fugl-Meyer Scale at each evalu-
ation point are provided in Table V. The
scores increased from the initial assessment
through the last evaluation at 12 weeks. The
correlations of the Balance Scale with the total
scores and subscores of the Barthel Index and
Fugl-Meyer Scale for each assessment are dis-
played in Table VI. The correlations with the
Barthel scores were 0.80 or higher and be-
tween 0.62 and 0.94 for the Fugl-Meyer scores.
We specified location at 12 weeks as a
criterion variable for testing the ability of the
Balance Scale to differentiate amongst known
groups of stroke patients.19 The results of the
analysis of variance are displayed in Table
VII. The mean scores are highest for the
patients at home (45.0), lowest for those still
in hospital (8.6), and intermediate for pa-
tients in rehabilitation centres (31.1). All
comparisons of group means were statisti-
cally significant.
In this section of the study, the performance
of the Balance Scale was compared to the
Barthel Index and the Fugl-Meyer Scale. The
associations between the Balance Scale and the
measures of function and motor performance
were as hypothesized. At 1 2 weeks the patients
were either at home, in rehabilitation centres,
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MEASURING BALANCE IN THE ELDERLY
or still in the hospital. The Balance Scale scores
clearly differentiated the three groups.
The Laboratory
The mean values, standard deviations, and
correlation matrix for the Balance Scale, Barthel
Mobility Subscale, Timed "Up and Go", and
Tinetti Balance Subscale are displayed in T able
VIII. The Product Moment correlations ranged
from 0.67 to 0.91, with the exception of that
between the Timed "Up and Go" test and the
Barthel Mobility Subscale (0.48).
The laboratory tests provided four measures
of spontaneous sway and four measures of
sway induced by pseudo-random perturba-
tions in the movement of the platform. Table
IX presents the correlation matrix of the Bal-
ance Scale scores and the laboratory param-
eters. The average correlation of the Balance
Scale scores with spontaneous measures
(-0.55) was marginally higher than the corre-
lations with the pseudo-random perturbation
scores (-0.38). The results indicate that the
Balance Scale correlates satisfactorily with the
laboratory measures. Given the sample size,
the numbers of measures, and the uncertain
meaning of the laboratory tests, the results
must be interpreted with caution.
DISCUSSION
The correlations of the Balance Scale with
global ratings of caregivers, self-ratings by the
elderly, and laboratory measures of sway were
in the hypothesized direction, moderately
strong, and statistically significant. As well, the
mean Scale scores distinguished between the
use of mobility aids and also differentiated
stroke patients according to whether they were
at home, in a rehabilitation centre, or in an
acute hospital at the end of the follow-up
period.
These data provide information to support
concurrent criterion validity. Although no
"gold standard" exists for assessing balance,
associations with judgements of subjects and
caregivers suggest that the Scale is actually
measuring the capacity to balance. The mean
Scale scores of the elderly residents, grouped
according to their use of mobility aids, dem-
onstrate a gradient effect with those using no
aids having the highest scores and those who
use a walker, the lowest. Similarly, in consid-
ering the stroke patients by location of evalu-
ation, there are discernable differences across
TABLE VI
Product-Moment correlations of the Balance Scale with the Barthel Index and
Fugl-Meyer Scores of completed stroke patients at each evaluation point (N=60)
Initial 4-Week 6-Week 12-Week
Evaluation Evaluation Evaluation Evaluation
Barthel Index .90 .87 .90 .93
ADL Subscale .81 .80 .82 .86
Mobility Subscale .92 .85 .92 .94
Fugl-Meyer Scale .70 .77 .77 .82
Arm Subscale .62 .69 .69 .76
Lee Subscale .71 .80 .76 .79
Balance Subscale .84 .87 .88 .94
TABLE VII
Mean Balance Scale scores (SD) of stroke patients by location of evaluation
Acute Care Rehabilitation Home/
Hospital Centre Community
Mean Balance Scale Score 8.1 31.1 45.0
N 14 20 26
95% CI 1.8-14.5 21.6-40.5 40.6-49.3
F = 28.673, DF = 2,57, P < .0001
TABLE VIII
Means and correlation matrix of the clinical variables measured in the
laboratory study (N=31)
Balance Barthel Mobility Timed Tinetti Balance
Scale Subscale "Up and Go" Subscale
Mean (SD) 38.2 (9.8) 41.8 (8.4) 26.9 (17.9) 16.2 (5.3)
Barthel Mobility .67
Timed "Up and Go" -.76 -.48
Tinetti Subscale .91 .76 -.74
All p values statistically significant (<.01 )
the groups. Patients still in hospital had the
lowest scores reflecting the fact they are the
most severely involved. Conversely, those with
the highest scores have returned home. These
findings support the hypothesis that subjects
can be differentiated by scores on the Scale.
Moreover, the strong association between
Balance scores and other clinical indicators of
balance and mobility, as well as the moderate
correlations with the patterns of sway are in
line with expectations about the degree of
relationships between clinical and laboratory
measures.
For the elderly residents, the Balance score
at baseline, as well as visual deficits and a recent
fall, were significant predictors of the occur-
rence of multiple falls over the next year. In
reality, there is no one factor or characteristic
of an individual responsible for causing falls,
but it is intuitively reasonable that difficulties
with balance facilitate the event. Thus, the
contributions of the Balance scores to the
logistic regression model provide evidence for
the predictive criterion validity of the Scale.
The Balance scores of stroke patients were
strongly associated with those of the Barthel
Index and the Fugl-Meyer Scale over the 12-
week follow-up period. Based on evidence
from the literature,8'913'20 we had hypoth-
esized that measures of functional and motor
performance should be positively related to
the Balance Scale since strength is required
for balance, and balance is the necessary basis
upon which to superimpose functional ac-
tivities. The findings substantiate construct
validity.
Validation of any measure is an ongoing
process and thus the results reported here
require confirmation by other investigators.
Nonetheless, we believe that the Balance Scale
is valid. When information is available on its
other psychometric properties, clinicians and
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MEASURING BALANCE IN THE ELDERLY
TABLE IX
Correlation Matrix of the Balance Scale Scores and the Laboratory Parameters (N)
Variables Balance SAPRMS SAPSPD SMLRMS SMLSPD PAPRMS PAPSPD PMLRMS PMLSPD
SAPRMS -.4760
(30)
P=.008
SAPSPD -.6713 .3520
(30) (30)
P=.000 P=.056
SMLRMS -.4612 .6934 .6157
(30) (30) (30)
P=.010 P=.000 P=.000
SMLSPD -.5780 .4888 .8452 .8612
(30) (30) (30) (30)
P=.001 P=.009 P=.000 P=.000
PAPRMS -.4915 .5067 .1242 .2546 .2122
(31) (30) (30) (30) (30)
P=.005 P=.004 P=.51 3 P=.1 74 P=.260
PAPSPD -.4207 -.0443 .6914 .1351 .4283 -.0073
(31) (30) (30) (30) (30) (31)
P=.018 P=.816 P=.000 P=.476 P=.019 P=.969
PMLRMS -.2180 .3431 .0379 .4723 .3978 .4748 -.0543
(29) (28) (28) (28) (28) (29) (29)
P=.258 P=.074 P=.848 P=.01 1 P=.036 P=.009 P=.780
PMLSPD -.3954 .0176 .6734 .4479 .8515 .1939 .7186 .4564
(29) (28) (28) (28) (28) (29) (29) (29)
P=.034 P=.929 P=.000 P=.017 P=.000 P=.314 P=.000 P=.013
Codes
Balance Balance Scale Scores
SAPRMS Amplitude Spontaneous Sway (A-P) SAPSPD Speed Spontaneous Sway (A-P)
SMLRMS Amplitude Spontaneous Sway (M-L) SMLSPD Speed Spontaneous Sway (M-L)
PAPRMS Amplitude Pseudorandom Sway (A-P) PAPSPD Speed Pseudorandom Sway (A-P)
researchers will have a new tool capable of
assessing the ability to balance.
ACKNOWLEDGEMENTS
We thank Tammy Abramovitch-Ostroff,
Any Brouillette, Jacqueline Harvey, Phyllis
Havercroft, Liliane Holtman, Diane Keiling,
Kathryn Lexow-Nixon, Cathy Misener and
Vicki Smith for their work as research assis-
tants, Joanne Boisvert, Monica Kilfoil,
Kathleen Norman and Anna Peruzzi as evalu-
ators and Pamela Holiday for participation
in the laboratory study. We are also indebted
to staff at the Catherine Booth Hospital,
Griffi th-McConnell Residence, Jewish Re-
habilitation Hospital, Julius Richardson
Hospital, Montreal Convalescent Hospital,
Montreal General Hospital, Montreal Neu-
rological Hospital and the Royal Victoria
Hospital in Montreal; Baycrest Terrace, Fel-
lowship Towers, Isabel & Arthur Meighen
Lodge and Sunnybrook Health Science Cen-
tre in T oronto, for their interest and coopera-
tion. Finally we are grateful to the subjects
and their family members who participated
in the study.
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