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Communicating With Patients: What

Happens in Practice?
1. Lisa Roberts and
2. Sally J Bucksey

+ Author Affiliations

1. L Roberts, PhD, MCSP, is Superintendent Physiotherapist, Physiotherapy


Department, Southampton University Hospitals NHS Trust, Southampton, Hampshire,
United Kingdom, and Senior Lecturer, School of Health Professions and
Rehabilitation Sciences, Southampton University, Southampton, Hampshire, United
Kingdom
2. SJ Bucksey, MSc, MCSP, is Physiotherapy Manager, West Dorset Hospitals NHS
Trust, Dorchester, Dorset, United Kingdom. She was a student in the School of Health
Professions and Rehabilitation Sciences, Southampton University, when this work
was completed
1. Address all correspondence to Mrs Bucksey at: sally.bucksey@wdgh.nhs.uk

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Abstract
Background and Purpose Communication is the most important aspect of practice that
health care professionals have to master. The purpose of this study was to measure the
content and prevalence of verbal and nonverbal communications between physical therapists
and patients with back pain.

Subjects Seven physical therapists and 21 patients with back pain participated in this study.

Methods The first interaction following the initial assessment was recorded with a video
camera. The outcome measures were the Medical Communications Behavior System (verbal
communication) and frequencies of nonverbal behaviors (affirmative head nodding, smiling,
eye gaze, forward leaning, and touch). Semistructured interviews were undertaken with the
physical therapists to determine the perceived influence of the video camera.

Results A total of 2,055 verbal statements were made. Physical therapists spent
approximately twice as much time talking as patients, with content behaviors (such as taking
history and giving advice) comprising 52% of verbal communications. The most prevalent
nonverbal behaviors were touch by physical therapists (54%) and eye gaze by patients (84%).

Discussion and Conclusion The prevalence and content of communication can be measured
with video analysis and validated tools. Communication is an extremely important but
underexplored dimension of the patient-therapist relationship, and the methods described here
could provide a useful model for further research and reflective practice.
Communication has been described as the most important aspect of practice that health
professionals have to master1 and an essential requirement underpinning any successful
encounter.2 It has been widely studied within the fields of medicine, nursing, psychology,
psychotherapy, and social science, and the complexity of measuring interactions between
patients and health care professionals is well recognized.

It is important to consider not only what is said but also the manner in which it is conveyed,
as communication traditionally incorporates verbal and nonverbal behaviors. Depending on
the situation and the words used, verbal communication may be used for the transference of
information or instruction as well as for conveying empathy in order to establish a
relationship.3 The effectiveness of any verbal message conveyed to another individual relies
on his or her ability to listen, hear, and assimilate the message appropriately.4 Nonverbal
communication includes all behaviors that convey messages without the use of verbal
language.5 Attempts have been made to quantify the relative importance of verbal and
nonverbal behaviors, with estimates of the nonverbal component comprising 55% to 97%,6
90%,7 and 93%8 of the message. Despite the variations in these values, nonverbal aspects of
communication are consistently thought to be more influential than verbal behaviors.
According to Waddell,9 when the nonverbal message conflicts with the verbal message,
people probably will not believe what is said.

Although the importance of communication in health care interactions is undisputed, its


influence on treatment outcomes is less clear. Current data suggest that positive effects occur
when people feel empowered and believe that they have been heard10; therefore, a good
clinical encounter10 leads to better outcomes. This view has been substantiated by reports of
increased patient knowledge,11 improvements in initial beliefs about medications,11 improved
adherence to treatment regimens,1113 greater understanding of information given,12 and
enhanced satisfaction.11,12,14 This view is not universal, however, as some researchers have
argued that the explanatory models used by health care professionals intersect with the beliefs
of patients and create relationships that do not result in predictable, linear outcomes.15

Recently, interest has grown in examining the implications for clinical care of more patient-
centered approaches15 across the health care professions. Within the psychotherapy literature,
the development of a strong therapeutic alliance16 has been widely considered, and it has
been stated that the relationship between the client and the psychotherapist, more than any
other factor, determines the effectiveness of psychotherapy.17 Similarly, within the field of
nursing, the importance of communication has been recognized, in particular, during the
initial phase of the nurse-patient relationship, when roles are clarified and rapport and
standards are established.18 Within the field of medicine, it has been claimed that 80% of
patients complaints arise from a breakdown in communication,19 a finding that highlights the
importance of this topic. Furthermore, communication assumes a special importance when
things go awry; in a study of 227 patients and relatives who were taking legal action through
medical negligence solicitors, explanation and apology was the most frequently cited action
after the incident that might have prevented litigation.20

With regard to physical therapy, the need to give attention to communication has been
accelerated by the emergence of patient-centered perspectives.21 When Stenmar and
Nordholm22 investigated clinicians perceptions of the most important factors in successful
treatment in their sample of 187 Swedish physical therapists, they found that the majority
perceived the patient-therapist relationship and patients resources to be more important to
treatment success than the treatment itself.
Despite the importance of communication, there is no gold standard instrument for measuring
communication, and various methods have been used within the health care fields; qualitative
methods have been used to determine health care professionals and patients opinions of
what constitutes an effective interaction,23 and quantitative methods have been used to
measure verbal and nonverbal communications with an array of classification schemes.
Although these methods have resulted in greater insight into styles of communication,
relatively little still is known about the content of health care consultations.24 To date, this
work generally has focused on doctor-patient interactions and has been reported less widely
in other health care professions.

Within the setting of physical therapy, Talvitie3 investigated the interaction between the
clinician and the patient by using a form of interaction analysis to record verbal and
nonverbal communications. This method involved the use of an observational instrument
based on the Didactic Process Analysis in the Helsinki taxonomy, which was originally
designed for use in a classroom setting.25 The measure had been adapted (without
revalidation) to suit the classification of verbal communication and socioaffective
characteristics in the setting of physical therapy. Despite its apparent validity, Talvitie3
considered this measure to be inappropriate for use within the setting of physical therapy
because of insensitivity within the coding categories.

Therefore, the search continues for an appropriate, validated tool for measuring the
communication that takes place during clinical encounters. Only when the content of this
communication is known can clinicians establish ways to optimize the relationship, maximize
the nonspecific treatment effects (eg, the patient who experiences less pain during a
consultation with a warm, empathetic health care professional), and enhance the patient's
experience. Given this context, the purpose of this study was to measure the content and
prevalence of the verbal and nonverbal communications that occur between physical
therapists and patients with low back pain in an outpatient setting.

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Method
Study Design

A pragmatic, prospective, observational study was undertaken in an acute care hospital and in
a Primary Care Trust in southern England to identify the verbal and nonverbal
communications that occur between physical therapists and patients with low back pain
during treatment sessions. The study design included mixed methods (quantitative and
qualitative), as outlined in the Figure.
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Figure.

Summary of study design. GP=general practitioner.

Participants

All physical therapists (n=16) working in the participating departments were given an
information sheet outlining the study. Clinicians whose caseload did not include patients with
low back pain were excluded (n=2), ensuring that all participating therapists were currently
treating patients with low back pain. In addition, any clinicians who had specific knowledge
of the outcome measures to be used were excluded (n=1) to minimize bias attributable to
prior knowledge of the communication categories.

In an outpatient setting, people with low back pain are among the most prevalent consumers
of physical therapy. Although it is essential to build rapport and develop a strong patient-
therapist relationship, there are additional physical barriers that can present a challenge in this
population. First, patients frequently experience discomfort when sitting (eg, to give a
history), and the therapist must remain sensitive to this situation. Second, some components
of the initial assessment and subsequent treatment may involve palpating the spine (which
usually occurs with the patient lying prone). This scenario potentially limits the opportunities
for demonstrating nonverbal behaviors, such as eye gaze, thereby increasing the need for
skillful verbal communication.

Therefore, we decided to limit the patient population to any adult patients referred to the
physical therapy departments with a diagnosis of low back pain. The duration of back pain
was not specified in the inclusion criteria, and patients were eligible to participate whether or
not their symptoms were referred into the lower limb, as these factors were assumed not to
influence the communication occurring during the interaction. Patients with signs and
symptoms suggesting possible serious spinal pathology were excluded, as were people whose
first language was not English, because of the exploratory nature of the study.

Of the 13 physical therapists (4 men and 9 women) who agreed to take part in the study, 7
female clinicians (2 employed by an acute care hospital and 5 employed by the Primary Care
Trust) successfully recruited patients. Their mean number of years of qualification was 9
(range=0.533 years), with 3 clinicians (43%) at the more experienced (senior I) grade, 3
(43%) at the senior II grade, and 1 (14%) at the least experienced (staff) grade. Twenty-one
patients reporting low back pain were recruited for the study (12 men [57%] and 9 women
[43%]). The mean age of the patients was 48 years (range=2176 years).

Data Collection

To measure communication, it is necessary to directly observe the interaction taking place


between the physical therapist and the patient.26 This interaction can be recorded with either
videotapes or audiotapes, although videotape recording has the advantage of being able to
record nonverbal communication in addition to verbal utterances. Conversely, recording
patients in a state of undress may deter potential participants and could raise ethical issues.
For the purposes of this study, recording nonverbal communication was a priority; therefore,
with express (written) consent from both parties, the interaction between the physical
therapist and the patient was recorded with videotape during the first treatment session
following the initial assessment. This session was chosen because it was a less structured
encounter than the initial assessment but was still early enough in the patient's treatment to
capture the developing therapeutic relationship.

A tripod-mounted Sony camera (model CCD-FX200E/FX270E)* was placed centrally along


the side partition of the treatment cubicle to maximize the view of both the patient and the
clinician as discreetly as possible. Because of ethical constraints, the camera was manually
operated by the researcher, who was present in the treatment cubicle (and confined the
videotape recording to the head and neck of participants throughout the data collection
process).

Following the treatment session, a brief, semistructured interview was undertaken with the
physical therapist to determine the perceived influence of the presence of the manually
operated video camera, in comparison with the therapist's usual practice.

Outcome Measures

Verbal communication.

In order to explore the interaction between the physical therapist and the patient, a validated
outcome measure of verbal communication, the Medical Communications Behavior System
(MCBS), was used.27 The MCBS was developed to measure the communication occurring in
situations involving multiple health care providers27 and has categories for informational
(content), relational (affective), and negative behaviors for both clinicians and patients. These
categories were subdivided further into 13 clinician behaviors, 7 patient behaviors, and 3
miscellaneous categories (Tab. 1). In order to maintain the use of the measure in its original
form, the term behavior was adopted throughout instead of the term communication.

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Table 1.

Examples of Categories Within the Medical Communications Behavior System27

Psychometrically, the interrater reliability of the MCBS, assessed with the Pearson
correlation coefficient, was greater than .70 for all behaviors occurring more frequently than
2% of the time during an observational study of 101 genetic counseling sessions.27 Factor
analysis was done and was found to provide some construct validity, supporting the a priori
organization of the behaviors into informational, relational, and negative behaviors (but with
further subdivisions for informational behaviors).27 In addition, criterion validity has been
determined with the Roter Interaction Analysis System.27

Trends in nonverbal communication.

The frequencies of the 5 nonverbal behaviorsaffirmative head nodding, smiling, eye gaze,
forward leaning, and touchdescribed by Heintzman et al28 were recorded at 40-second
intervals for both the physical therapist and the patient. This outcome measure was developed
in the field of business and was subsequently used by Caris-Verhallen et al6 in the settings of
home nursing and care of older people; the interrater reliability of the nonverbal behaviors
was calculated, using the Pearson correlation coefficient, to be between .70 and .98.

Data Analysis

To determine the content and prevalence of the verbal and nonverbal communications that
occurred between the physical therapists and the patients, the primary analysis involved
classifying the verbal communication by use of the MCBS and measuring the frequencies of
nonverbal behaviors at 40-second intervals. The videotapes were analyzed by a trained,
independent assistant, who classified the verbal utterances into the categories shown in Table
1. An interrater reliability exercise for coding these categories was done by the researcher and
the independent assistant using the Pearson correlation coefficient with 3 pilot therapist-
patient dyads.

In addition to recording the frequencies of the MCBS categories, we recorded the durations
of the treatment sessions in minutes and seconds. Because of variations in the length of the
treatment sessions, the proportion of time that the physical therapist and the patient spent
talking was determined as a percentage for each category.

Analysis of verbal and nonverbal communications was done with descriptive statistics by use
of the Statistical Package for the Social Sciences (SPSS, version 10.0). As before, an
interrater reliability exercise for coding the nonverbal behaviors was done prior to data
collection. The verbatim transcripts of the semistructured interviews were analyzed
independently by the researcher and the assistant, and a thematic analysis was used to
identify emergent themes.

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Results
Duration
At the time of the study, follow-up appointments were usually allocated 20-minute slots.
From the 21 interactions observed between patients and physical therapists, 312 minutes of
videotape were recorded. The mean durations of the treatment sessions were 14 minutes 51
seconds. The minimum duration noted was 8 minutes 26 seconds, and the maximum duration
noted was 31 minutes 45 seconds.

Interrater Reliability of Verbal and Nonverbal Behaviors

During pilot work, good interrater reliability between the researcher and the independent
assistant was demonstrated for both verbal communication (r =.97) and nonverbal
communication (physical therapist r =.98, assistant r =.86).

Verbal Communication

During the 21 sessions analyzed, 2,055 statements were recorded and classified by use of the
MCBS, with a mean of 98 statements per session. Overall, clinicians made approximately
twice as many statements as patients made. Each MCBS category was recorded as a
percentage of the total verbal communication (Tab. 2), demonstrating that overall, content
behaviors represented the highest proportions of verbal communication carried out by both
physical therapists (52%) and patients (26%).

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Table 2.

Medical Communications Behavior System Categories as Percentages of Total


Communicationa

A secondary analysis took into account sex (of patients, given that all physical therapists were
women), seniority (ie, grade of staff), and patients ages. Of these 3 factors, seniority affected
the MCBS categories the most, with the more senior staff members (senior I grade) showing
a higher proportion of physical therapist affective behavior (20%) than the senior II grade
staff members (12%) or the least experienced (staff grade) staff members (12%). The results
of analyses of patients ages and genders were unremarkable.

Nonverbal Communication

The nonverbal behaviors, observed at 40-second intervals during the treatment sessions, are
summarized in Table 3. Among the 468 time points observed, the highest proportions of
nonverbal behavior for the physical therapists were represented by touch (54%) and then by
eye gaze (32%), whereas for the patients, the most frequent nonverbal behavior was eye gaze
(84%).

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Table 3.

Nonverbal Behaviors28,a

Perceived Influence of the Camera on Communication

Although the physical therapists reported that the more times they were videotaped, the easier
they found it to relax, the majority considered that they had decreased the amount of non
physical therapy chat that occurred, in comparison with their usual practice; this finding
resulted in an underrepresentation of this aspect of communication during this study.

Perceived Influence of the Camera on Behavior

As determined by the thematic analysis, 5 of the 7 physical therapists considered that the
presence of the manually operated video camera influenced their behavior. They identified 3
areas of perceived changes in their behavior: the extent of treatment planning beforehand, the
selection of treatment techniques, and a reduction in the amount of time during which the
patient was in a state of undress. With regard to treatment planning, one clinician remarked:
I think that the thought of the video camera makes you think what you are going to include
in the treatment so that you are absolutely clear about what you are going to do in the
treatment session before you go in.

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Discussion
This exploratory study was designed to measure the content and prevalence of the verbal and
nonverbal communications that occur between physical therapists and patients with low back
pain in an outpatient setting. For the 2,055 verbal statements recorded, the ratio was 2:1 in
favor of the physical therapists. This ratio differs from that found in previous research by Ong
et al,29 who reported that, in a doctor-patient oncology setting, patients and doctors
communicated relatively equally during their consultation. The higher percentage of physical
therapist content communication in the present study may have been attributable to the fact
that, after the initial assessment, the first treatment session usually involved giving advice and
information (eg, about posture, ergonomic and lifestyle factors, and other forms of self-
management); discussing psychosocial factors; explaining the risks, benefits, and alternatives
of any treatments offered; gaining consent for any techniques performed; and evaluating their
outcomes. Physical therapists are likely to have longer appointment times than doctors, make
fewer referrals to other health care professionals, and spend more time applying treatments;
these factors may account for the differences between the studies.

Previous research showed that considerable affective behaviors are required for an effective
interaction between a physical therapist and a patient.30 In the present study, these behaviors
were shown to be less common than content behaviors; a possible explanation is that a
considerable amount of advice still was being imparted to the patients during the early
sessions. It is possible that affective behaviors become more prevalent in subsequent sessions,
when the therapeutic relationship is more established; this issue is worthy of further research.
A more likely reason for the underrepresentation of empathic behaviors in the present study,
however, was the presence of the video camera, as the therapists reported that this decreased
the amount of nonclinical communication that occurred. This potential limitation also was
identified in previous studies.31,32 It is not known from the present study what influence the
camera was perceived to have on the patients communication, as this factor was not
measured; this issue is worthy of further research.

Further analysis of the data showed that sex (of the patient) made little difference in the
categories of verbal communication recorded in the present study. From the pool of 4 male
and 9 female physical therapists, only 7 female clinicians successfully recruited patients into
the study. Therefore, it was not possible in the present study to explore the content and
prevalence of interactions involving male clinicians and to compare them with those
involving female clinicians. This is a topic for further research, as other studies showed that,
in general, women (both patients and health care professionals) spoke more during a medical
interaction than men33 and that female-female interactions were likely to result in greater
frequencies of affective communications.34 The present study also showed that experienced
physical therapists demonstrated affective behaviors more readily than their junior
colleagues. A possible explanation is that therapists with less experience often lack
confidence in their clinical abilities and so tend to focus on treatment techniques rather than
on more affective components, such as patients feelings. This notion is supported by the
qualitative work carried out by Jensen et al,35 and such sentiments are likely to be
compounded by the presence of the video camera.

During the 21 treatment sessions observed, the numbers of nonverbal behaviors recorded at
40-second intervals for patients and physical therapists were 40 and 652, respectively (a ratio
of 1:16). Caris-Verhallen et al6 and Ambady et al26 considered that viewing sections of an
interaction is an adequate indication of the interaction as a whole, and in the present study,
468 time points were sampled. The results showed that the physical therapists demonstrated
nonverbal behaviors that facilitated rapport building, such as eye contact and head nodding.
This finding is in accordance with the findings of previous research carried out in the health
care field,6 which suggested that nurses use mainly eye gaze, head nodding, and smiling to
establish a good relationship with their patients.

With regard to touch, Gyllensten et al36 suggested that physical therapists use touch to
positively influence their relationship with patients. Perhaps not surprisingly, the highest
proportion of nonverbal behavior recorded for clinicians in the present study was represented
by touch, a result that may have been expected as a consequence of the hands-on contact that
occurred during physical therapy treatment sessions. Unfortunately, it was not possible to
determine whether therapists used affective, rather than therapeutic, touch to facilitate
relationships with their patients because of the lack of sensitivity in the single category
touch in the outcome measure chosen. Within the nursing literature, the category touch
has been subdivided into 2 categories: instrumental touch, which is defined as deliberate
physical contact necessary to perform a task, and affective or expressive touch, which is
relatively spontaneous and not necessary for the completion of a task.6

In future research measuring interactions within the setting of physical therapy, we


recommend that touch be subdivided into instrumental touch (eg, executing a manual therapy
technique), demonstration (eg, when therapists demonstrate on themselves how to modify an
activity or perform an exercise), and affective touch (eg, making tactile contact with a patient
to offer reassurance). Any changes in the outcome measure would require revalidation prior
to use.

The results also indicated that the physical therapists and the patients demonstrated high
proportions of eye contact (156 and 36 times, respectively). Therapists learn at an
undergraduate level about the importance of body language, in particular, eye contact, which
is reported to promote a favorable treatment outcome.7,37 More specifically, physical
therapists eye contact has been shown to increase patients confidence and demonstrate that
the clinician is interested in the patient's condition.37 During the treatment of patients with
low back pain, however, maintaining eye contact and building this confidence may become
problematic if the patients spend a significant amount of time lying prone. Further
underreporting of nonverbal behaviors in the present study may have arisen because of the
presence of the researcher and the video camera and, on a practical level, it was not always
possible to observe both the clinician and the patient simultaneously with a single video
camera.

Although the present study showed that aspects of verbal and nonverbal communications can
be measured with video analysis and validated outcome measures, a number of limitations
were evident. The background noise within the department, coupled with the divergent
positioning of patients and physical therapists, may have resulted in some underreporting of
communications. The use of 2 microphones helped to minimize this problem; however,
multiple wall-mounted cameras would have been preferable but were not permitted for
ethical reasons.

Previous studies acknowledged the importance of recording both the verbal and the nonverbal
behaviors that occur during an interaction; however, few authors attempted to do so,6
especially within the setting of physical therapy.3 Although the outcome measures chosen for
the present study had not been used previously in such a setting, they were able to effectively
record the content and prevalence of verbal and nonverbal behaviors that occurred. Despite
being able to measure these aspects of communication, however, they were not able to
determine sequences or patterns of communication; this is a topic for further research. In
addition, the most prevalent category in the MCBS tool lacked sensitivity. In future studies, it
would be advantageous to subdivide the verbal content category into offering advice (such
as when modifying an activity) and giving instruction (such as when teaching an exercise),
as the balance of power may be perceived differently during these interactions. Any such
modifications would need to be validated against the original MCBS.

The methods used in the present study for recording the prevalence and content of verbal and
nonverbal communications could be applied to further research (eg, mapping of entire care
episodes). In the present study, we considered only the first follow-up appointments for
patients with low back pain; however, it would be important to consider the initial assessment
as well as subsequent treatments to record the content of the interactions as the relationship
develops. Once this baseline is established, research can be extended to include issues of
culture and patients needs and expectations, as their effect on communication is largely
unknown.

In clinical practice, recording initial assessments (with express consent) can provide valuable
information and material for reflection, helping to identify communication skills and
strategies and the impact that they appear to have on patients.38 Such reflection is important
because communication is a skill and, like all skills, it requires practice to be performed
well.39

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Conclusion
In the present study, we explored an area of physical therapist practice that is universally
regarded as extremely important but is underrepresented within the health care literature. It
has been shown that it is possible to reliably record the prevalence and content of verbal and
nonverbal communications with video analysis and valid tools, such as the MCBS and the
positive nonverbal behaviors of Heintzman et al.28 Although the physical therapists in the
present study perceived that the presence of the camera (operated by the researcher)
influenced their behavior and communication, this influence became less of an issue the more
times they were recorded on videotape.

The methods described here could be used in future research to further explore the patient-
therapist relationship (eg, mapping of entire care episodes, patterns of communication, and
issues such as sex and culture). Once the content of a physical therapy encounter is
established, the next challenge is to use communication skills that maximally enhance
treatment outcomes. As part of this process, video analysis could be used for teaching
purposes to provide feedback to clinicians to improve their communication skills, maximize
the nonspecific treatment effects, and improve the patient's experience.

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Footnotes
Both authors provided concept/idea/research design and writing. Mrs Bucksey
provided data collection and analysis and fund procurement, Dr Roberts provided
project management and institutional liaisons. The authors acknowledge Sue High,
Department of Social Statistics, Southampton University, for statistical advice; the
physical therapy outpatient staff at Stoneham Centre, Southampton City PCT; and
financial support from the Arthritis and Rheumatism Campaign and the Chartered
Society of Physiotherapy.
This work was presented at the 14th International Congress of the World
Confederation for Physical Therapy; June 712, 2003; Barcelona, Spain.
Ethical approval for this study was granted by the Southampton and South West Local
Research Ethics Committee.
* Sony Corp, Pipers Way, Thatcham, Berkshire, United Kingdom RG19 4LZ.

SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

Received March 9, 2006.

Accepted January 8, 2007.

Physical Therapy
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