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4
Defining Cognitive
Rehabilitation Therapy
In the early part of the 20th century, improvements and advancements
in medical care, protective gear, evacuation procedures, and early stabili-
zation in the field began to contribute to the increased survival of brain
injured soldiers, enabling even severely injured individuals to survive and
attempt to recover from brain injuries. To enhance recovery of brain injury
survivors, clinicians and researchers saw the need to provide cognitive as
well as physical rehabilitation. They developed a range of therapies for
patients with nontraumatic brain injuries, such as stroke, that causes lan-
guage (aphasia) or visuospatial skill impairments. Likewise, for traumatic
brain injury (TBI), clinicians and researchers developed a range of therapies
for attention, memory, and executive function impairments; treatments for
social and behavioral problems; and programs for adjusting to disability.
THE BREADTH OF REHABILITATION
In broad terms, rehabilitation principally focuses on the enhancement
of human functioning and quality of life. In contrast, other branches of
health care focus primarily on prevention and treatment of disease. Re-
habilitation accepts the complex correspondence between disease and the
ability to function: a disease may be eradicated while disability remains;
disability can be reduced in the face of permanent injury or chronic disease.
Rehabilitation is often considered in regard to improving physical disabili-
ties. For a person with paralysis, rehabilitation might examine whether the
individual’s strength could be improved through exercise, whether the ten-
dons of nonparalyzed muscles could be surgically transferred to a mechani-
75
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76 COGNITIVE REHABILITATION THERAPY FOR TBI
cally useful site, whether braces or a wheelchair might allow the person to
navigate the community despite the paralysis, and even whether architec-
tural modifications, urban planning, or transportation services could help
overcome barriers to mobility. The treatment interventions used in physical
rehabilitation include traditional drug and surgical treatments, as well as
physical exercise, technology (e.g., braces, wheelchairs), skill training (e.g.,
learning how to use a wheelchair), and social policies and services (e.g.,
accessible transportation).
However, rehabilitation is not limited to improving physical disability.
Cognitive rehabilitation attempts to enhance functioning and independence
in patients with cognitive impairments as a result of brain damage or dis-
ease, most commonly following TBI or stroke. As with physical rehabilita-
tion, cognitive rehabilitation may include interventions that aim to lessen
impairments, or interventions that aim to lessen the disabling impact of
those impairments. Interventions are applied through technology and other
compensatory strategies that may allow the individual with cognitive im-
pairment to accomplish important life activities and more fully participate
in society.
Cognitive rehabilitation therapy (CRT) may sometimes be confused
with cognitive behavioral therapy. It is important to distinguish between
the two. While not mutually exclusive and sometimes delivered conjointly,
these two therapies are certainly separate and distinct, differing in both
treatment goals and techniques. CRT is used to rehabilitate thinking skills
(e.g., attention, memory) impaired by a brain injury. Cognitive behavioral
therapy is commonly used for a variety of emotional and psychiatric dis-
orders, including mood, anxiety, and psychotic disorders, as well as sleep
disturbance and chronic pain. Cognitive behavioral therapy typically cen-
ters on modifying maladaptive thoughts and emotional behaviors and using
psychoeducation regarding symptoms and expectations for recovery. The
latter technique also may be a component of CRT. Cognitive behavioral
therapy includes training in anxiety management and how to recognize and
reappraise distorted negative thoughts, and, for some disorders, exposure
to anxiety-provoking or distressing stimuli with the intent of forming new
adaptive emotional associations with the feared stimuli. The 2008 Institute
of Medicine (IOM) report, Treatment of Posttraumatic Stress Disorder: An
Assessment of the Evidence, provides a more comprehensive description of
cognitive behavioral therapy.
The breadth of treatments included in CRT mirrors that of the World
Health Organization’s International Classification of Functioning, Disabil-
ity, and Health (WHO-ICF). As described in Chapter 1, the WHO-ICF
framework recognizes impairments in body structures and functions (e.g.,
impaired memory) as a result of disease or injury, and limitations in activi-
ties and participation, i.e., the ability to carry out important daily activities
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DEFINING COGNITIVE REHABILITATION THERAPY
(e.g., remembering weekly appointments) and the ability to participate in
society (e.g., employment, home, school, or community). Activity and par-
ticipation limitations result when the person with the impairment(s) inter-
acts with the physical and social environment. For example, an individual
with TBI may have difficulty learning and remembering new information.
With repeated training, the individual may be able learn some basic rou-
tines, such as writing appointments and other important information down
in a daily planner and consulting it frequently. These routines enable the
person to keep track of a schedule and other important tasks despite mem-
ory impairment. Several professional organizations endorse the use of the
WHO-ICF for characterizing CRT, including the American Occupational
Therapy Association, the American Physical Therapy Association, and the
American Speech-Language-Hearing Association (American Occupational
Therapy Association 2011; American Physical Therapy Association 2003;
American Speech-Language-Hearing Association 2003b).
AN EVOLVING DEFINITION OF CRT
Specific cognitive and communication needs of patients with brain
injury propelled the parallel development of CRT within multiple profes-
sional disciplines, including clinical psychology, neuropsychology, speech-
language pathology, occupational therapy, physical therapy, and physiatry
(i.e., rehabilitation medicine) (Prigatano 2005). Collaboration with aca-
demic colleagues in other disciplines such as cognitive psychology also oc-
curred. The various disciplines share a common goal: each intends to help
patients with cognitive impairments function more fully, either by focusing
on the impairment itself or the activities affected by the impairment (as de-
scribed by the WHO-ICF framework). Chapter 5 provides full descriptions
of the disciplines and providers of CRT, and their approaches to treatment.
The heterogeneity of the possible interventions makes it challenging to
narrowly define the concept of CRT, or how to effectively apply it. Current
definitions of CRT focus on the intention to improve or accommodate one
or more impaired cognitive functions, rather than on the contents or active
ingredients of treatment. Intentional definitions can limit the interpretation
of CRT evidence since treatment efficacy and effectiveness depend more on
the contents and processes of treatment than the intention of the clinician
providing it. Table 4-1 includes assembled definitions of CRT based on
intent.
The most commonly referenced definition of CRT is interdisciplin-
ary, endorsed by the Brain Injury Interdisciplinary Special Interest Group
(BI-ISIG) of the American Congress of Rehabilitation Medicine (ACRM).
This description allows for comprehensive, interdisciplinary rehabilitation
programs with interventions to restore or reorganize function, compensate
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78 COGNITIVE REHABILITATION THERAPY FOR TBI
TABLE 4-1 Definitions of Cognitive Rehabilitation Therapy by
Organization
Organization Definition
Brain Injury “Cognitive rehabilitation is a systematically applied set of medical
Association of and therapeutic services designed to improve cognitive functioning
America and participation in activities that may be affected by difficulties
in one or more cognitive domains. . . . Cognitive rehabilitation is
often part of comprehensive interdisciplinary programs” (Katz et al.
2006).
Brain Injury “Cognitive rehabilitation is a systematic, functionally oriented
Interdisciplinary service of therapeutic cognitive activities, based on an assessment
Special Interest and understanding of the person’s brain-behavior deficits. Services
Group (BI-ISIG) are directed to achieve functional changes by (1) reinforcing,
strengthening, or reestablishing previously learned patterns of
behavior, or (2) establishing new patterns of cognitive activity or
compensatory mechanisms for impaired neurological systems”
(Harley et al. 1992).
U.S. Veterans “Cognitive rehabilitation is one component of a comprehensive
Administration (VA) brain injury rehabilitation program. It focuses not only on the
specific cognitive deficits of the individual with brain injury, but also
on their impact on social, communication, behavior, and academic/
vocational performance. Some of the interventions used in cognitive
rehabilitation include modeling, guided practice, distributed
practice, errorless learning, direct instruction with feedback,
paper-and-pencil tasks, communication skills, computer-assisted
retraining programs, and use of memory aids. The interventions
can be provided on a one-on-one basis or in a small group setting”
(Benedict et al. 2010).
for impaired function through new cognitive patterns or external devices,
and enable individuals to adapt to their new level of functioning. CRT may
target specific cognitive domains (e.g., attention, reasoning, planning), and
may be delivered in various contexts.
Differences across definitions of CRT are based on theoretical differ-
ences regarding the underlying cognitive mechanisms that result in behav-
ioral changes. The Brain Injury Association of America, the largest U.S.
advocacy organization for individuals with brain injury, summarizes this
issue: “Theoretical models of cognitive rehabilitation vary along several
different dimensions. Treatments may be process specific, focused on im-
proving a particular cognitive domain such as attention, memory, language,
or executive functions. Alternatively, treatments may be skill-based, aimed
at improving performance of particular activities. The overall goal may
be restoring function in a cognitive domain or set of domains or teaching
compensatory strategies to overcome domain specific problems, improving
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DEFINING COGNITIVE REHABILITATION THERAPY
performance of a specific activity, or generalizing to multiple activities”
(Katz et al. 2006).
CRT Attributes
This section includes descriptions of the key distinctions within CRT,
which may be useful in clarifying the contents of treatment and analyzing
efficacy for different types of patients. These dichotomies include modular
versus comprehensive, restorative versus compensatory, and contextualized
versus decontextualized treatments. These dichotomies are not mutually
exclusive categories by which to classify CRT treatments; they serve as
important distinctions at understanding underlying cognitive processes and
ways providers have attempted to treat cognitive deficits. These approaches
to CRT evolved somewhat differently, from different philosophical per-
spectives and for different purposes, such as treating focal versus diffuse
injuries, although considerable overlap exists. Focal brain injuries, such as
stroke or brain tumors, may result in one or a small number of cognitive
impairments and largely spare other cognitive processes. In contrast, diffuse
(i.e., multifocal) brain injuries resulting from trauma often result in multiple
cognitive and behavioral impairments. Hence, an emphasis on interdisci-
plinary CRT for individuals with TBI is warranted.
Modular Versus Comprehensive Treatments
In modular models of CRT, treatments are generally aimed at a single
cognitive impairment, such as memory (“memory remediation”) or lan-
guage (“aphasia therapy”). Such treatments, when delivered alone, might
be expected to enhance activities and participation most effectively in
patients with a single or predominant impairment (i.e., patients with a
more focal impairment). In contrast, patients with multiple impairments
(i.e., deficits in attention and memory, along with impulsivity and depres-
sion) may receive a comprehensive program also referred to as “holistic,”
“multi-modal,” or “neuropsychological rehabilitation.” Comprehensive
programs typically contain a mix of modular treatments that target specific
cognitive impairments, treatments that address self-awareness of the impact
of cognitive deficits, and individual or group therapies that facilitate coping
with residual deficits and their social consequences. For example, a com-
prehensive program for patients with moderate or severe TBI might begin
with a comprehensive neuropsychological assessment, along with a patient
and family interview of current difficulties in activities, social behavior,
and mood. From this assessment, certain patient-specific modules might
be selected. Consider a female patient who frequently becomes stalled in
complex tasks and often forgets appointments and commitments. She might
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80 COGNITIVE REHABILITATION THERAPY FOR TBI
receive specific individualized treatment focusing on task-related problem
solving, along with training in the effective use of a daily planner. In addi-
tion, she might participate in daily group discussions with other patients
about the ways in which their lives have changed; group members receive
feedback and support for their attempts to cope with and adapt to those
life changes. She might also receive individual psychotherapy to address
depression, along with periodic joint sessions with her husband to help him
understand the sources of her unreliability as well as address his own sense
of the loss of his familiar partner. Specific adaptations of CRT for patients
with TBI reflect the domains most commonly impaired, notably attention,
memory, social communication, and executive function. Figures 4-1 and 4-2
illustrate the differences and overlap in these dichotomies.
Restorative Versus Compensatory Treatments
Restorative treatments are aimed directly at improving, strengthening,
or normalizing specific impaired cognitive functions. Such treatments fre-
quently have an “exercise-like” aspect in that they may involve intensive
and repetitive use of a particular cognitive process while gradually increas-
ing the level of difficulty or the processing demands. Patients with attention
deficits may, for example, be provided with a series of computer tasks that
require detection of targets on the screen at an increasing pace. Such tasks
may increase in difficulty along a number of dimensions (e.g., pacing, to
focus on speeded processing, or task duration, to focus on sustained at-
tention), and the difficulty along each dimension increases as performance
improves.
Compensatory treatments, in contrast, seek to provide alternative strat-
egies for carrying out important activities of daily living despite residual
cognitive impairment. The compensations may be internal, as when a
person with memory impairment learns mental strategies for organizing
material for better recall (e.g., learning to group items to be remembered
in categories as an aide to retrieval), or external, as when such a person
adopts the use of electronic reminder technology. Compensatory treatments
are typically more tailored to specific needs of the individual, to the person’s
willingness to use the strategy, and to the demands of specific activities. For
example, strategies for remembering a list of groceries are likely to differ
from strategies for retaining class material at school. In both cases, writing
may be used (a grocery list versus taking notes), but the form may differ.
Paper and pencil may be sufficient for a grocery list, but taking notes may
need to be supplemented by audio recordings of the lecture.
There is debate over whether true restoration ever occurs or whether
the behavioral improvements simply become more like the norm and thus,
less visible. Because there is no “window into the brain,” it is difficult to
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Modular Potential Mediators
CRT and Moderators of
Modular CRT
Outcomes:
Effectiveness
Post-Acute TBI Change Due to Participation in
Impairment in Modular CRT Personal factors Society;
§ Age
Cognitive Function Restorative: Quality of Life
Outcome:
§ Coping
Lessening of
Activities
§ Extent and type of Improvements
impairment in a
Impaired Cognitive
comorbidities and in:
Improvement
specific, targeted
Domain
their treatment § Employment
domain (e.g., in ability to
Attention
§
§ Substance abuse status
carry out
improved attention)
Language and
§
§ Awareness of deficit* § Role in the
important
communication
home
AND/OR daily activities
Memory
§
Environment § Educational
in the person’s
Visuospatial
§ Compensatory: § Social support attainment
physical and
perception Lessening of § Disability supports/ § Community
social
Executive function
§ disabling impact of service status participation
environment
impaired cognitive § Transportation access § Quality of life
domain, through § Family/
specific Adeguacy/quality of caregiver
compensatory delivery of the CRT health
strategies or intervention
technologies § Appropriately trained
providers
§ Standardized manuals
and equipment/
facilities
FIGURE 4-1 Model for modular CRT.
* For some domains, the CRT intervention may also target deficit awareness; for example, videotape of a social interaction followed
F igure 4-1 Broadside
81
by a critique will increase awareness of deficit in language and communication.
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Potential Mediators
82
Comprehensive
and Moderators of
CRT
Comprehensive
CRT Effectiveness
Change Due to Outcomes:
Comprehensive Personal factors Participation in
Post-Acute TBI § Age
CRT Society;
§ Coping
Impairments Outcomes:
Restorative: Quality of Life
§ Extent and type of
Lessening of Activities
physical comorbidities Improvements
Impaired Cognitive impairment in one or Improvement
and symptoms* and in:
Domain more cognitive in ability to
their treatment quality § Employment
§ Attention domains carry out
§ Substance abuse status
§ Language and
important § Role in the
communication
daily activities
AND/OR Environment home
§ Memory
in the person’s
§ Social support § Educational
§ Visuospatial
physical and
Compensatory: § Disability supports/ attainment
perception
social
§ Lessening of service status § Community
§ Executive function
disabling impact environment
§ Transportation access participation
of one or more § Quality of life
impaired Adeguacy/quality of and well-
cognitive domains delivery of the being
Deficit awareness
§ Increase in deficit comprehensive CRT § Family/
awareness intervention caregiver
§ Appropriately trained health
Psychological co- AND/OR
providers
morbidity:
§ Standardized manuals
§ Fatigue Reduction in
and equipment/
symptoms of
§ Anxiety
facilities
psychological co-
§ Depression
morbidity
§ PTSD
Interference among
treatment components**
FIGURE 4-2 Model for multi-modal/comprehensive CRT.
* For example: visual impairment, headache, dizziness.
** For example: side effect of medication for depression interferes with attention.
F igure 4-2 Broadside
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DEFINING COGNITIVE REHABILITATION THERAPY
determine if restoration of a cognitive process is possible. The ability to
translate a treatment task to real-world applications is largely dependent
on the circumstances of the individual with cognitive deficits. The lure of
restorative approaches is that, if effective, they could impact a broad range
of activities affected by the same impairment. For example, if attention
capacity can truly be restored, then all of the activities suffering from inat-
tention would likely improve. Compensatory strategies tend to be designed
around important activities rather than around the impairment itself and,
therefore, tend to be more local solutions. However, the impact of compen-
satory strategies may be more visible, since task accomplishment serves as
direct evidence of the success of the strategy.
Contextualized Versus Decontextualized Treatments
CRT interventions also differ in the degree to which they take place in
the real world or use materials and tasks from the patient’s everyday life.
Decontextualized assessment and treatment targets specific cognitive pro-
cesses often using artificial treatment tasks, such as pressing a key when a
computer presents a number but not a letter. This artificial task attempts
to enhance attention. Another artificial task is repeating words in lists of
increasing length in attempt to improve working memory span. Decontex-
tualized approaches provide more opportunity for pure manipulation of a
single dimension, on the assumption that specific cognitive processes can
be isolated and treated somewhat independently from each other. However,
attempting to train attention during a cooking task may reveal obstacles
related to manual coordination in slicing and chopping, planning and se-
quencing of the cooking steps, and reading the instructions (Adamovich
1998; Sohlberg and Mateer 2001).
Contextualized therapy addresses cognitive impairments as they dis-
rupt activities and skills in various milieus (American Speech-Language-
Hearing Association 2003a; Hartley 1995; Ylvisaker and Feeney 1998).
For example, a contextualized treatment may include a focus on driving to
observe the occasions in which the patient appears to be distracted from
the driving task, allowing for an opportunity to provide specific feedback
about how to manage these difficulties (e.g., “When you approach an in-
tersection, you should stop talking to your passenger.”). It has been argued
that contextualized treatments that occur within a familiar environment, or
deal with personally important tasks, are likely to enhance motivation for
treatment, improve self-awareness of strengths and weaknesses, and ensure
that the strategies learned are applicable to the patient’s personal situation.
However, such treatments are more cumbersome to deliver than those based
on standardized materials that can be delivered in a clinic or office.
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84 COGNITIVE REHABILITATION THERAPY FOR TBI
Contextualized treatments also are more difficult to evaluate, standard-
ize, and disseminate because doing so requires the therapist to have the
skills necessary to design and execute them, and generally requires more
availability/effort from the patient. A decontextualized attention training
program can be a specific computer program with internal rules for task
progression, which is disseminated in standard form. In contrast, contextu-
alized attention training would be an approach to finding out what activi-
ties are most disrupted by inattention from the individual patient, how to
simplify those activities during training, and how to assess progress.
Application of CRT Attributes
Attributes of CRT are not mutually exclusive options, and various at-
tributes can be combined in a multitude of ways. Modular treatments, for
example, can be aimed at either restoration or compensation. One treat-
ment might consist of a hierarchical set of “attention exercises” designed to
strengthen attentional capacities. Alternatively, one might provide compen-
sations such as unpredictable auditory tones to alert an inattentive patient,
training the patient to ask a speaker to repeat a point, or having the patient
work in a quiet environment. Comprehensive programs may contain a mix
of both restorative and compensatory treatment types. Modular treatments
can also be either contextualized or decontextualized. As noted, modular
treatments aimed at restoration, in particular, are likely to be decontextu-
alized, in that they may seek to abstract the essence of a cognitive process
from its natural context to more tightly focus the treatment. Compensatory
modular treatments, however, such as training in memory strategies, are
often applied to the real-world activities the patient faces.
Implications of CRT Attributes on Treatment and Research
Practitioners and researchers acknowledge that the ultimate goal of
treatment should be functionally meaningful improvements in the patient
(i.e., activities, participation, or quality of life), and there may be many ap-
proaches to reaching this goal (Sohlberg and Mateer 2001). A one-size-fits-
all method of treatment may not be effective because of the heterogeneity
of injuries, differences in premorbid personal, social, and environmental
circumstances, and differences in the activities of importance to individual
patients. Heterogeneity of TBI further complicates studies of CRT impact
and may mask benefit in subgroups that the study cannot detect due to
small sample size or other limitations in study design.
In general, CRT attributes may shape expectations about the types of
possible treatment outcomes and the types of patients most likely to benefit,
and therefore may be useful for clinical reasoning; however, rehabilitation
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DEFINING COGNITIVE REHABILITATION THERAPY
professionals often use a variety of therapy approaches, providing interven-
tions that target activities and participation while systematically address-
ing the underlying cognitive impairment(s). For example, individuals may
benefit from intensive practice of memory encoding strategies (modular,
decontextualized, compensatory) to bolster remembering new information,
while also practicing applying these strategies to various types of material
and in various contexts (modular, contextualized, compensatory). Alterna-
tively, a modular treatment may not have substantial impact on activities
and participation in a patient with multiple impairments unless other co-
existing cognitive and emotional factors are concurrently addressed, as in
a comprehensive program. Likewise, a contextualized, compensatory treat-
ment may not restore an underlying cognitive impairment or even impact
behavior change in an environment beyond where the strategy was taught.
These treatment attributes also affect the feasibility and design of
research that might advance the evidence regarding CRT. For patients
with multifocal or diffuse injuries, evaluation of the effectiveness of CRT
in terms of real clinical impact faces a particular challenge. Even highly
efficacious modular treatments may have impact on specific measures of
the targeted impairment, but may fail to show improvement in real-world
activities, participation, or quality of life. For example, if attention can be
substantially improved in a patient who still has memory deficits, difficulty
solving problems, and inappropriate social behavior, this may have little
impact on employment or the development of social relationships. Com-
prehensive treatment programs, by targeting multiple impairments as well
as skills for coping with residual impairments, may have more substantial
life impact, but they provide no insight into the necessary or sufficient in-
gredients for a successful treatment outcome.
These attributes also affect the experimental designs that are most ap-
plicable and feasible for advancing the science of CRT. Specifically, modular
restorative treatments are relatively amenable to randomized controlled tri-
als (RCTs). In an RCT, therapists can design similar appearing treatments
that differ in the active ingredients and deliver one treatment or the other
at random to research subjects. For example, to assess whether “continued
attention deficits” is a critical attention challenge, a study may compare a
program with static attention exercises with a progressive program that
advances with patient improvement.
RCTs involving comprehensive treatments are more difficult to design
and execute, because of the need to distill a multifaceted treatment, often
individually tailored, into standard form. A study evaluating comprehen-
sive treatment programs ideally will include a manual specifying the rules
that link assessment to selection of specific treatment elements, and how
those elements will be advanced or tailored to individual performance. It
is difficult to deliver a control treatment in this case, since plausible but
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86 COGNITIVE REHABILITATION THERAPY FOR TBI
inert treatments of a compensatory nature are modified to the person or
environment and are more likely to be tailored to each patient’s specific task
priorities. Furthermore, such treatment programs are expensive to provide
without clinical revenue, which would preclude intentionally designing an
ineffective comparison treatment.
CONCLUSION
CRT is an umbrella term for a group of interventions that are used to
support or ameliorate cognitive impairments, as well as the changes that
occur in everyday functioning as a result of these impairments. Patients with
TBI often have multiple identifiable cognitive impairments, coupled with
mood or other behavioral disturbances, a reduced awareness of their own
cognitive and behavioral limitations, and reductions in social competence.
Although some patients with isolated impairments may achieve substantial
treatment benefits in terms of activities and participation from treatment
of a single deficit, others may require a combination of treatments aimed
at multiple problems to achieve comparable outcomes. The heterogeneous
array of treatments available, as well as the lack of a unified theoretical
framework for defining and quantifying them, makes definitive evaluation
of their effectiveness particularly challenging.
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