Electrocortical Analysis of Patients with Intercostobrachial Pain Treated with TENS after Breast Cancer Surgery
Identifieur interne : 004116 ( Pmc/Corpus ); précédent : 004115; suivant : 004117Electrocortical Analysis of Patients with Intercostobrachial Pain Treated with TENS after Breast Cancer Surgery
Auteurs : Julio Guilherme Silva ; Camila Gonçalves Santana ; Kelly Rosane Inocêncio ; Marco Orsini ; Sergio Machado ; Anke BergmannSource :
- Journal of Physical Therapy Science [ 0915-5287 ] ; 2014.
Abstract
[Purpose] Among the physical therapeutic procedures to decrease pain, there is transcutaneous electrical neural stimulation (TENS). There is no consensus about its efficacy for oncological patients, especially for post-mastectomy pain and eletrocortical changes in somatosensory areas. The aim of this study was to analyze acute electrocortical changes after TENS treatment of patients with intercostobrachial post mastectomy pain. [Subjects] Eighteen patients were divided into acupuncture (A) and burst (B) group. [Methods] In this pre and post-intervention study each group was measured for EEG analysis in absulte power in alpha band (8–14 Hz). Outcomes variables were the alpha waveband in the sensorymotor cortex and pain pre-and-post TENS intervention. Data were analyzed using ANOVA to compare times (rest, 10 and 15 min), group and electrodes. Pain was analyzed using percentual pain evaluation (PPE) in both groups. [Results] Outcomes indicate main effects of time and electrodes because of slow (8–10 Hz) and fast alpha (10–12 Hz) wavebands decreased. PPE reduced 88.4% in A and 66.3% in G. [Conclusion] TENS promoted electrical modification in the parietal region and a decrease in pain. Future studies should investigate other wave must be proposed for other bands and use different methods of EEG analysis to elucidate the actual mechanisms behind the efficacy of TENS treatment.
Url:
DOI: 10.1589/jpts.26.349
PubMed: 24707082
PubMed Central: 3976001
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PMC:3976001Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Electrocortical Analysis of Patients with Intercostobrachial Pain Treated
with TENS after Breast Cancer Surgery</title><author><name sortKey="Silva, Julio Guilherme" sort="Silva, Julio Guilherme" uniqKey="Silva J" first="Julio Guilherme" last="Silva">Julio Guilherme Silva</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Santana, Camila Goncalves" sort="Santana, Camila Goncalves" uniqKey="Santana C" first="Camila Gonçalves" last="Santana">Camila Gonçalves Santana</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Inocencio, Kelly Rosane" sort="Inocencio, Kelly Rosane" uniqKey="Inocencio K" first="Kelly Rosane" last="Inocêncio">Kelly Rosane Inocêncio</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Orsini, Marco" sort="Orsini, Marco" uniqKey="Orsini M" first="Marco" last="Orsini">Marco Orsini</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Machado, Sergio" sort="Machado, Sergio" uniqKey="Machado S" first="Sergio" last="Machado">Sergio Machado</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Bergmann, Anke" sort="Bergmann, Anke" uniqKey="Bergmann A" first="Anke" last="Bergmann">Anke Bergmann</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24707082</idno><idno type="pmc">3976001</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3976001</idno><idno type="RBID">PMC:3976001</idno><idno type="doi">10.1589/jpts.26.349</idno><date when="2014">2014</date><idno type="wicri:Area/Pmc/Corpus">004116</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">004116</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Electrocortical Analysis of Patients with Intercostobrachial Pain Treated
with TENS after Breast Cancer Surgery</title><author><name sortKey="Silva, Julio Guilherme" sort="Silva, Julio Guilherme" uniqKey="Silva J" first="Julio Guilherme" last="Silva">Julio Guilherme Silva</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Santana, Camila Goncalves" sort="Santana, Camila Goncalves" uniqKey="Santana C" first="Camila Gonçalves" last="Santana">Camila Gonçalves Santana</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Inocencio, Kelly Rosane" sort="Inocencio, Kelly Rosane" uniqKey="Inocencio K" first="Kelly Rosane" last="Inocêncio">Kelly Rosane Inocêncio</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Orsini, Marco" sort="Orsini, Marco" uniqKey="Orsini M" first="Marco" last="Orsini">Marco Orsini</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Machado, Sergio" sort="Machado, Sergio" uniqKey="Machado S" first="Sergio" last="Machado">Sergio Machado</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Bergmann, Anke" sort="Bergmann, Anke" uniqKey="Bergmann A" first="Anke" last="Bergmann">Anke Bergmann</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Physical Therapy Science</title><idno type="ISSN">0915-5287</idno><idno type="eISSN">2187-5626</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p> [Purpose] Among the physical therapeutic procedures to decrease pain, there is
transcutaneous electrical neural stimulation (TENS). There is no consensus about its
efficacy for oncological patients, especially for post-mastectomy pain and eletrocortical
changes in somatosensory areas. The aim of this study was to analyze acute electrocortical
changes after TENS treatment of patients with intercostobrachial post mastectomy pain.
[Subjects] Eighteen patients were divided into acupuncture (A) and burst (B) group.
[Methods] In this pre and post-intervention study each group was measured for EEG analysis
in absulte power in alpha band (8–14 Hz). Outcomes variables were the alpha waveband in
the sensorymotor cortex and pain pre-and-post TENS intervention. Data were analyzed using
ANOVA to compare times (rest, 10 and 15 min), group and electrodes. Pain was analyzed
using percentual pain evaluation (PPE) in both groups. [Results] Outcomes indicate main
effects of time and electrodes because of slow (8–10 Hz) and fast alpha (10–12 Hz)
wavebands decreased. PPE reduced 88.4% in A and 66.3% in G. [Conclusion] TENS promoted
electrical modification in the parietal region and a decrease in pain. Future studies
should investigate other wave must be proposed for other bands and use different methods
of EEG analysis to elucidate the actual mechanisms behind the efficacy of TENS
treatment.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Tiezzi, Dg" uniqKey="Tiezzi D">DG Tiezzi</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Bevilacqua, Jl" uniqKey="Bevilacqua J">JL Bevilacqua</name></author><author><name sortKey="Kattan, Mw" uniqKey="Kattan M">MW Kattan</name></author><author><name sortKey="Changhong, Y" uniqKey="Changhong Y">Y Changhong</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Fabro, Ea" uniqKey="Fabro E">EA Fabro</name></author><author><name sortKey="Bergmann, A" uniqKey="Bergmann A">A Bergmann</name></author><author><name sortKey="Amaral E Silva, B" uniqKey="Amaral E Silva B">B Amaral-e-Silva</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Jung, Bf" uniqKey="Jung B">BF Jung</name></author><author><name sortKey="Ahrendt, Gm" uniqKey="Ahrendt G">GM 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Phys Ther Sci</journal-id><journal-id journal-id-type="iso-abbrev">J Phys Ther Sci</journal-id><journal-id journal-id-type="publisher-id">JPTS</journal-id><journal-title-group><journal-title>Journal of Physical Therapy Science</journal-title></journal-title-group><issn pub-type="ppub">0915-5287</issn><issn pub-type="epub">2187-5626</issn><publisher><publisher-name>The Society of Physical Therapy Science</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24707082</article-id><article-id pub-id-type="pmc">3976001</article-id><article-id pub-id-type="publisher-id">jpts-2013-381</article-id><article-id pub-id-type="doi">10.1589/jpts.26.349</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original</subject></subj-group></article-categories><title-group><article-title>Electrocortical Analysis of Patients with Intercostobrachial Pain Treated
with TENS after Breast Cancer Surgery</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Silva</surname><given-names>Julio Guilherme</given-names></name><degrees>PhD, PT</degrees><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref rid="cor1" ref-type="corresp"><sup>*</sup></xref></contrib><contrib contrib-type="author"><name><surname>Santana</surname><given-names>Camila Gonçalves</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Inocêncio</surname><given-names>Kelly Rosane</given-names></name><xref ref-type="aff" rid="aff3"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Orsini</surname><given-names>Marco</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Machado</surname><given-names>Sergio</given-names></name><xref ref-type="aff" rid="aff4"><sup>4</sup></xref><xref ref-type="aff" rid="aff5"><sup>5</sup></xref></contrib><contrib contrib-type="author"><name><surname>Bergmann</surname><given-names>Anke</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref ref-type="aff" rid="aff6"><sup>6</sup></xref></contrib><aff id="aff1"><label>1)</label> Department of Physical Therapy, Federal University of Rio de Janeiro (UFRJ), Brazil</aff><aff id="aff2"><label>2)</label> Rehabilitation Science Masters Program, Augusto Motta University Center (UNISUAM), Brazil</aff><aff id="aff3"><label>3)</label> Municipal Rehabilitation Center (CMR), Department of Physical Therapy in Oncology, Brazil</aff><aff id="aff4"><label>4)</label> Panic and Respiration Laboratory, Institute of Psychiatry, Federal University of Rio de Janeiro (UFRJ), Brazil</aff><aff id="aff5"><label>5)</label> Quiropraxia Program, Central University, Chile</aff><aff id="aff6"><label>6)</label> National Cancer Institute (INCA), Brazil</aff></contrib-group><author-notes><corresp id="cor1"><label>*</label>Corresponding author. Julio Guilherme Silva, Rehabilitation Science Masters Program, Augusto Motta
University Center (UNISUAM): Praça das Nações, n° 34 − 3° andar. Bonsucesso, Rio de
Janeiro, CEP 21.041-021, Brazil. (E-mail:
<email xlink:href="jglsilva@yahoo.com.br">jglsilva@yahoo.com.br</email>)</corresp></author-notes><pub-date pub-type="epub"><day>25</day><month>3</month><year>2014</year></pub-date><pub-date pub-type="ppub"><month>3</month><year>2014</year></pub-date><volume>26</volume><issue>3</issue><fpage>349</fpage><lpage>353</lpage><history><date date-type="received"><day>13</day><month>8</month><year>2013</year></date><date date-type="accepted"><day>22</day><month>9</month><year>2013</year></date></history><permissions><copyright-statement>2014©by the Society of Physical Therapy Science</copyright-statement><copyright-year>2014</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/"><license-p>This is an open-access article distributed under the terms of the Creative
Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License. </license-p></license></permissions><abstract><p> [Purpose] Among the physical therapeutic procedures to decrease pain, there is
transcutaneous electrical neural stimulation (TENS). There is no consensus about its
efficacy for oncological patients, especially for post-mastectomy pain and eletrocortical
changes in somatosensory areas. The aim of this study was to analyze acute electrocortical
changes after TENS treatment of patients with intercostobrachial post mastectomy pain.
[Subjects] Eighteen patients were divided into acupuncture (A) and burst (B) group.
[Methods] In this pre and post-intervention study each group was measured for EEG analysis
in absulte power in alpha band (8–14 Hz). Outcomes variables were the alpha waveband in
the sensorymotor cortex and pain pre-and-post TENS intervention. Data were analyzed using
ANOVA to compare times (rest, 10 and 15 min), group and electrodes. Pain was analyzed
using percentual pain evaluation (PPE) in both groups. [Results] Outcomes indicate main
effects of time and electrodes because of slow (8–10 Hz) and fast alpha (10–12 Hz)
wavebands decreased. PPE reduced 88.4% in A and 66.3% in G. [Conclusion] TENS promoted
electrical modification in the parietal region and a decrease in pain. Future studies
should investigate other wave must be proposed for other bands and use different methods
of EEG analysis to elucidate the actual mechanisms behind the efficacy of TENS
treatment.</p></abstract><kwd-group><title>Key words</title><kwd>Transcutaneous electric nerve stimulation</kwd><kwd>Mastectomy</kwd><kwd>Electroencephalography</kwd></kwd-group></article-meta></front><body><sec id="s1"><title>INTRODUCTION</title><p>Breast cancer is the second most frequent type of cancer worldwide, and is the most common
cancer among women<xref rid="r1" ref-type="bibr">1</xref><sup>)</sup>. The National Cancer
Institute of Brazil, (INCA) registered around 50 thousand cases of breast cancer in 2012,
with an estimated risk of 49 cases per 100 thousand women<xref rid="r2" ref-type="bibr">2</xref><sup>)</sup>. The routine procedure for staging and management of breast cancer
is the axillary lymph node dissection or lymph node biopsy. These procedures cause
anatomical injury which may result in lymphedema<xref rid="r3" ref-type="bibr">3</xref><sup>)</sup>, nerve injury, shoulder dysfunction or pain<xref rid="r4" ref-type="bibr">4</xref><sup>)</sup>.</p><p>Post-mastectomy pain syndrome is a pain that persists over a 3-month period. It is defined
as a chronic pain that begins after breast cancer surgery. It is frequently located in the
anterior or lateral regions of thorax, axillary and/or medial upper arm, and is experienced
as burning pain, shooting pain, pressure sensation or numbness<xref rid="r4" ref-type="bibr">4</xref><sup>)</sup>. Jung et al.<xref rid="r5" ref-type="bibr">5</xref><sup>)</sup>distinguished four subtypes of neuropathic pain resulting from breast cancer surgical
treatment: phantom breast syndrome, neuralgia, intercostobrachial nerve pain, neuroma and
pain of other nerve injuries.</p><p>In Brazilian studies, the incidence of pain syndrome 6 months after breast cancer surgery
is 52.9% and it is associated with younger age (<40 years) and axillary lymphedenectomy
when more than 15 lymph nodes are removed. The incidence of intercostobrachial pain is
52.9%, that of shoulder pain is 27.2%, phantom breast pain in 3.2% and that of neuroma is
1.3%<xref rid="r4" ref-type="bibr">4</xref><sup>)</sup>. The management of pain syndrome
is complex and multidimensional with several forms of intervention. There is a growing
interest in investigating alternative therapeutic approaches, such as transcutaneous nerve
electrical stimulation (TENS)<xref rid="r7" ref-type="bibr">7</xref>, <xref rid="r8" ref-type="bibr">8</xref><sup>)</sup>, in oncology. TENS is a non-invasive technique used to
promote the symptomatic relief of acute and chronic pain, its mechanism of action is based
on the gate theory of pain<xref rid="r8" ref-type="bibr">8</xref><sup>)</sup>. In oncology
and palliative setting, TENS has been used to control acute and chronic pain, partly because
of its low cost, favorable side-effect profile and safety<xref rid="r9" ref-type="bibr">9</xref><sup>)</sup>. Nevertheless, investigations of the therapeutic effects of TENS on
brain activity have been rare scarce, especially, in women with intercostobrachial nerve
pain due to breast cancer treatment. Both TENS (acupuncture and burst) have effects on the
neurophysiological activities of receptors and also induce the expression of endogenous
opioids<xref rid="r6" ref-type="bibr">6</xref><sup>)</sup>. Because of this, there is a
need to investigate the electrical cortical behavior during TENS interventions.</p><p>Within this context, this study aimed to verify the acute effects of the electrical
activity in the somatosensory cortex of two different types of TENS, i.e. acupuncture and
burst, as a therapy for breast cancer patients with intercostobrachial nerve pain. Since it
is known that the main areas involved in pain mechanisms are the somatosensory areas (i.e.,
parietal areas), we hypothesized that different patterns of parietal EEG activity would be
induced by administration of TENS acupuncture and burst.</p></sec><sec sec-type="methods" id="s2"><title>SUBJECTS AND METHODS</title><p>A randomized clinical trial study was conducted of breast cancer patients who had pain
syndrome due to intercostobrachial nerve injury. Eighteen patients were recruited by the
physical therapy service. Inclusion criteria were: absence of mental impairment determined
by a score of ≥ 27 in the Mini Mental State Examination (MMSE); no history of psychoactive
or psychotropic substance use (screened by a previous anamnesis and a clinical examination);
and intercostobrachial nerve pain present ipsilateral the operated side. The exclusion
criteria: any other local or systemic pain condition; less than 6 to 8 hours of sleep prior
to the experiment; and intake of caffeine 48 hours prior to the experiment.</p><p>All subjects were informed the experimental protocol and signed a consent form before
participating in this study. The study was approved by the Ethics Committee of Augusto Motta
University Center (number 019/2011), in compliance with the rules provided for research on
human subjects contained in the Resolution of the National Health Council.</p><p>Eligible participants were randomly distributed to Group A − TENS Acupuncture (n = 9) or
Group B − TENS Burst (n = 9). At the time of TENS application, the patients were blind
regarding the treatment group they were in, as well as the procedure to be performed. EEG of
subjects in both groups was measured, at rest and 10 and 15 min after TENS application. EEG
was recorded simultaneously the TENS application. The EEG analysis was carried out at home
and on the tenth minute during the application of TENS. We used a two-channel
microcomputer-controlled electro-stimulator (Ibramed − Neurodyn Portable TENS/FES, Brazil).
Among the possible modalities of TENS, we chose TENS acupuncture and burst. Our choice was
based on thier similarity in the application times needed to obtain analgesia (10–15 min).
TENS acupuncture is pre-programmed with an automatic range of intensity and frequency, with
a descending pulse time of 275 µs and a rising pulse of 175 µs and increasing pulse
repetition frequency from 5 to 25 Hz over a period of 12.5 s. TENS burst is also programmed
with 7 pulses of cycle on of 28 ms and cycle-off of 472 ms (2 Hz) with a pulse time of
150 µs.</p><p>The International 10/20 System<xref rid="r10" ref-type="bibr">10</xref><sup>)</sup> for
electrodes was used with 20-channel EEG system (BrainNet BNT-EEG EMSA-Medical Instruments,
Brazil). The 20 electrodes were arranged in a nylon cap (ElectroCap Inc., Fairfax, VA, USA)
to record monopolar derivations from reference electrodes attached to the earlobes. In
addition, two 9-mm diameter electrodes were attached above and on the external corner of the
right eye, in a bipolar electrode montage, for monitoring eye-movement (EOG) artifacts. The
impedance of EEG and EOG electrodes was kept between 5–10 KΩ. The data acquired had total
amplitude of less than 100 µV. The EEG signal was amplified with a gain of 22,000,
analogically filtered between 0.01 Hz (high-pass) and 100 Hz (low pass), and sampled at
240 Hz. The software EEG-Captação (EMSA-DELPHI 5.0) was used for EEG acquisition.</p><p>First, EEG signals were evaluated by visual inspection. We then we used independent
component analysis (ICA) to identify the sources of artifacts (i.e., blink, muscle and
saccade-related artifacts). Next, we removed those portions of the EEG record that clearly
showed blink-related artifacts “influence” by visual inspection and those that showed
blink-related artifacts “contamination” according to ICA. The data were collected using the
bi-auricular reference electrodes and they were transformed (re-referenced) using the
average reference after we conducted the artifact elimination using ICA. The power spectral
density (PSD) was calculated directly from the square modulus of the FFT (Fast Fourier
Transform). The calculation was performed using MATLAB 5.3 (Mathworks, Inc.). We extracted
quantitative EEG parameters within a time window of 4s before and after the treatment.
Thereafter, all raw EEG trials were visually controlled and trials contaminated with ocular
or muscle artifacts were discarded. The FFT resolution was 1/4 s–0.25 Hz. To examine a
stationary process, the “Run-test” and “Reverse-Arrangement test” were applied.
Specifically, the stationary process was accepted for each 4s period (epoch’s duration). In
this way, the threshold was defined as the average plus three standard deviations in
artifact-free EEG; periods showing a total power higher than this threshold were excluded
from the analysis.</p><p>Therapeutic outcome was assessed using the Visual Analogical Scale (VAS) with a score of 0
indicating “no pain” and a score of 10 indicating “intolerable pain”. The subjects
self-assessed initial pain (IP) and final pain (FP) after TENS intervention. After this, the
changes of pain was calculated due percent pain evaluation (PPE) with the formula PPE = [(IP
− FP)÷ IP] × 100%.</p><p>The parietal lobe was chosen because of its involvement in sensory processes, such as
pain<xref rid="r10" ref-type="bibr">10</xref>, <xref rid="r11" ref-type="bibr">11</xref><sup>)</sup>. Thus, we selected the electrodes P3, Pz and P4 for absolute power
analysis and we divided alpha band in slow (8–10 Hz) and fast alpha (10–12 Hz). Absolute
power was defined as the total energy intensity of an electrode on a certain region in the
different frequency bands<xref rid="r12" ref-type="bibr">12</xref><sup>)</sup>. For the
sample size calculation, we considered women with intercostobrachialgia nerve pain receiving
physical therapy. We estimated an improvement of 30% in pain, with a confidence interval
(CI) of 95% and with a power of 80%. Therefore, 9 patients were required in each group, for
a total of 18 subjects.</p><p>Subjects’ characteristics and sociodemographic data are presented using descriptive
statistics (i.e., mean and SD). Pain was analyzed due modal value and the comparison of PPE
(i.e. pre and post TENS intervention) in both groups. With respect to EEG data, absolute
alpha power was the dependent variable of interest. The statistical analysis of absolute
alpha power was performed using the software SPSS version 17. Data were transformed in
Log<sub>10</sub> for approximation to normal distribution<xref rid="r13" ref-type="bibr">13</xref><sup>)</sup>. The Kolmogorov-Smirnov test was used to test the distribution of
the EEG data. When the data showed a normal distribution, was used ANOVA to compare pre- and
post-treatment values of (i resting EEG and 10 and 15 min of each group with a significance
level of 95% (p ≤ 0.05). The analysis was limited to three three topographically
representative electrode of the parietal cortex: P3, Pz and P4).</p></sec><sec sec-type="results" id="s3"><title>RESULTS</title><p>Eighteen patients with a mean age of 54.38 years old (SD 8.153) were studied. <xref rid="tbl_001" ref-type="table">Tables 1</xref> and<xref rid="tbl_002" ref-type="table">2</xref><table-wrap id="tbl_001" orientation="portrait" position="float"><label>Table 1.</label><caption><title> Group A (Acupunture)</title></caption><table frame="hsides" rules="groups"><thead><tr><td align="center" rowspan="1" colspan="1">Subject</td><td align="center" rowspan="1" colspan="1">Age</td><td align="center" rowspan="1" colspan="1">Type of surgery</td><td align="center" rowspan="1" colspan="1">VAS (Pre)</td><td align="center" rowspan="1" colspan="1">VAS (Post)</td><td align="center" rowspan="1" colspan="1">% Pain reduced</td><td align="center" rowspan="1" colspan="1">Duration of surgery (months)</td></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">69</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">100</td><td align="center" rowspan="1" colspan="1">12</td></tr><tr><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">43</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">100</td><td align="center" rowspan="1" colspan="1">24</td></tr><tr><td align="center" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">61</td><td align="center" rowspan="1" colspan="1">Segmentectomy</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">100</td><td align="center" rowspan="1" colspan="1">12</td></tr><tr><td align="center" rowspan="1" colspan="1">4</td><td align="center" rowspan="1" colspan="1">61</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">7</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">85.8</td><td align="center" rowspan="1" colspan="1">8</td></tr><tr><td align="center" rowspan="1" colspan="1">5</td><td align="center" rowspan="1" colspan="1">57</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">7</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">85.8</td><td align="center" rowspan="1" colspan="1">25</td></tr><tr><td align="center" rowspan="1" colspan="1">6</td><td align="center" rowspan="1" colspan="1">61</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">4</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">85.8</td><td align="center" rowspan="1" colspan="1">21</td></tr><tr><td align="center" rowspan="1" colspan="1">7</td><td align="center" rowspan="1" colspan="1">43</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">7</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">85.8</td><td align="center" rowspan="1" colspan="1">24</td></tr><tr><td align="center" rowspan="1" colspan="1">8</td><td align="center" rowspan="1" colspan="1">48</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">7</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">85.8</td><td align="center" rowspan="1" colspan="1">18</td></tr><tr><td align="center" rowspan="1" colspan="1">9</td><td align="center" rowspan="1" colspan="1">57</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">6</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">66.7</td><td align="center" rowspan="1" colspan="1">13</td></tr><tr><td align="left" valign="bottom" rowspan="1" colspan="1">Mean (SD)</td><td align="center" rowspan="1" colspan="1">55.9 ± 8.99</td><td align="left" valign="bottom" rowspan="1" colspan="1"></td><td align="left" valign="bottom" rowspan="1" colspan="1"></td><td align="left" valign="bottom" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">88.4±10.7</td><td align="center" rowspan="1" colspan="1">17.4 ± 6.37</td></tr></tbody></table><table-wrap-foot><p>VAS: Visual analogical Scale, Pre and Post (after 15 min) TENS intervention, %
Percent pain reduced; SD: Standard Deviation</p></table-wrap-foot></table-wrap><table-wrap id="tbl_002" orientation="portrait" position="float"><label>Table 2.</label><caption><title> Group B (Burst)</title></caption><table frame="hsides" rules="groups"><thead><tr><td align="center" rowspan="1" colspan="1">Subject</td><td align="center" rowspan="1" colspan="1">Age</td><td align="center" rowspan="1" colspan="1">Type of surgery</td><td align="center" rowspan="1" colspan="1">VAS (Pre)</td><td align="center" rowspan="1" colspan="1">VAS (Post)</td><td align="center" rowspan="1" colspan="1">% Pain reduced</td><td align="center" rowspan="1" colspan="1">Duration of surgery (months)</td></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">57</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">8</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">75</td><td align="center" rowspan="1" colspan="1">12</td></tr><tr><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">50</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">100</td><td align="center" rowspan="1" colspan="1">3</td></tr><tr><td align="center" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">51</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">5</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">100</td><td align="center" rowspan="1" colspan="1">13</td></tr><tr><td align="center" rowspan="1" colspan="1">4</td><td align="center" rowspan="1" colspan="1">48</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">10</td><td align="center" rowspan="1" colspan="1">7</td><td align="center" rowspan="1" colspan="1">30</td><td align="center" rowspan="1" colspan="1">15</td></tr><tr><td align="center" rowspan="1" colspan="1">5</td><td align="center" rowspan="1" colspan="1">68</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">7</td><td align="center" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">40</td><td align="center" rowspan="1" colspan="1">36</td></tr><tr><td align="center" rowspan="1" colspan="1">6</td><td align="center" rowspan="1" colspan="1">61</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">10</td><td align="center" rowspan="1" colspan="1">5</td><td align="center" rowspan="1" colspan="1">50</td><td align="center" rowspan="1" colspan="1">9</td></tr><tr><td align="center" rowspan="1" colspan="1">7</td><td align="center" rowspan="1" colspan="1">53</td><td align="center" rowspan="1" colspan="1">Segmentectomy</td><td align="center" rowspan="1" colspan="1">9</td><td align="center" rowspan="1" colspan="1">4</td><td align="center" rowspan="1" colspan="1">55.6</td><td align="center" rowspan="1" colspan="1">27</td></tr><tr><td align="center" rowspan="1" colspan="1">8</td><td align="center" rowspan="1" colspan="1">47</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">8</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">75</td><td align="center" rowspan="1" colspan="1">20</td></tr><tr><td align="center" rowspan="1" colspan="1">9</td><td align="center" rowspan="1" colspan="1">44</td><td align="center" rowspan="1" colspan="1">Mastectomy</td><td align="center" rowspan="1" colspan="1">7</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">71.5</td><td align="center" rowspan="1" colspan="1">21</td></tr><tr><td align="center" rowspan="1" colspan="1">Mean (SD)</td><td align="center" rowspan="1" colspan="1">53.2 ± 7.58</td><td align="center" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">7 (mode)</td><td align="center" rowspan="1" colspan="1">2 (mode)</td><td align="center" rowspan="1" colspan="1">66.3±24.6</td><td align="center" rowspan="1" colspan="1">17.3 ± 9.9</td></tr></tbody></table><table-wrap-foot><p>VAS: Visual Analogical Scale, Pre and Post (after 15 min) TENS intervention; (%)
Percent pain evaluation; SD: Standard Deviation</p></table-wrap-foot></table-wrap> show the general characteristics of the subjects (mean ± SD), as well as the
results of VAS (pre and post-intervention) and PPE and type of surgery for each of the two
groups (TENS acupunture and burst).</p><p>After the EEG analysis showed there were a decreases in slow and fast alpha absolute power
in both groups, in all electrodes. In the acupunture group, compared to at rest the slow
alpha average at rest decreased by more than half 15 min at all electrode: Pz (0.178 to
0.078 µV<sup>2</sup> Log<sub>10</sub>); P3 (0.189 to 0.096 µV); P4 (0.199 to 0.079 µV), and
all the differences were significant: p=0.009; p=0.005; p=0.002, respectively (<xref rid="tbl_003" ref-type="table">Table 3</xref><table-wrap id="tbl_003" orientation="portrait" position="float"><label>Table 3.</label><caption><title> Acupunture group: slow and fast alpha</title></caption><table frame="hsides" rules="groups"><thead><tr><td align="center" rowspan="1" colspan="1"></td><td align="center" colspan="4" rowspan="1">Slow Alpha<hr></hr></td><td align="center" colspan="4" rowspan="1">Fast Alpha<hr></hr></td></tr><tr><td align="center" valign="middle" rowspan="1" colspan="1">Electrode</td><td align="center" rowspan="1" colspan="1">Resting EEG<break></break>(µV<sup>2</sup> Log<sub>10</sub>)</td><td align="center" rowspan="1" colspan="1">EEG 10 min<break></break>(µV<sup>2</sup> Log<sub>10</sub>)</td><td align="center" rowspan="1" colspan="1">EEG 15 min<break></break>(µV<sup>2</sup> Log<sub>10</sub>)</td><td align="center" valign="middle" rowspan="1" colspan="1">p </td><td align="center" rowspan="1" colspan="1">Resting EEG<break></break>(µV<sup>2</sup>Log<sub>10</sub>)</td><td align="center" rowspan="1" colspan="1">EEG 10 min<break></break>(µV<sup>2</sup> Log<sub>10</sub>)</td><td align="center" rowspan="1" colspan="1">EEG 15 min<break></break>(µV<sup>2</sup> Log<sub>10</sub>)</td><td align="center" valign="middle" rowspan="1" colspan="1">p</td></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1">PZ</td><td align="center" rowspan="1" colspan="1">0.178</td><td align="center" rowspan="1" colspan="1">0.107</td><td align="center" rowspan="1" colspan="1">0.078</td><td align="center" rowspan="1" colspan="1">*</td><td align="center" rowspan="1" colspan="1">0.192</td><td align="center" rowspan="1" colspan="1">0.119</td><td align="center" rowspan="1" colspan="1">0.073</td><td align="center" rowspan="1" colspan="1">*</td></tr><tr><td align="center" rowspan="1" colspan="1">P3</td><td align="center" rowspan="1" colspan="1">0.189</td><td align="center" rowspan="1" colspan="1">0.132</td><td align="center" rowspan="1" colspan="1">0.096</td><td align="center" rowspan="1" colspan="1">*</td><td align="center" rowspan="1" colspan="1">0.177</td><td align="center" rowspan="1" colspan="1">0.158</td><td align="center" rowspan="1" colspan="1">0.101</td><td align="center" rowspan="1" colspan="1">*</td></tr><tr><td align="center" rowspan="1" colspan="1">P4</td><td align="center" rowspan="1" colspan="1">0.199</td><td align="center" rowspan="1" colspan="1">0.121</td><td align="center" rowspan="1" colspan="1">0.076</td><td align="center" rowspan="1" colspan="1">*</td><td align="center" rowspan="1" colspan="1">0.207</td><td align="center" rowspan="1" colspan="1">0.197</td><td align="center" rowspan="1" colspan="1">0.082</td><td align="center" rowspan="1" colspan="1">*</td></tr></tbody></table><table-wrap-foot><p>* statistical significance (p<0.05)</p></table-wrap-foot></table-wrap>).</p><p>As for the fast alpha, there was a slight decrease at the P4 electrode from 0.207 µV at
rest to 0.197 µV at (<xref rid="tbl_003" ref-type="table">Table 3</xref>). However, the
energy pattern remained similar to the slow alpha at the P3 and Pz electrodes. P3 and PZ
showed progressive decreases in absolute power</p><p>The results for group B were similiar. There were decreases in absolute slow alpha power at
all electrodes (P3, Pz and P4) all of which were significant p=0.01; p=0.04 and p=0.008
respectively. The changes between rest and 10 min were greater than the change between 10
and 15 min (<xref rid="tbl_004" ref-type="table">Table 4</xref><table-wrap id="tbl_004" orientation="portrait" position="float"><label>Table 4.</label><caption><title> Burst group: slow and fast alpha</title></caption><table frame="hsides" rules="groups"><thead><tr><td align="left" valign="top" rowspan="1" colspan="1"></td><td align="center" colspan="4" rowspan="1">Slow Alpha<hr></hr></td><td align="center" colspan="4" rowspan="1">Fast Alpha<hr></hr></td></tr><tr><td align="center" valign="middle" rowspan="1" colspan="1">Electrode</td><td align="center" rowspan="1" colspan="1">Resting EEG<break></break>(µV<sup>2</sup>Log<sub>10</sub>)</td><td align="center" rowspan="1" colspan="1">EEG 10 min<break></break>(µV<sup>2</sup> Log<sub>10</sub>)</td><td align="center" rowspan="1" colspan="1">EEG 15 min<break></break>(µV<sup>2</sup> Log<sub>10</sub>)</td><td align="center" valign="middle" rowspan="1" colspan="1">p</td><td align="center" rowspan="1" colspan="1">Resting EEG<break></break>(µV<sup>2</sup> Log<sub>10</sub>)</td><td align="center" rowspan="1" colspan="1">EEG 10 min<break></break>(µV<sup>2</sup> Log<sub>10</sub>)</td><td align="center" rowspan="1" colspan="1">EEG 15 min<break></break>(µV<sup>2</sup> Log<sub>10</sub>)</td><td align="center" valign="middle" rowspan="1" colspan="1">p</td></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1">PZ</td><td align="center" rowspan="1" colspan="1">0.208</td><td align="center" rowspan="1" colspan="1">0.120</td><td align="center" rowspan="1" colspan="1">0.076</td><td align="center" rowspan="1" colspan="1">*</td><td align="center" rowspan="1" colspan="1">0.201</td><td align="center" rowspan="1" colspan="1">0.134</td><td align="center" rowspan="1" colspan="1">0.091</td><td align="center" rowspan="1" colspan="1">*</td></tr><tr><td align="center" rowspan="1" colspan="1">P3</td><td align="center" rowspan="1" colspan="1">0.189</td><td align="center" rowspan="1" colspan="1">0.154</td><td align="center" rowspan="1" colspan="1">0.082</td><td align="center" rowspan="1" colspan="1">*</td><td align="center" rowspan="1" colspan="1">0.173</td><td align="center" rowspan="1" colspan="1">0.162</td><td align="center" rowspan="1" colspan="1">0.112</td><td align="center" rowspan="1" colspan="1">*</td></tr><tr><td align="center" rowspan="1" colspan="1">P4</td><td align="center" rowspan="1" colspan="1">0.177</td><td align="center" rowspan="1" colspan="1">0.131</td><td align="center" rowspan="1" colspan="1">0.098</td><td align="center" rowspan="1" colspan="1">*</td><td align="center" rowspan="1" colspan="1">0.204</td><td align="center" rowspan="1" colspan="1">0.174</td><td align="center" rowspan="1" colspan="1">0.089</td><td align="center" rowspan="1" colspan="1">*</td></tr></tbody></table><table-wrap-foot><p>* statistical significance (p<0.05)</p></table-wrap-foot></table-wrap>).</p><p>In fast alpha band, in the burst group, there was also a decrease in absolute alpha power
more intense in Pz (0.201 µV to 0.091 µV) and P4 (0.204 to 0.089 µV) electrodes between the
rest and 15 min moment conditions. But in P3 the fall was less accentuated. In all
electrodes P3, P4 e Pz, the differences were significant with main effect fot the moment
(p=0.03; p=0.005 e 0.012) respectively (<xref rid="tbl_004" ref-type="table">Table
4</xref>).</p></sec><sec sec-type="discussion" id="s4"><title>DISCUSSION</title><p>Our study aimed to investigate the acute effects of TENS acupuncture and burst on the
parietal EEG activity of breast cancer patients with intercostobrachial nerve pain. Our
results show there were decreases in pain sensation in both groups. In the burst group, the
difference between pre- and post-treatment was 4 points in VAS and 66.3% pain reduced in
PPE. The pain difference in the acupuncture group was also 4 points and an 88.4% reduction
for PPE. These results provide further evidence that TENS application for patients with
breast cancer relieves pain due to the analgesic effect. The physiological mechanism of TENS
action is postulated to be electrical stimulation through the skin inhibiting the
transmission of pain impulses through the spinal cord, as well as the release of endogenous
opioids, as endorphins, by the brain or the spinal cord<xref rid="r14" ref-type="bibr">14</xref>,<xref rid="r15" ref-type="bibr">15</xref>,<xref rid="r16" ref-type="bibr">16</xref><sup>)</sup>.</p><p>The complexity of the neurophysiological mechanisms suggests the need for multiple methods
to appropriate control. The most commonly used drug substances for the control of
postoperative pain are the opiates, which are inhibitors of type C-fibers. Approximately 75%
of spinal opioid receptors are found surrounding the presynaptic C-fiber. However nerve
fibers of A-Delta type are not inhibited by the drug, therefore, the use of other techniques
is needed in order exercise adequate pain control. TENS reduces nociceptive activity evoked
in cells of the medullary dorsal horn when applied in receptor areas. It activaes myelinated
nerve fibers afferent of lager diameter the smaller diameter C fibers, which are not
myelinated and have slower conduction and are unable to transmit a nerve impulse<xref rid="r14" ref-type="bibr">14</xref>, <xref rid="r17" ref-type="bibr">17</xref>, <xref rid="r18" ref-type="bibr">18</xref><sup>)</sup>.</p><p>Results of this study corroborate the evidence of a study in which volunteers were
instructed not to use the drug, indicating that the pharmacological extra feature proved to
be successful for pain inhibition, justifying the activation of A-delta and C- fibers for
the results that were found.</p><p>Another mechanism for analgesia, as mentioned above, is the release of opioids, through
what we call the pain suppression system. This activation increases the synthesis of
neurotransmitters such as endorphins, enkephalins, serotonin, among others (endogenous
opioid system and serotonin), which inhibit activity over the components of the nociceptive
system, by modulation of the neuronal transmission activity located in the medullary dorsal
horn<xref rid="r15" ref-type="bibr">15</xref>, <xref rid="r19" ref-type="bibr">19</xref>,
<xref rid="r20" ref-type="bibr">20</xref><sup>)</sup>. Both types of current (acupuncture
and burst) used in this study reduced of pain, which is reflected in explains the similar
VAS’s results.</p><p>The results show a decrease in slow and fast absolute alpha power during TENS application
compared to the resting state, reflecting greater activation of the parietal region. This
region is known to be responsible for orientation and attention toward painful sensory
stimuli, and is described in literature describing it as a multimodal association area<xref rid="r21" ref-type="bibr">21</xref><sup>)</sup>. We verified a decrease slow and fast
alpha rhythms in parietal cortex during TENS application. Studies have indicated that slow
alpha is associated to non-specific brain processes to the type of task (energy demands),
while fast alpha is related with specific somatosensory processes<xref rid="r22" ref-type="bibr">22</xref>, <xref rid="r23" ref-type="bibr">23</xref><sup>)</sup>. A decrease in
alpha activity is associated with a state of high excitability and low inhibitory control,
while an increase in alpha activity represents a low excitability and is related to a
relaxed condition. Thus, our results can be interpreted as greater attention to the painful
processes during the TENS application.</p><p>This suggests that during the experiment the subjects were aware of the painful processes.
This finding is consistent with the literature and indicates that changes in the alpha band
related to pain<xref rid="r21" ref-type="bibr">21</xref><sup>)</sup>.</p><p>In addition, the decrease in alpha power during the application of TENS could be explained
by the organization of pain-related cortical areas<xref rid="r24" ref-type="bibr">24</xref>,
<xref rid="r25" ref-type="bibr">25</xref><sup>)</sup>. Studies have reported
attention-related decreases in alpha power over the parietal cortex in the absence of a
target stimulus. They employed a cue stimulus that immediately preceded the target. The cue
stimulus predicted exactly when the target was going to appear, and the decrease in alpha
activity occurred during the cue − target stimulus interval<xref rid="r26" ref-type="bibr">26</xref>,<xref rid="r27" ref-type="bibr">27</xref>,<xref rid="r28" ref-type="bibr">28</xref>,<xref rid="r29" ref-type="bibr">29</xref><sup>)</sup>.</p><p>In our opinion, the TENS for breast cancer patient can be used as an alternative to other
treatments, specially for intercostobrachial nerve pain. Because is eqsy to apply and there
are few contra-indications, patients can be treated with TENS without major problems. Beside
our data suggest that both types of TENS (acupunture and burst) reduce the pain. Our results
indicate the slight tendency of TENS acupunture to provoque greater analgesia.</p><p>This results differs considerably from our experiment, in which TENS was not cued and was
given at long, random inter-stimulus intervals and was, therefore, unpredictable. Hence,
attention-related decreases in alpha in the absence of a stimulus may not occur under this
condition. This implies that merely thinking about a painful stimulus will not elicit the
same changes in alpha as presenting an actual painful stimulus. Our data suggests a
somatotopic organization in the parietal cortex after TENS application. We conclude that
TENS changed electrical activities in the cortical of patients with intercostobrachial nerve
pain. There were no significant differences between TENS acupuncture and burst, and both
types reduced the pain. We recommend new investigations in order to replicate these findings
utilizing different times and phase of intercostobrachial pain to comprehend cortical
phenomenon during TENS action.</p></sec></body><back><ref-list><title>REFERENCES</title><ref id="r1"><label>1</label><mixed-citation publication-type="journal"><person-group><name><surname>Tiezzi</surname><given-names>DG</given-names></name></person-group>: <article-title>Epidemiologia do câncer de mama</article-title>.
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