Case Report

Use of a Patient-Specific Outcome Measure and a Movement Classification System to Guide Nonsurgical Management of a Performer with Low Back Pain A Case Report

Ruth L. Chimenti, P.T., D.P.T., Ph.D., Linda R. Van Dillen, P.T., Ph.D., and Lynnette Khoo-Summers, P.T., D.P.T.

Abstract and acrobatic activities decreased from A challenge in treating performing 4/10 at initial evaluation to less than or Low back pain (LBP) can be detrimental athletes is balancing their motivation equal to 1/10 by discharge. It is concluded to the career of a circus arts performer, yet to return to sport with adequate time that using an outcome measure to assess there is minimal population-specific litera- for injured tissues to heal. An outcome difficulty of activities chosen by the patient ture to guide care. Moreover, reluctance measure that quantifies symptoms and education on how to avoid movement to discontinue training and the need to patterns associated with LBP symptoms with patient-chosen activities can resume end-range lumbar motion can im- can help facilitate return to performance. help inform this . In contrast, pede the success of conservative care. The region-specific outcome measures, purpose of this case report is to describe the such as the Modified Oswestry Dis- use of a patient-specific outcome measure alf of adolescents who take ability Questionnaire (Modified and a movement classification system to OSW),3 do not capture limitations structure a home exercise program (HEP) part in sports outside of for an adolescent training to be a have at least one in populations with unique physical Hepisode of low back pain (LBP).1 In activity demands. An outcome mea- performer. The patient was a 16-year- old female with a 10-month history of particular, those who participate in sure developed by Stratford and col- 4 LBP. A Movement System Impairment a sport that requires repetitive trunk leagues addresses this issue by having examination indicated that she had lower motions may be at an even greater risk patients choose and rate the difficulty abdominal weakness, gluteal weakness, and for developing LBP and prolonged of five activities that are important for hip flexors that were short and stiff; hence, disability.1,2 Aerial arts require the use them. This type of measure can help extension and rotation were repeated pat- of end-range trunk motions, such as integrate management of an athlete’s terns of lumbopelvic movement associ- extension and rotation, coupled with motivation to return to sport with ated with her LBP symptoms. The patient additional loading, for example when consideration of how certain activities was seen for 16 visits over 16 weeks. The affect symptoms. HEP focused on minimizing lumbopelvic lifting other participants in opposed extension and rotation movements while directions. The patient presented in Treatment of a circus performer can improving abdominal and gluteal strength this case report is an adolescent train- be especially challenging because they and hip flexor flexibility. Resumption of ac- ing to be a circus performer. Due to need to use end-range trunk motions robatic activities was guided by the Patient- difficulty managing LBP symptoms, and are often reluctant to discontinue Specific Functional Scale. As measured by she sought care from a performing training completely. Additionally, to this scale, her difficulty with five functional arts physical therapist. our knowledge, there are no published studies to guide physical therapy intervention for circus performers. Ruth L. Chimenti, P.T., D.P.T., Ph.D., Department of Physical Therapy and The purposes of this case report are Rehabilitation Science at the University of Iowa, Iowa City, Iowa. Linda R. Van to describe 1. the use of a patient- Dillen, P.T., Ph.D.,and Lynnette Khoo-Summers, P.T., D.P.T.,Program in Physical specific outcome measure to structure Therapy, Washington University School of Medicine, St. Louis, Missouri. return to sport with an athlete who Correspondence: Ruth L. Chimenti, P.T., D.P.T., Ph.D., Department of Physical will not completely cease all symptom Therapy and Rehabilitation Science, Westlawn 2116, Iowa City, Iowa 52242; provoking activities, 2. a Movement [email protected]. System Impairment examination of a

Copyright © 2017 J. Michael Ryan Publishing, Inc. https://doi.org/10.12678/1089-313X.21.4.185 185 186 Volume 21, Number 4, 2017 • Journal of Medicine & Science patient with chronic LBP, and 3. an Additionally, her LBP symptoms pre- lumbar movement of lateral shift to individualized treatment for a circus vented her from sitting for longer than the ipsilateral side. She had no pain performer. 1 hour, which disrupted her ability with side-bending to the right but to attend academic classes and travel reported SIJ pain when side-bending Methods by car to performance venues outside to the left. She reported decreased Subject Information of the city. Lifting heavy objects also pain when the examiner provided A 16-year-old female circus performer increased her pain, which interfered manual support to the trunk, block- with LBP was referred to physical with her performance in acts that ing a left lateral shift in the lumbar therapy. She was 5'5'' tall, weighed required lifting or supporting another region during a left side-bend. Due to 125 pounds, and had a body mass person. Her goal for therapy was to the patient’s report of pain in the SIJ index of 20.8 kg/m2. Her LBP began perform in a circus troupe without region, the motion was also repeated gradually some 10 months prior to LBP symptoms. The subject was in- with manual pelvic compression, her first physical therapy visit at our formed that data concerning her case but this did not reduce pain. With clinic. On initial evaluation, she re- would be submitted for publication, trunk rotation, she experienced no ported an average pain of 4/10 on the and she approved this procedure. LBP symptoms but demonstrated Verbal Numeric Scale (VNS), which decreased rotation excursion to the has been demonstrated to be reliable Visual Appraisal right. These trunk motion tests indi- and valid for use with adolescents. She During subjective exam, it was noted cated that LBP symptoms might be reported no previous history of LBP that the patient preferred to sit with associated with asymmetrical lumbo- and denied associated symptoms in her legs crossed and her upper body pelvic movement. her legs. Imaging results from plain leaning toward one side, resulting in During limb motion tests, a repeat- radiographs, magnetic resonance im- side-bending and rotation of the low ed pattern of lumbopelvic extension aging, computed tomography scan, back. and rotation was again noted. With and a bone scan were unremarkable the motion of a straight leg raise, the for pathology. Palpation patient demonstrated lumbopelvic ex- Before beginning physical therapy She was tender to palpation from L4 tension and rotation when lifting each at our clinic, she was treated by an to S2 vertebrae and bilaterally from leg. She reported mild LBP symptoms osteopathic doctor who performed the posterior superior iliac spine but denied neural tension or SIJ pain. adjustments to the lumbar spine and (PSIS) to approximately 2 cm inferior The examiner manually stabilized the pelvis. The patient had also previ- to the PSIS. patient’s pelvis to prevent lumbopel- ously seen a physical therapist who vic extension and rotation, which prescribed abdominal strengthening, Movement Tests decreased the discomfort associated muscle energy techniques, and used A Movement System Impairment ex- with the straight leg raise. She dem- sacroiliac joint (SIJ) mobilizations, amination was performed in order to onstrated lumbopelvic extension and Transcutaneous Electrical Nerve Stim- identify what lumbopelvic movements rotation but no symptoms with the ulation (TENS), and an acupuncture provoked the patient’s symptoms.5 following limb motion tests: single pen. She also had an Aspen® LSO If a trunk or limb motion provoked leg stance, sitting knee extension, hip brace (Aspen Medical Products, Ir- symptoms, then the patient was asked and knee flexion in supine, side-lying vine, California) to help control LBP to repeat the same motion while the hip abduction, and prone hip lateral symptoms. Due to a lack of symptom examiner manually blocked the as- rotation with the knee flexed to 90°. relief with these modalities, the pa- sociated lumbopelvic movement. If These limb motion tests indicated that tient sought care from a performing symptoms were reduced by blocking lumbopelvic extension and rotation arts physical therapist. lumbopelvic movement, then the test were repeated patterns of movement The patient was a home-schooled was positive for that movement system and might be a contributing factor high school student with a very ac- impairment. If a motion was associ- to her LBP symptoms with acrobatic tive lifestyle. She had been training ated with lumbopelvic movement but activities.10,11 in circus arts for over 10 years and did not provoke symptoms, then it was performing professionally with was noted in the exam as a repeated Muscle Strength and Length a local circus troupe in a variety of pattern of lumbopelvic movement. The patient’s lower abdominal circus activities, including acrobat- Movement tests and the diagnosis of strength was less than 1/5, accord- ics, tumbling, acts, tightrope a movement-based impairment have ing to the lower abdominal strength walking, , lyra, , been shown to be reliable in patients test described by Sahrmann.5 When and . She practiced and per- with LBP.6-9 performing the lower abdominal formed 6 to 7 days per week for 3 to During two trunk motion tests, strength test, the patient demon- 4 hours per day before her LBP injury. a pattern of lumbopelvic extension strated lumbopelvic extension and Her primary complaint was LBP as- and rotation was noted. When the rotation but reported no pain. She sociated with acrobatic activities, such patient performed the motion of a had difficulty recruiting the obliques as back walkovers and hula hooping. side-bend, there was an associated and transverse abdominus and instead Journal of Dance Medicine & Science • Volume 21, Number 4, 2017 187

Table 1 Manual Muscle Test (MMT) Grade (Range 0-5) at Initial ing circus training. These included Evaluation and Discharge terminating all activities that required Initial Discharge end-range lumbar extension, such as back walkover or rotation as in Muscle Left Right Left Right hula hooping. Aerials were the most Gluteus Maximus 4 5 5 5 important activity for her to resume Posterior Gluteus Medius 3+ 4 4 5 since they were most commonly used in performances. In order to help her Lower Abdominals < 1 3/5 stay active and manage her symptoms, she was instructed to do only two or primarily used her rectus abdominus, Therefore, avoidance of lumbopelvic three acrobatic activities per day and as indicated by abdominal distension. extension and rotation was the move- then track how long she had pain Lower quarter muscle strength and ment based classification used to guide afterward. If she had pain longer length tests were performed according the intervention. than 15 minutes, she should reduce to the procedures described by Ken- her amount of activity or replace the dall and coworkers.12 Manual muscle Prognosis most aggravating activity with a less testing revealed that gluteal weakness The patient was young, had no medi- vigorous one. was more evident on the left side than cal comorbidities, and was experienc- The patient’s mother was also in- the right (Table 1). The 2-joint hip ing her first episode of LBP. Addition- structed in a taping technique of the flexor length test demonstrated that ally, she reported decreased pain with low back to help control the amount the tensor fascia lata (TFL), rectus stabilization of the lumbar spine dur- of lumbopelvic extension and rota- femoris, and iliopsoas muscles were ing movement tests. For these reasons, tion (Fig. 1). The patient reported stiff bilaterally. The TFL was the only she had a good prognosis, despite the immediate pain relief with the tape, hip flexor that was short bilaterally, 10-month duration of her current and the right side was stiffer than symptoms and the failure of previous the left. conservative care interventions to decrease LBP symptoms. Special Tests The Cluster tests for the SIJ were per- Intervention formed as described by Cibulka and The intervention consisted of 1. edu- Koldehoff.13 The patient was positive cation regarding her movement im- for 3/4 tests, including uneven PSIS pairments of lumbopelvic extension alignment in sitting, leg length change and rotation and 2. a home exercise between prone with the legs straight to program minimizing lumbopelvic prone with bilateral knee flexion, and extension-rotation while improving forward bend with one PSIS moving abdominal and gluteal muscle recruit- higher than the other. ment and hip flexor flexibility. Diagnosis Education The patient’s diagnosis was consistent The Patient-Specific Functional Scale Figure 1 with the movement system diag- was used to discuss which activities For the low back taping tech- nique, white tape was applied without nosis of lumbar extension-rotation were the most important to her and 5 tension to protect the skin over the syndrome. Contributing factors in- her current difficulty and pain with lumbar region. The patient then sat in an cluded 1. reproduction of symptoms those activities (Table 1). Based on un-weighted position by using her arms to with lumbopelvic extension or rota- this discussion, the patient was given support body weight, and her posture was tion during sitting, side-bending, and advice on how to manage her symp- corrected to a neutral position. Inelastic straight leg raise; 2. repeated pattern toms during daily and circus activities. tape was then applied to form an “X” of lumbopelvic extension and rotation For daily activities, the patient was on her low back, with the middle of the with trunk and limb motion tests; instructed to avoid lumbopelvic ex- “X” centered on the spine. To correct for 3. decreased abdominal and gluteal tension and rotation during sitting rotation, the first diagonal was applied strength; and 4. short and stiff hip by avoiding crossing her legs and us- with tension to pull the spine back into a flexors. A differential diagnosis of SIJ ing the back of the chair to support neutral position, and the second diagonal was applied with less tension. Horizontal dysfunction was considered due to a neutral spine. Additionally, she was strips were placed as needed for support. tenderness in the PSIS area bilater- instructed to improve her sleeping Additional strips of tape were applied ally and positive Cibulka cluster tests. posture by using a pillow between her as she moved into a standing position if However, she did not have pain relief knees at night. needed. Care was taken to ensure that with compression of the pelvis dur- Specific recommendations were spinal motion but not hip motion was ing the side-bending movement test. given to limit her activity level dur- limited by the taping. 188 Volume 21, Number 4, 2017 • Journal of Dance Medicine & Science

Table 2 Home Exercise Program Phase I (1-4 weeks) II (5-8 weeks) III (9-12 weeks) IV (13-16 weeks) Focus Muscle Recruitment Strength Balance Performance Target Muscle Group: Abdominals Exercise Hip and knee flexion Hip and knee flexion Hip and knee flexion Hip and knee flexion from a Description #1 from a hook-lying from a hook-lying from a standing hook-lying position while in a Figure 2A position while position with both feet position handstand position maintaining a neutral starting on a pillow lumbar spine; return to hook-lying Patient-Specific Control the leg movement with your lower abdominals by flattening your abdomen. Initially, recruitment of lower Instructions abdominals may be most successful during exhale, which activates the appropriate muscles. Place hands on hip crease to monitor for activation of the hip flexors. Exercise Hip abduction and Hip abduction and NA Hip abduction and rotation Description #2 lateral rotation from a lateral rotation from a while in a handstand position hook-lying position, hook-lying position with return to hook-lying varied width between foot and knee flexion angles Patient-Specific Do not let lumbopelvic region rotate as hip abducts. Place hands on hips to monitor for lumbopelvic movement. Instructions Exercise NA Circling movements Circling movements Circling movements of the Description #3 of the head, arms, of the head, arms, head, arms, upper back, and upper back, and legs in upper back, and legs legs in standing with quick standing in standing on a weight shifts foam surface Patient-Specific Rotate only in specified region and keep lumbopelvic region stable. Instructions Exercise Arm flexion from a Arm flexion and Arm flexion and For progression see exercise #5 Description #4 quadruped position, contralateral leg contralateral return to starting extension in quadruped leg extension in position quadruped on a foam surface Patient-Specific Do not extend or rotate in lumbar spine as arm flexes overhead. Instructions Exercise NA Back extension with use Back extension while Back extension from a Description #5 of arms in prone sitting on a ball squatting position to arms overhead with TheraBand resistance Patient-Specific Keep abdominals contracted as you move into trunk extension. Focus on extending more in the upper back than Instructions the lower back. (Continued on next page) and it allowed her to spend a longer 1 month (Table 2). Patient educa- nal exercises, she was cued to avoid period of time sitting and perform- tion on movement impairments was abdominal distension and relax the ing acrobatic activities with less pain. reinforced with the home exercise hip flexors (Fig. 2A). For the gluteal The taping technique also gave her program, which was practiced during exercises, she was cued to use the glu- proprioceptive feedback so that she clinic visits. Feedback was provided teus maximus for hip extension rather could feel when she started to extend to the patient at each visit, and she than the hamstrings or lumbar exten- or rotate in her low back. was given cues on how to minimize sors and to use the posterior gluteus lumbopelvic extension and rotation medius for hip abduction rather than Home Exercise Program with all exercises. Initially exercises TFL (Fig. 2B). These exercises were The home exercise program consisted focused on muscle recruitment. For performed the maximum number of of a progression of exercises in four example, to minimize substitution of repetitions possible while maintaining phases, which each lasted for about other muscle groups during abdomi- neutral lumbopelvic alignment, often Journal of Dance Medicine & Science • Volume 21, Number 4, 2017 189

Table 2 Home Exercise Program (Continued) Phase I (1-4 weeks) II (5-8 weeks) III (9-12 weeks) IV (13-16 weeks) Focus Muscle Recruitment Strength Balance Performance Target Muscle Group: Gluteals Exercise Hip and knee extension Hip and knee extension Hip and knee Hip and knee extension while Description #1 from a hook-lying from a hook-lying extension from a in a handstand position position while position at end of standing position maintaining a neutral plinth, so that hip is in lumbar spine, return to full extension before hook-lying returning to start position Patient-Specific Use abdominals to prevent lumbar extension or rotation. Place hands on hips to monitor for lumbopelvic Instructions movement. Use the gluteals to extend the hip, rather than hamstrings or muscles of the low back. Exercise Hip abduction from a Hip abduction from a Hip abduction in Hip abduction in a handstand Description #2 side-lying position side-lying position with standing position with back of heel Figure 2B TheraBand lightly pressing into the wall Patient-Specific Place hand on hip to monitor for lumbopelvic rotation. Instructions Exercise NA Tendus (hip flexion, Tendus in relevé Quick tendus as if preparing Description #3 abduction and extension (supporting leg in to start an acrobatic move with knee straight and a position of peak toes in contact with the heel rise) or hip/ floor) knee flexion of the supporting side Patient-Specific Make sure that pelvis is level and do not “sit” or adduct hip on supporting side. Instructions Exercise NA Forward lunges in Lunges to the front, Quick weight shifts as if Description #4 standing side, and diagonal landing from an acrobatic move Patient-Specific Use hip abductors to support pelvis and prevent hip adduction on supporting side. Instructions only 5 to 10 repetitions, 3 times per stabilize the low back while allowing manage symptoms during resumption day. Once the patient demonstrated more extension in her upper back and of a higher level of activity. that she was consistently able to hips. The gluteal exercises were also In the last phase of therapy, ex- control lumbopelvic motion with a progressed to include larger dynamic ercises focused on integrating the specific exercise, the physical therapist movements of the legs as she was able muscle recruitment, strengthening, progressed to the exercises of the next to maintain a neutral lumbopelvic and balance components from pre- phase. alignment. vious phases into activities used in In phase II, the patient was better During phase III, the abdominal the circus (Table 2). The integration able to recruit the targeted muscle and gluteal exercises were progressed of physical therapy exercises with groups and so exercises progressed with both increased resistance and circus-specific activities was based to focus on strengthening (Table 2). inclusion of balance training (Table on research demonstrating limited Abdominal and gluteal exercises were 2). The extent of the balance chal- carryover of postural control in one done on alternating days for 3 sets of lenge included in her home exercise position to postural control in anoth- 10 to 15 repetitions. The abdominal program depended on her ability to er position.14 Therefore, in general, exercises were progressed to include perform the exercise with minimal exercises were progressed from lying trunk stabilization with increased leg increase in lumbopelvic extension or down to standing to being upside range of motion, upper extremity rotation in the clinic. Also during this down (Fig. 2). As the patient gained movements, and trunk extension. phase, the frequency of the home ex- the ability to control lumbopelvic ex- The purpose of the prone back exten- ercise program was decreased to only tension and rotation in each position, sion exercise was to help the patient a few exercises 3 days a week to bal- she was instructed to think about the resume pain-free trunk extension. ance her increased activity level with same control during acrobatic moves For this exercise, she was instructed resumption of more circus activities. that transitioned through similar to recruit her lower abdominals to Tape was used more frequently to help postures. For example, the original 190 Volume 21, Number 4, 2017 • Journal of Dance Medicine & Science

A B

Figure 2 Phases I through IV of exercise progressions for A, lower abdominals with hip flexion and B, gluteals. exercises of supine unilateral hip and to using more than one body part, Numeric Scale (VNS).15-17 On her knee flexion and side-lying hip ab- then to standing on a foam surface, last visit, she reported 5/10 pain on duction were repeated in a handstand and finally with the addition of quick the VNS during a conditioning class position to simulate her need for weight shifts. By the end of therapy, in which she was resuming a wide lumbopelvic control during activities she was able to hula hoop with one variety of circus arts activities that she in which she was upside down (Fig. hoop without pain and was gradually had discontinued due to pain prior to 2B). Hula hooping, which involved starting to add more hoops. therapy. While overall her strength controlling 10 weighted hula hoops improved, at discharge she still had at once on multiple body parts, was Results some weakness of the right poste- one of the last activities that she was The patient was seen for a total of 16 rior gluteus medius and abdominals able to resume due to pain limita- visits over 16 weeks. All pain scores (Table 1). tions. In standing, she did circling decreased over time, except for her last Her score on the Modified OSW movements with her head, arms, reported “worst pain” score (Table 3). decreased to 2% at discharge from upper back, and legs. Initially, she The decreases in her worst pain and 16% at the start of therapy;3 how- did only one movement at a time average pain over the last week were ever, there was little change in her while minimizing lumbopelvic rota- greater than 2, the minimal clinically score between most visits (Table 3). tion, then exercises were progressed important difference for the Verbal The difficulty of five activities chosen Journal of Dance Medicine & Science • Volume 21, Number 4, 2017 191

Table 3 Outcome Measures by Phase of Intervention and at Discharge feeling when her lumbar spine was Outcome Measure Phase I Phase II Phase III Phase IV Discharge extended or rotated. However, she gained self-awareness first through VNS (range 0-10) verbal and manual feedback during Worst pain 10 6 5 2 5 strengthening exercises and then Avg pain 4 4 2 1 1 during acrobatic activities. The use of a low back taping technique also Lowest pain 1 1 0 1 0 helped increase awareness of a neutral Modified OSW (%) 16 18 Missing 15 2 spine alignment while simultaneously restricting lumbar extension and ro- Table 4 Individualized Activity Measures by Phase of Intervention and at tation. By discharge, she was able Discharge to self-correct her alignment during Activity Phase I Phase II Phase III Phase IV Discharge . The described intervention po- Sitting 4 3 0 0 0 tentially could have been improved Aerials 7 4 2 2 1 by placing a greater emphasis on Hula hooping 8 NA NA 0* 0* controlling lumbopelvic rotation Front walk over 9 2 0 1 0 in the initial phases of treatment. At discharge, the patient reported Back walk over 10 4 NA 1 0 continued LBP symptoms when NA, not applicable because patient did not perform activity in past week; *When performed hula hooping with multiple weighted with one hula hoop. hoops. This continued impairment with rotation-related circus activities by the patient, as measured by the as to what activities were continued may have been recognized sooner if Patient-Specific Functional Scale,4 or discontinued.4 We found that we had included a lower level activity gradually decreased over time (Table having an honest conversation with that involved lumbopelvic rotation 4). By discharge, the length of time the patient about how to participate on the Patient-Specific Functional that she could sit was no longer lim- in sports while eliminating the most Scale.4 Based on our experience with ited due to LBP symptoms. She also exacerbating activities was an effective this case, we recommend including no longer had LBP symptoms with way to assess and progress her home a variety of both high and low diffi- movements requiring end-range lum- exercise program. culty activities on the Patient-Specific bar extension, such as front and back Use of a patient-specific outcome Functional Scale. walkovers. However, aerials and hula measure is a valuable tool in the indi- hooping, which required lumbopelvic vidualization of an exercise program Conclusion rotation, continued to aggravate her for athletes.4 Little change between This case report demonstrates the use LBP symptoms. visits was demonstrated by our pa- of the Patient-Specific Functional After discharge, the patient contin- tient’s scores on the Modified OSW.18 Scale and Movement System Impair- ued training and performing in the A review of specific activities listed on ment examination to individualize circus arts. At 1 year after complet- the Modified OSW, such as personal treatment for a circus performer with ing physical therapy, she reported no care and employment or homemak- LBP. The patient in this case report pain with circus arts activities and was ing, did not help guide treatment be- was highly motivated to continue performing professionally. cause there was no quantifiable change acrobatic activities despite LBP symp- over time.18 In contrast, assessing her toms. Using an outcome measure Discussion difficulty with activities identified on to assess difficulty of activities cho- Athletes often have difficulty comply- the Patient-Specific Functional Scale sen by the patient was informative ing with cessation of all potentially helped inform the decision regard- when guiding gradual resumption injurious activities due to external and ing level of activity resumption and of acrobatics. Education on how to internal pressures to perform despite focus of her home exercise program. avoid movements associated with pain. The intervention described in Because of the unique nature of circus LBP symptoms during exercise and this case report began with an assess- activities, a high level of individualized performance also facilitated return to ment of the patient’s current acrobatic treatment and outcome measurement acrobatic activities. activities; which of those were most is needed. difficult due to LBP, and which were Another key advantage of the inter- Acknowledgments most important for her to resume as vention was that the patient learned to This work was supported by intra- soon as possible. This information was minimize lumbar extension and rota- mural funding from the Program in used to complete the Patient-Specific tion during functional and athletic Physical Therapy at Washington Uni- Functional Scale and inform decisions activities. Initially, she had difficulty versity School of Medicine, St. Louis, 192 Volume 21, Number 4, 2017 • Journal of Dance Medicine & Science

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