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Samenvatting Clinical Sports Medicine met aanvullingen
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Uitgebreide samenvatting (386 pagina's) van Clinical Sports Medicine, uitgebreid met relevante literatuur voor de fysiotherapie.
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Keesjan HeerikhuisenMsc. Sportfysiotherapeut | Hogeschool Rotterdam
CLINICAL SPORTS MEDICINE
Samenvatting
Met toevoegingen uit Extremiteiten (R. Schuitemaker en D.L. van Egmond; 2006),
Dynamiek van het menselijk bindweefsel (J.J. de Morree; 2014), Sportgericht©,
Fysiopraxis©, Musculoskeletale aandoeningen in de sport (R. van Cingel; 2008-2012),
Orthopedische Casuïstiek (K. van Nugteren en D. Winkel; 2008-2016) VSG-Richtlijnen,
KNGF-Richtlijnen en gepubliceerde artikelen (PubMed).
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,Masteropleiding Sportfysiotherapie Clinical Sports Medicine
INHOUDSOPGAVE
Hoofdstuk 4: Acute Sportblessures ....................................................................................................................... 18
Botweefsel ........................................................................................................................................................ 18
Gewricht ........................................................................................................................................................... 18
Gewrichtskraakbeen..................................................................................................................................... 18
Consequenties voor de praktijk .................................................................................................................... 19
Ligamenten en spieren ..................................................................................................................................... 19
Beschadiging van het bindweefsel ............................................................................................................... 20
Herstel van beschadigd bindweefsel ............................................................................................................ 20
Functioneel herstel ....................................................................................................................................... 21
Consequenties voor de praktijk .................................................................................................................... 22
Artikelen Sportgericht© (Sportgericht 1/2018) ................................................................................................. 23
Sportblessures vanuit neuropathisch perspectief ........................................................................................ 23
Belasting en belastbaarheid van bindweefsel .................................................................................................. 24
De invloed van stress op de kwaliteit van bindweefsel ................................................................................ 25
Cortisol, corticosteroïden en hun invloed op bindweefsel .......................................................................... 25
Metaforen als hulpmiddel bij patiëntvoorlichting ....................................................................................... 26
Hoofdstuk 5: Overbelastingsblessures .................................................................................................................. 27
Botoverbelasting............................................................................................................................................... 27
Osteïtis en periostitis ........................................................................................................................................ 28
Peesoverbelastingsletsels (Jill Cook en Craig Purdam) ..................................................................................... 28
Artikel Sportgericht (2017, nummer 2)............................................................................................................. 29
Van tendinitis en tendinose naar tendinopathie: Behandeling van sporters met peesklachten ................. 29
Artikel Sportgericht (2019, nummer 6) ............................................................................................................. 31
Verschillen tussen pezen in het boven- en onderlichaam bij de behandeling van tendinopathie (prof. Jill
Cook) ............................................................................................................................................................ 31
Hoofdstuk 8: Klinische aspecten van biomechanica en sportblessures ................................................................ 33
De ideale biomechanica van de onderste extremiteit – de basis ..................................................................... 33
Beweging van het gewricht van de onderste ledemaat ............................................................................... 33
Staande neutrale positie .............................................................................................................................. 34
Biomechanica bij beweging – hardlopen .......................................................................................................... 34
Hiellanding (hiellanding tot voet plat) .......................................................................................................... 34
Midstance (voet plat naar hak van de grond) .............................................................................................. 35
Afzetfase (hak van de grond naar teen van de grond) ................................................................................. 35
Hak- en voorvoetlanding vergelijken............................................................................................................ 36
Biomechanisch onderzoek van de onderste extremiteit .................................................................................. 36
Structureel (statisch) biomechanisch onderzoek ......................................................................................... 36
Functionele tests van de onderste extremiteit ............................................................................................ 37
Biomechanica van de bovenste extremiteit ..................................................................................................... 38
Biomechanica van het werpen ..................................................................................................................... 38
Normale biomechanica van de scapula tijdens het werpen ........................................................................ 40
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,Masteropleiding Sportfysiotherapie Clinical Sports Medicine
Hoofdstuk 9: Basisprincipes van blessurepreventie.............................................................................................. 41
Systematische blessurepreventie ..................................................................................................................... 41
Interne risicofactoren ................................................................................................................................... 42
Externe risicofactoren .................................................................................................................................. 42
Provocerend moment .................................................................................................................................. 42
Voordelen en beperkingen van het model ................................................................................................... 42
Warming-up ...................................................................................................................................................... 42
FIFA 11+ Warming-Up .................................................................................................................................. 43
Preventie en prestatiegericht rekken ............................................................................................................... 44
De timing van het rekken is essentieel ......................................................................................................... 44
Stof tot nadenken – specificiteit van rekken en mogelijke werkingsmechanismen..................................... 44
De functies van verschillende soorten rekoefeningen ................................................................................. 44
Tapen en bracen ............................................................................................................................................... 45
Taping ........................................................................................................................................................... 45
Bracing .......................................................................................................................................................... 45
Beschermende uitrusting.................................................................................................................................. 45
Geschikte uitrusting .......................................................................................................................................... 45
Hardloopschoenen ....................................................................................................................................... 45
Hardloopspikes ............................................................................................................................................. 46
Voetbalschoenen .......................................................................................................................................... 47
Tennisrackets................................................................................................................................................ 47
Geschikte ondergrond ...................................................................................................................................... 48
De juiste training............................................................................................................................................... 49
Trainingsprincipes en trainingswetmatigheden ........................................................................................... 49
Trainingsmethoden ...................................................................................................................................... 50
Training van kracht en vermogen ..................................................................................................................... 51
Isotonische krachttraining ............................................................................................................................ 51
Plyometrische training ................................................................................................................................. 51
Snelheidstraining .......................................................................................................................................... 51
Specifieke vaardigheidstraining.................................................................................................................... 51
Crosstraining................................................................................................................................................. 53
Voldoende herstel ........................................................................................................................................ 53
KRS (Kracht Revalidatie Systeem) ..................................................................................................................... 53
Artikelen Sportgericht....................................................................................................................................... 55
Wat werkt bij sportblessurepreventie? ........................................................................................................ 55
Een snelle toename van belasting; belangrijkste oorzaak sportblessures ................................................... 56
Hoofdstuk 11: Principes van de diagnose: Klinisch onderzoek ............................................................................. 60
Een diagnose stellen ......................................................................................................................................... 60
Anamnese ..................................................................................................................................................... 60
Onderzoek .................................................................................................................................................... 60
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,Masteropleiding Sportfysiotherapie Clinical Sports Medicine
Hoofdstuk 13: Behandeling voor muskuloskeletale aandoeningen ...................................................................... 62
Acute behandeling ............................................................................................................................................ 62
Immobilisatie en vroege mobilisatie................................................................................................................. 62
Beschermde mobilisatie ............................................................................................................................... 63
Continue passieve beweging ........................................................................................................................ 63
Geneesmiddelen ............................................................................................................................................... 63
Analgetica ..................................................................................................................................................... 63
Corticosteroïden ........................................................................................................................................... 65
Manuele therapie ............................................................................................................................................. 65
Gewrichtsmobilisatie .................................................................................................................................... 65
Hoofdstuk 14: Core Stability ................................................................................................................................. 66
Anatomie .......................................................................................................................................................... 66
Ossale en ligamentaire structuren ............................................................................................................... 66
De thoracolumbale fascie ............................................................................................................................. 67
Paraspinale spieren ...................................................................................................................................... 67
Quadratus lumborum ................................................................................................................................... 67
Buikspieren ................................................................................................................................................... 67
Heupgordelspieren ....................................................................................................................................... 67
Diafragma en bekkenbodem ........................................................................................................................ 67
Onderzoek van de core stability ....................................................................................................................... 68
Trainen van de coremusculatuur ...................................................................................................................... 68
Viscositeit van wervelkolom en bekken verminderen ................................................................................. 68
biofeedback en real-time echografie ........................................................................................................... 68
Stabiliteitsonderzoek en training ................................................................................................................. 68
Functionele progressie ................................................................................................................................. 68
Hoofdstuk 15: Principes van revalidatie................................................................................................................ 69
Spierconditionering .......................................................................................................................................... 70
Spieractivatie en motorische controle ......................................................................................................... 70
Spierkracht en uithoudingsvermogen .......................................................................................................... 70
Cardiovasculaire fitheid ................................................................................................................................ 70
Flexibiliteit (gewrichten en spieren) ............................................................................................................. 70
Proprioceptie ................................................................................................................................................ 70
Functionele oefeningen ................................................................................................................................ 71
Sportspecifieke vaardigheden ...................................................................................................................... 71
Correctie van biomechanische afwijkingen .................................................................................................. 71
Fasen van revalidatie ........................................................................................................................................ 71
Beginfase ...................................................................................................................................................... 71
Tussenfase/pre-participatiefase ................................................................................................................... 71
Gevorderde fase ........................................................................................................................................... 72
Return-to-play .............................................................................................................................................. 72
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,Masteropleiding Sportfysiotherapie Clinical Sports Medicine
Secundaire preventie ........................................................................................................................................ 72
Progressie van de revalidatie ............................................................................................................................ 72
Soort activiteit .............................................................................................................................................. 72
Duur van de activiteit ................................................................................................................................... 72
Frequentie .................................................................................................................................................... 72
Intensiteit ..................................................................................................................................................... 72
Complexiteit van de activiteit ....................................................................................................................... 73
Revalidatieprogramma’s monitoren ................................................................................................................. 73
Psychische strategieën om het herstel te bevorderen ..................................................................................... 73
Conclusie ........................................................................................................................................................... 73
Hoofdstuk 17: Hersenschudding en hoofdletsel bij het sporten .......................................................................... 74
Definitie van een hersenschudding .................................................................................................................. 74
Preventie van een hersenschudding................................................................................................................. 74
Pathofysiologie van een hersenschudding ....................................................................................................... 74
Klachten en symptomen ................................................................................................................................... 74
Behandeling van een hersenschudding ............................................................................................................ 75
SCAT 5 ........................................................................................................................................................... 76
Return-to-play na een hersenschudding .......................................................................................................... 81
Algemene aandachtspunten bij hoofdletsel ..................................................................................................... 82
Etiologie ........................................................................................................................................................ 82
Intern en extern letsel .................................................................................................................................. 82
Classificatie en pathofysiologie .................................................................................................................... 82
Hoofdstuk 18: Hoofdpijn ....................................................................................................................................... 84
Veel voorkomende oorzaken van hoofdpijn: ................................................................................................... 84
Hoofdpijn en sport ............................................................................................................................................ 84
Vasculaire hoofdpijn ......................................................................................................................................... 84
Migraine ....................................................................................................................................................... 84
Clusterhoofdpijn ........................................................................................................................................... 85
Cervicogene hoofdpijn ...................................................................................................................................... 85
Sportgerelateerde oorzaken van hoofdpijn ...................................................................................................... 86
Hoofdstuk 19: Aangezichtsletsel ........................................................................................................................... 87
Functionele anatomie van het aangezicht ........................................................................................................ 87
Aangezichtsletsel .............................................................................................................................................. 87
Neus.............................................................................................................................................................. 88
Oor................................................................................................................................................................ 88
Oog ............................................................................................................................................................... 89
Tanden .......................................................................................................................................................... 89
Botfracturen in het aangezicht ......................................................................................................................... 89
Hoofdstuk 20: Nekpijn .......................................................................................................................................... 90
KNGF Richtlijn Nekpijn (2016)........................................................................................................................... 92
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,Masteropleiding Sportfysiotherapie Clinical Sports Medicine
Behandelprofielen ........................................................................................................................................ 96
Nekpijnsyndromen ........................................................................................................................................... 98
Conclusie ........................................................................................................................................................... 99
Hoofdstuk 21: Schouderklachten .......................................................................................................................... 99
Functionele anatomie ....................................................................................................................................... 99
Artrokinematica en osteokinematica van de schouder .................................................................................... 99
Humerus ....................................................................................................................................................... 99
Scapula ....................................................................................................................................................... 100
Clavicula...................................................................................................................................................... 102
Innervatie........................................................................................................................................................ 102
Bewegingskoppelingen ................................................................................................................................... 105
Klinisch perspectief ......................................................................................................................................... 105
Anamnese ................................................................................................................................................... 106
Onderzoek .................................................................................................................................................. 106
Aanvullende onderzoeken.......................................................................................................................... 107
Behandeling van veelvoorkomende schouderaandoeningen ........................................................................ 107
Subacromiaal Pijnsyndroom (SAPS) ........................................................................................................... 108
Rotator cuff-letsels ..................................................................................................................................... 115
Letsels aan het labrum glenoïdale .............................................................................................................. 115
Luxaties van het glenohumeraal gewricht ................................................................................................. 116
Instabiliteit ................................................................................................................................................. 117
Hill-Sachs leasie .......................................................................................................................................... 118
SNN-praktijkrichtlijn Adhesieve capsulitis (Frozen Shoulder) .................................................................... 118
Acuut acromio-claviculair gewrichtsletsel .................................................................................................. 125
Zwemschouder ........................................................................................................................................... 126
Referred pain .............................................................................................................................................. 128
Overige (minder frequente) schouderaandoeningen ................................................................................ 128
Thoracic Outlet Syndrome (TOS) ................................................................................................................ 129
Laesie van de n. thoracicus longus ............................................................................................................. 129
Laesie van de n. accessorius ....................................................................................................................... 129
Praktische aanbevelingen voor schouderrevalidatie (zonder operatie) ......................................................... 130
Praktische aanbevelingen voor schouderrevalidatie (na operatie) ................................................................ 130
Acute fase ................................................................................................................................................... 130
Herstelfase ................................................................................................................................................. 131
Functionele fase ......................................................................................................................................... 131
Scapular Rehabilitation Algorithm (Cools) ................................................................................................. 131
Factoren die een normaal herstelproces kunnen belemmeren ..................................................................... 132
Artikelen Sportgericht (2017, nummer 2 en 3) (2017, nummer 1 en 5) ......................................................... 132
Weer sporten na een stabiliserende schouderoperatie? ........................................................................... 132
Motor control bij een pijnlijke schouder .................................................................................................... 133
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,Masteropleiding Sportfysiotherapie Clinical Sports Medicine
Hoofdstuk 22: Pijn aan de elleboog en arm ........................................................................................................ 137
Functionele anatomie ..................................................................................................................................... 137
Functionele aspecten van de elleboogregio ............................................................................................... 138
Stabiliteit van de elleboog .......................................................................................................................... 138
Innervatie ................................................................................................................................................... 140
Artrokinematica en osteokinematica: Beweeggedrag in de keten ................................................................. 140
Ulna en radius ............................................................................................................................................ 140
Laterale elleboogpijn ...................................................................................................................................... 142
Klinisch perspectief .................................................................................................................................... 142
Mediale elleboogpijn ...................................................................................................................................... 144
Klinisch perspectief .................................................................................................................................... 144
Posterieure elleboogpijn ................................................................................................................................ 146
Bursitis olecrani .......................................................................................................................................... 146
Posterieur impingement............................................................................................................................. 146
Acuut elleboogletsel ....................................................................................................................................... 147
Fracturen .................................................................................................................................................... 147
Luxaties....................................................................................................................................................... 147
Peesrupturen .............................................................................................................................................. 148
Beknelling van de nervus interosseus posterior (radiaal tunnelsyndroom) ............................................... 148
Artikelen Sportgericht (2017, nummer 1) en Artikel Physios (2015, nummer 3) ........................................... 149
Niet alles is een tenniselleboog bij de bovenhandse sporter ..................................................................... 149
Elleboogklachten bij de bovenhandse sporter ........................................................................................... 149
Hoofdstuk 23: Polsklachten ................................................................................................................................ 153
Functionele Anatomie .................................................................................................................................... 153
Functionele aspecten van de distale onderarmverbinding en het TFCC .................................................... 153
Functionele en biomechanische aspecten van de carpus .......................................................................... 154
Sturing en stabilisatie van de carpus .......................................................................................................... 155
Bijzondere gewrichtsposities en capsulair patroon ................................................................................... 155
Artrokinematica van de pols ........................................................................................................................... 156
Functionele ketens in de carpus ................................................................................................................. 156
Artrokinematica van de carpus .................................................................................................................. 156
Acute polsblessures (algemeen) ..................................................................................................................... 157
Klinisch perspectief .................................................................................................................................... 157
Fracturen ........................................................................................................................................................ 159
Luxatie van de carpale beenderen ............................................................................................................. 160
Subacute en chronische polsklachten ............................................................................................................ 160
Extra-articulaire aandoeningen .................................................................................................................. 161
Turnpols: Letsels aan de distale epifyse van de radius............................................................................... 162
Gevoelloosheid en pijn aan de hand .......................................................................................................... 164
Hoofdstuk 24: Hand- en vingerletsels ................................................................................................................. 165
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,Masteropleiding Sportfysiotherapie Clinical Sports Medicine
Artrokinematica en osteokinematica van de gewrichten van de duim .......................................................... 165
Het CMC-gewricht van de duim ................................................................................................................. 165
Het MCP-gewricht van de duim ................................................................................................................. 166
Het IP-gewricht van de duim ...................................................................................................................... 166
Artrokinematica en osteokinematica van de gewrichten van de vingers ....................................................... 166
De CMC-gewrichten II-V ............................................................................................................................. 166
De MCP-gewrichten II-V ............................................................................................................................. 166
De PIP-gewrichten II-V ................................................................................................................................ 167
Letsels aan vingers en hand ............................................................................................................................ 167
Etiologie ...................................................................................................................................................... 167
Klinisch perspectief .................................................................................................................................... 168
Fracturen van de metacarpalia ....................................................................................................................... 169
Metacarpale I ............................................................................................................................................. 169
Fracturen van de andere metacarpalia ...................................................................................................... 169
Fracturen van de falangen .............................................................................................................................. 169
Proximale falanxfracturen .......................................................................................................................... 169
Fracturen van de middelste falangen ......................................................................................................... 169
Distale falanxfracturen ............................................................................................................................... 170
Luxatie van de metacarpofalangeale gewrichten ........................................................................................... 170
Luxaties van de vingergewrichten .................................................................................................................. 170
Luxaties van het PIP-gewricht .................................................................................................................... 170
Luxaties van het DIP-gewricht .................................................................................................................... 170
Ligament- en peesletsels ................................................................................................................................ 170
Skiduim: Distorsie van het ulnaire collaterale ligament van het eerste metacarpofalangeale gewricht of
MCP-gewricht ............................................................................................................................................. 170
Letsels aan het radiaire collaterale ligament van het eerste MCP-gewricht .............................................. 170
Kapseldistorsie van het eerste MCP-gewricht ............................................................................................ 171
Distorsie van het PIP-gewricht ................................................................................................................... 171
Malletvinger ............................................................................................................................................... 171
Boutonnière-deformiteit ............................................................................................................................ 171
Avulsie van de pees van de flexor digitorum profundus ............................................................................ 171
Trigger finger .............................................................................................................................................. 172
Hoofdstuk 25: Pijn aan de thoracale wervelkolom en borst ............................................................................... 172
Pijn aan de thoracale wervelkolom ................................................................................................................ 172
Klinisch perspectief .................................................................................................................................... 172
Aandoeningen aan thoracale intervertebrale gewrichten ......................................................................... 174
Aandoeningen aan de costovertebrale en costotransversale gewrichten ................................................. 174
De ziekte van Scheuermann ....................................................................................................................... 174
T4-syndroom .............................................................................................................................................. 174
Een dysbalans in de houding van de nek, schouders en thoracale wervelkolom ...................................... 175
Pijn op de borst ............................................................................................................................................... 175
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,Masteropleiding Sportfysiotherapie Clinical Sports Medicine
Klinisch perspectief .................................................................................................................................... 176
Ribtrauma ................................................................................................................................................... 177
Referred pain vanuit de thoracale kolom ................................................................................................... 177
Aandoeningen aan het sternoclaviculair gewricht ..................................................................................... 178
Ostochondritis (Syndroom van Tietze) ....................................................................................................... 178
Stressfractuur van de ribben ...................................................................................................................... 179
Ruptuur van de m. obliquus internus ......................................................................................................... 179
Hoofdstuk 26: Lage rugpijn ................................................................................................................................. 180
Epidemiologie ................................................................................................................................................. 180
Klinisch perspectief ......................................................................................................................................... 180
Aandoeningen die lagerugpijn veroorzaken en waarbij een definitieve diagnose gesteld kan worden .... 180
Somatische lage rugpijn ............................................................................................................................. 181
Functionele (klinische) instabiliteit bij lage rugpijn .................................................................................... 181
Anamnese ................................................................................................................................................... 182
Lichamelijk onderzoek ................................................................................................................................ 182
KNGF Richtlijn - Lage rugpijn (2013) ............................................................................................................... 183
Prognose en beloop.................................................................................................................................... 183
Profielen lage rugpijn ................................................................................................................................. 186
Acute zenuwwortelcompressie ...................................................................................................................... 188
Etiologie ...................................................................................................................................................... 188
Klinische kenmerken .................................................................................................................................. 188
Stressfractuur van de pars interarticularis ..................................................................................................... 189
Etiologie ...................................................................................................................................................... 189
Klinische kenmerken .................................................................................................................................. 189
Behandeling ................................................................................................................................................ 189
Lumbale hypermobiliteit ................................................................................................................................ 189
Hoofdstuk 27: Pijn in de bilstreek ....................................................................................................................... 190
Klinisch perspectief ......................................................................................................................................... 191
Anamnese ................................................................................................................................................... 191
Onderzoek .................................................................................................................................................. 191
Aanvullend onderzoek ................................................................................................................................ 192
Referred pain vanuit de lumbale wervelkolom .............................................................................................. 192
Aandoeningen aan het SI-gewricht................................................................................................................. 193
Etiologie en functionele anatomie ............................................................................................................. 194
Klinische kenmerken .................................................................................................................................. 194
Risicofactoren ............................................................................................................................................. 194
Behandeling ................................................................................................................................................ 194
Hamstrings origo tendinopathie ..................................................................................................................... 195
Etiologie en klinische kenmerken ............................................................................................................... 195
Behandeling ................................................................................................................................................ 195
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, Masteropleiding Sportfysiotherapie Clinical Sports Medicine
Bursitis Ischiadica............................................................................................................................................ 195
Minder vaak voorkomende oorzaken ............................................................................................................. 196
Blessure aan de quadratus femoris ............................................................................................................ 196
Stressfractuur van het os sacrum ............................................................................................................... 196
Proximale avulsieletsels van de hamstrings/apofysitis/avulsiefractuur van het tuber ischiadicum .......... 196
Aandoeningen aan de piriformis ................................................................................................................ 197
Hoofdstuk 28: Heupgerelateerde pijn................................................................................................................. 197
Functionele Anatomie .................................................................................................................................... 197
Passieve gewrichtsstabiliteit ...................................................................................................................... 198
Actieve gewrichtsstabiliteit ........................................................................................................................ 200
Anatomie van het bovenbeen .................................................................................................................... 201
Neurofysiologische aspecten van de heupregio......................................................................................... 202
Artrokinematica en osteokinematica van de heup ......................................................................................... 202
Flexie en (hyper)extensie (S=0o) ................................................................................................................. 202
Abductie en adductie (S=0o) ....................................................................................................................... 202
Horizontale abductie en horizontale adductie (S=0o) ................................................................................ 203
Exorotatie en endorotatie (S=0o)................................................................................................................ 203
Frontale exorotatie en frontale endorotatie (S=90o) ................................................................................. 203
Klinisch perspectief ......................................................................................................................................... 204
Kinderen ..................................................................................................................................................... 204
Heupgerelateerde pijn bij sporters ............................................................................................................ 205
Ziekten en aandoeningen van het bot-spierstelsel en bindweefsel van het heupgewricht ....................... 205
Femoraal-acetabulair impingement ........................................................................................................... 206
Labrumlaesies ............................................................................................................................................. 208
Rupturen van het ligamentum teres .......................................................................................................... 209
Synovitis ..................................................................................................................................................... 209
Chondropathie en artrose .......................................................................................................................... 210
Congenitale heupdysplasie......................................................................................................................... 212
Epiphysiolysis capitis femoris ..................................................................................................................... 212
Ziekte van Perthes ...................................................................................................................................... 212
Traumatische, exogene ziekten en aandoeningen van het heupgewricht ................................................. 212
Trochanter major pijnsyndroom (TMP) ...................................................................................................... 213
Factoren die kunnen bijdragen aan het ontstaan van heupgerelateerde pijn ............................................... 214
Extrinsieke factoren .................................................................................................................................... 214
Intrinsieke factoren .................................................................................................................................... 214
Operatieve behandeling van heupklachten .................................................................................................... 215
Revalidatie bij heupaandoeningen ................................................................................................................. 215
Het ontlasten en beschermen van beschadigde of mogelijk kwetsbare structuren .................................. 215
Herstel van de normale dynamica en neuromotorische controle ............................................................. 215
Criteria om weer te gaan sporten .............................................................................................................. 216
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