Skulder­skade behandling

Skulder­skade er en samlebetegnelse for en rekke tilstander som påvirker skulderleddet og dets omkringliggende strukturer. Disse kan inkludere senebetennelser, rifter i rotator­mansjetten, frossen skulder, instabilitet, brudd, og slitasjegikt. Smertene og funksjonstapet som oppstår kan ha en betydelig innvirkning på dagliglivet, arbeid og fritidsaktiviteter. I Norge finnes det et bredt spekter av behandlingsmetoder og kvalifiserte fagpersoner som kan bistå ved skulderplager. Denne artikkelen gir en oversikt over vanlige behandlinger og de profesjonelle gruppene som vanligvis utfører dem.

Behandling av skulderskader tilpasses individuelt basert på årsak, alvorlighetsgrad, pasientens alder, aktivitetsnivå og generelle helse. En grundig diagnostisk prosess, ofte inkludert klinisk undersøkelse og bildediagnostikk som ultralyd eller MR, ligger til grunn for valget av behandlingsstrategi. Behandlingen kan grovt deles inn i konservativ behandling og kirurgisk behandling. Konservativ behandling fokuserer på å redusere smerte, gjenopprette funksjon og unngå videre skade, mens kirurgi vurderes når konservative tiltak ikke gir tilstrekkelig resultat, eller ved mer alvorlige strukturelle skader.

Konservativ Behandling

Konservativ behandling er ofte førstevalget ved skulderskader og involverer en kombinasjon av hvile, smertelindring, fysioterapi og eventuelt medikamenter. Målet er å la kroppens egne reparasjonsprosesser få jobbe uforstyrret, samtidig som symptomene lindres og funksjonen gradvis gjenopprettes. Tanken her er å gi skulderen den beste sjansen til å lege seg selv, som en hage som får riktig stell for å blomstre.

Smertelindring og Anti-inflammatoriske Tiltak

For å redusere smerte og betennelse, som ofte er fremtredende symptomer ved skulderskader, kan ulike tiltak benyttes.

Medikamentell Behandling

• Ikke-steroide anti-inflammatoriske legemidler (NSAIDs): Legemidler som ibuprofen, naproxen eller diklofenak kan forskrives for å redusere smerte og betennelse. Disse virker ved å hemme enzymer som er involvert i betennelsesprosessen.
• Paracetamol: Kan brukes som et smertelindrende alternativ eller i kombinasjon med NSAIDs, spesielt for milde til moderate smerter.
• Smertestillende kremer og geler: Topiske preparater kan påføres direkte på det smertefulle området for lokal smertelindring.

Andre Smertelindrende Tiltak

• Kulde- og varmeterapi: Påføring av isposer kan redusere akutt betennelse og smerte, spesielt etter en skade. Varmeterapi kan hjelpe med muskelspenninger og øke blodsirkulasjonen ved mer kroniske plager.
• Manuellterapi: Visse teknikker innen manuellterapi kan bidra til å lindre smerte ved å løsne opp spenninger og forbedre bevegelsen i skulderen og omkringliggende strukturer.

Fysioterapi og Rehabilitering

Fysioterapi er en hjørnestein i behandlingen av de aller fleste skulderskader. En fysioterapeut vil utarbeide et individuelt tilpasset treningsprogram som fokuserer på å gjenopprette styrke, bevegelighet, koordinasjon og funksjon.

Spesifikke Fysioterapeutiske Metoder

• Bevegelsestrening: Øvelser for å gjenopprette full bevegelighet i skulderleddet, som kan virke stivt eller begrenset. Dette kan inkludere passive, aktiv-assistive og aktive bevegelser.
• Styrketrening: Gradvis opptrening av muskulaturen rundt skulderen, spesielt rotator­mansjetten og musklene i øvre del av ryggen og nakken. Dette er avgjørende for å stabilisere leddet.
• Tøyninger: For å forbedre fleksibiliteten i musklene og kapselen rundt skulderen, noe som er spesielt viktig ved tilstander som frossen skulder.
• Riktig skuldermekanikk og holdning: Veiledning i hvordan man bruker skulderen optimalt i daglige aktiviteter for å unngå feilbelastning.
• Modaliteter: I tillegg til trening kan fysioterapeuter benytte seg av ulike hjelpemidler som ultralyd, elektrisk stimulering eller trykkbølgebehandling for å supplere treningen og redusere smerte.

Injeksjonsbehandling

I noen tilfeller kan injeksjoner være en del av den konservative behandlingen.

Kortisoninjeksjoner

• Kortikosteroider: Injeksjoner med kortison kan gis direkte inn i det betente området, for eksempel i slim­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­”
• Hyaluronsyreinjeksjoner: Kan brukes ved slitasjegikt for å smøre leddet.
• Platelet-rich plasma (PRP) injeksjoner: Brukes i visse tilfeller, men er mindre etablert og dekkes ikke alltid av det offentlige helsevesenet.

Kirurgisk Behandling

Kirurgi vurderes når konservative behandlingsmetoder ikke gir tilfredsstillende resultater, eller når det foreligger en betydelig strukturell skade. Målet med kirurgi er å reparere skadede strukturer og gjenopprette normal funksjon.

Vanlige Kirurgiske Inngrep

• Rotator­mansjett­reparasjon: Ved en skade eller komplett rift i rotator­mansjetten kan det være nødvendig å suturere eller feste de avrevne senene tilbake til beinet. Dette gjøres ofte artroskopisk (kikkhullskirurgi).
• Artroskopi: En minimalt invasiv teknikk der kirurger bruker et lite kamera og spesialverktøy for å diagnostisere og behandle tilstander som betennelse i leddkapselen, fjerning av betent vev, eller reparasjon av små rifter.
• Acromioplastikk: Operasjon for å utvide plassen under skulder­tak­benet (acromion), ofte utført ved impingement­syndrom for å redusere irritasjon av senene.
• Stabiliserende kirurgi: Ved gjentatt skulder­ute­ledd­ning (luksasjon) kan kirurgi være nødvendig for å stramme opp leddkapselen eller feste løse bindevev for å forhindre ytterligere ustabilitet.
• Protesereseksjon: Ved omfattende slitasjegikt (artrose) der leddet er sterkt nedbrutt, kan utskifting av skulderleddet med en protese være aktuelt.

Hvilke Profesjonelle Grupper Behandler Skulder­skader i Norge?

I Norge er det flere fagpersoner som har kompetanse til å diagnostisere og behandle skulderskader. Valget av behandler vil avhenge av plagens art, alvorlighetsgrad og pasientens behov.

Fastlege

Din fastlege er ofte det første kontaktpunktet ved skulderplager. Fastlegen kan:

• Foreta en innledende vurdering: Lytte til din sykehistorie, foreta en fysisk undersøkelse og vurdere dine symptomer.
• Sette i gang initial behandling: Forskreve smertestillende, gi råd om hvile og eventuelt henvise til fysioterapi.
• Vurdere behovet for videre utredning: Ved mistanke om mer alvorlige tilstander kan fastlegen henvise til bildediagnostikk eller spesialist.
• Henvisning til spesialist: Om nødvendig, vil fastlegen henvise deg videre til en ortoped eller annen relevant spesialist.

Fysioterapeut

Fysioterapeuter spiller en sentral rolle i rehabiliteringen av skulderskader. De er utdannet til å vurdere, diagnostisere og behandle bevegelsesapparatsykdommer.

Fysioterapeutens Rolle

• Skreddersydd treningsprogram: Utvikler og tilpasser øvelser for å styrke, tøye og forbedre bevegelsen i skulderen.
• Manuell behandling: Kan utføre teknikker som mobilisering, manipulasjon og muskulær behandling for å lindre smerte og stivhet.
• Rådgivning: Gir veiledning om smertehåndtering, ergonomi, aktivitetsmodifikasjon og forebygging av nye skader.
• Opptrening etter operasjon: Er avgjørende for en vellykket postoperativ rehabilitering.

Ortoped

Ortopeder er spesialister i kirurgi og medisin innenfor bevegelses­apparatet. De har den høyeste kompetansen innenfor diagnostikk og behandling av skader og sykdommer i muskler, skjelett, ledd og nerver.

Ortopedens Rolle

• Spesialistvurdering: Foretar grundige undersøkelser, inkludert tolking av bildediagnostikk (røntgen, CT, MR, ultralyd).
• Diagnostisering: Stiller endelig diagnose for komplekse skulderlidelser.
• Kirurgisk behandling: Utfører operasjoner på skulderen ved behov, fra små artroskopiske inngrep til større rekonstruksjoner eller proteser.
• Medisinsk behandling: Kan foreskrive mer spesifikke medisiner eller vurdere andre ikke-kirurgiske behandlingsalternativer.

Kiropraktor

Kiropraktorer er autoriserte helse­profesjonelle som diagnostiserer, behandler og forebygger funksjonelle plager i bevegelses­apparatet.

Kiropraktorens Rolle

• Muskel- og skjelett­behandling: Fokuserer på sammenhengen mellom ryggsøylen, bekkenet og ekstremitetene, inkludert skulderen.
• Justering og mobilisering: Kan utføre manipulasjons- og mobiliseringsteknikker for å gjenopprette optimal funksjon i ledd og vev.
• Tilleggsbehandling: Kan også benytte seg av andre metoder som tøyninger, øvelser og rådgivning.

Naprapat

Naprapater jobber med pasienter som har smerter og nedsatt funksjon i muskel- og skjelettsystemet. De har en medisinsk utdanning med fokus på manuell medisin.

Naprapatens Rolle

• Diagnostisering og behandling: Vurderer og behandler funksjonelle plager i muskler og ledd.
• Manuell terapi: Benytter seg av manipulasjon, mobilisering, massasje og etterspurt behandling.
• Treningsveiledning: Gir øvelser og råd for selvhjelp og forebygging.

Idrettsfysioterapeut og Spesialiserte Fysioterapeuter

Enkelte fysioterapeuter har videreutdanning og spesialisering innen idrettsskader eller spesifikke områder som skulderrehabilitering. De kan tilby enda mer målrettet og avansert behandling.

Andre Fagpersoner

Avhengig av den spesifikke skulder­skaden, kan andre fagpersoner være involvert:

• Radiolog: Tolker bildediagnostikk som MR og CT­-skanning­er.
• Reumatolog: Ved mistanke om betennelsessykdommer i ledd som kan påvirke skulderen.
• Ergoterapeut: Kan bistå med tilpasning av hjelpemidler og strategier for å mestre dagliglivets utfordringer med nedsatt skulderfunksjon.

Behandlingsforløp og Samarbeid

Det er viktig å understreke at behandlingen av skulderskader ofte innebærer et samarbeid mellom ulike fagpersoner. Et typisk forløp kan være at fastlegen henviser til fysioterapeut, som igjen kan henvise videre til ortoped dersom tilstanden ikke bedres, eller ved behov for kirurgi. Imidlertid er dette ikke en fast mal, og veien til bedring kan se svært forskjellig ut for ulike individer.

Diagnostisk Prosess

En presis diagnose er fundamentet for effektiv behandling. Denne prosessen starter som regel ved kontakt med primærhelsetjenesten, ofte fastlegen.

Klinisk Undersøkelse

Den faglige vurderingen vil typisk inkludere:

• Anamnese: En grundig samtale om dine symptomer, skadehistorikk, tidligere plager, livsstil og aktivitetsnivå. Dette er som å samle puslebrikker for å forstå hele bildet.
• Fysisk testing: Spesifikke tester som vurderer bevegelighet, styrke, stabilitet og smerte­respons i skulderen. Dette kan involvere passiv og aktiv bevegelse, samt motstandstester.

Bildediagnostikk

Ved behov for mer detaljert informasjon kan følgende metoder benyttes:

• Røntgen: Kan påvise brudd, feilstillinger og tegn på slitasjegikt.
• Ultralyd: Er spesielt nyttig for å vurdere bløt­­­­­­­deler som sener (rotator­mansjetten) og slim­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­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