Can cervical spine instability cause heart palpitations and blood pressure problems?

Ross Hauser, MD

In this article, we will discuss how chest pain, a racing heartbeat, panic attacks, and anxiety may be coming from a cervical spine and neck instability pressing on the vagus nerve. It is important to realize that this may only be one possible explanation as to why seemingly healthy individuals, having been checked out by their cardiologist, have cardiovascular-type symptoms with seemingly no explanation.

“All of a sudden I had chest pain, chest heaviness, shortness of breath, and my heart was pounding.”

Someone will be in our office. They will tell us a story about a sudden, without cause, the onset of panic attacks. Such as this one:

I had an uncontrolled panic attack while driving to work. There was no new stress in my life, I was not even thinking “bad thoughts,” in fact I was not particularly thinking about anything. All of a sudden I had chest pain, chest heaviness, shortness of breath and my heart was pounding, I thought I was going to pass out. After I calmed down enough to drive again, I went home, laid down, and waited for this to subside. 

When searching for a possible cause of this event, this person revealed to us that she worked for a chiropractor and had a lot of cervical manipulation recently. Upon examination in our office with a digital motion x-ray (see below) it showed an incredible amount of upper cervical instability.  This, we suggested, may be the cause of these and other symptoms she was suffering from including head pressure, history of migraines, sensitivity to sound, intermittent blurry vision, off-balance, as well as brain fog.

A sudden recommendation for anti-anxiety medication – But I don’t think I have anxiety, but what else can it be?

We had a friend who was being recommended to start taking anti-anxiety medication. She wanted another opinion on this. That this friend was being recommended to anti-anxiety medication was somewhat surprising as we knew this person to be one of the calmest, most wonderful people we know. Great mother, great wife, nothing would suggest that she had anxiety. Not even to her.

Like the person above, she had new-onset anxiety, no reason, just happened one day while she was dropping off the kids at school.  When I asked her about her neck prior to the onset of the panic attacks, she gave me a long history of tension in her neck, various types of headaches, chiropractic care, cracking sounds up high on the neck, swishing in the ear, and basically the rest of the signs and symptoms of upper cervical instability.  I sent her to get a digital motion x-ray in her state which was significant for upper and mid cervical instability. We started treatments with Prolotherapy. (This is explained below).

“I was not surprised that my blood pressure was elevated and that I had rapid heart rate. My doctor was.”

Here is another story:

I started having strange and unexplainable heart attack-like, panic attack-like symptoms. These included chest pains, a rapid heartbeat, and breathing difficulties. Of course, this frightened me, I am young, late 20’s, how could I have a heart condition? I did have the classic heart attack warning signs, pain in my chest, pain going down my left arm, breathing difficulties. One particularly bad day I went to Urgent Care because of chest pain and panic. I was assured that I was not having a heart attack but I should visit my primary care doctor as soon as I could. This visit to the doctor reassured me a little, but not a lot. I had an EKG which was fine. I was not surprised that my blood pressure was elevated and that I had a rapid heart rate. I could tell that on my own.

At my primary care doctor, these elevated cardio symptoms were attributed to panic attacks and “white coat syndrome,” the anxiety of being in the doctor’s office and my anxiety about taking the tests. I had had these symptoms before, I did not feel they were “strong” enough to see a doctor because I was convincing myself they were panic attacks. I was just not sure what caused them.

Since I also had pain in my chest when I sneezed or coughed or moved a certain way, my doctor suggested that this was an orthopedic problem and that I should see a specialist. There I learned about these “rare,” problems of “Slipping Rib Syndrome,” and “Costochondritis.” Basically, it was inflammation and a rib problem. I was sent off to physical therapy and told to come back 4 weeks later to see if cortisone would be needed.

The one thing that did stick out during this conversation with my doctor was that when she asked me, “how and when did this all start?” I said I did not know, but at the same time I was becoming aware of the chest pains, I also noticed a developing and significant neck pain. Not in the front of my neck, but in the back of my neck. Which I thought was odd. I would have thought I would have had pain in my throat and jaw area.

I went to therapy and I went back to discuss a cortisone injection because my symptoms were getting worse and increasing. I started feeling faint, I was having dizzy spells, I was feeling nauseous from all this. My doctor was perplexed and suggested that I see an ENT and/or perhaps a neurologist, a cardiologist, a rheumatologist, and a gastrointestinal specialist. I did not understand all this, my EKG was good, my blood tests were fine, the chest x-ray revealed nothing extraordinary. But now, more testing.

This is when I started doing research on my own. When I added up my symptoms and I started searching I came upon information on cervical spine and neck instability and the possible compression of my vagus nerve and my cervical arteries. Things started to make sense. I started researching Heart Rate Variability

Let’s stop here to explain some points. You may have already performed your own research as we find that people who suffer from symptoms like those above have done extensive reading on the internet. We will do a short summary and a video presentation with Ross Hauser, MD.

Summary learning points of this video

At 1:00 of the video, Dr. Hauser refers to this image to describe the impact of compression of the vagus nerve and the glossopharyngeal nerve on heart rate and blood pressure

This image describes the impact of compression of the vagus nerve and the glossopharyngeal nerve on heart rate and blood pressure

This image describes the impact of compression of the vagus nerve and the glossopharyngeal nerve on heart rate and blood pressure

At 2:00 of the video – When a person has cervical instability especially upper cervical instability

At 2:20 of the video, the close proximity of the vagus nerve, the glossopharyngeal nerve, and the spinal accessory nerve to the C1-C2 vertebrae is demonstrated with this image

This image displays the close proximity of the vagus nerve, the glossopharyngeal nerve, and the spinal accessory nerve to the C1-C2 vertebrae. This proximity makes compression of these nerves common in cervical spine instability

This image displays the close proximity of the vagus nerve, the glossopharyngeal nerve, and the spinal accessory nerve to the C1-C2 vertebrae. This proximity makes compression of these nerves common in cervical spine instability.

Brief introduction of Prolotherapy as a treatment for this problem

At 3:00 of the video: We document the cervical instability by scanning with a Digital Motion X-Ray (explained below) and when instability in the C1-C2 region is found, we then tighten the stretched out ligaments with Prolotherapy. These injections are typically given once a month. It causes a tightening of the ligaments and once the cervical spine is made stable again the nerve sensors through the vagus nerve and the glossopharyngeal nerve start working correctly and the arrhythmias go away.

Autonomic nervous system (ANS) regulation and Heart Rate Variability – Is this the answer for some?


If the C1 vertebra is unstable and causes problems of “nerve pinching” this is how upper cervical instability can affect heart rate variable.

There is a difference between Heart Rate and Heart Rate Variability.

To understand what may be happening in these people we need to understand the autonomic nervous system. The autonomic nervous system operates automatically. That is why it is called the autonomic nervous system. By itself, without conscious instruction, the autonomic nervous system keeps your heart pumping, your blood flowing through your blood vessels, your lungs breathing, and a myriad of other activities that occur in your body all the time, every day of your life. Part of that myriad of duties includes the operation of the sympathetic nervous system and parasympathetic nervous system.

So here we have the autonomic nervous system and its components, the sympathetic nervous system and parasympathetic nervous system, that among its duties regulate your heart rate. Its main highway of communication is the vagus nerve of which there are two running down each side of the neck. The vagus nerve has great impact on heart function, as the cardiovascular afferents (afferents – simply the nerve fibers that send message to the brain as opposed to efferents, nerve fibers which send the response back) make up the greatest extent (compared to other organs) of the 85-90% of sensory fibers which make up the vagus nerve.

In other words, the majority of work the vagus nerve does is getting messages back and forth from brain to heart  These afferents (messages in) go through the nodose ganglion (nerve bundle) which sits in front of the atlas (C1 vertebra). If the C1 vertebra is unstable and causes problems of “nerve pinching” this is how upper cervical instability can affect heart rate variable.

Heart rate variability (HRV) monitoring for chronic health conditions and cervical instability cases

Ross Hauser, MD explains how monitoring HRV can be a helpful way to see how a person’s vagal tone and overall health are improving or declining. This is an objective test we have some patients monitor at home and we have a more comprehensive version that we can do in-office.

Summary transcript is below video:

Video summary:

Heart rate variability or HRV measures the functioning of the autonomic nervous system. It measures if the balance between the sympathetic nervous system (fight or flight) and the Parasympathetic system (rest and digest) is good or if this balance is off. When it is good the body is in a good position to heal and regenerate.

We do heart rate variability testing in the office and this testing gives us a sense of how balanced someone’s autonomic nervous system is. When somebody has a high vagal tone meaning their vagus nerves, which are the nerves in the body that give the body health, when the HRV is high, the person has better athletic ability they also have a greater resistance to stress.

When people have a low vagal tone they can’t handle stress, they’re much more prone to getting illnesses, they tend to have depression or they might have other signs like brain fog or melancholy and other psychological conditions. They are easily fatigued.

Diseases associated with low heart rate variability

Brain:

Heart:

Pancreas:

Endocrine:

Liver/Gallbladder:

Female/Male:

Children:

Cancer:

Gastrointestinal:

Autoimmune:

Neurologic:

Systemic:

What are we seeing in this image?

This is a chart that reveals autonomic testing results in a patient we saw in our office.

When hooked up and being monitored we can see that:

A heart rate variability test can give us a picture to show us how the person is doing as a relates to thoughts, memory, relationships. We can also test based on neck motions.

The motion of the neck and heart rate variability

In the above image, we can see that the second most stressful event for this person, besides the stressful memory, was a certain neck motion. In certain people, when they move their neck to a certain position, they can feel their overall body becoming more stressful and this is a real physiologic event that happens to them and the way that we document is with HRV testing.

The testing put patients in different stressor situations. This could include the stress of having to perform mathematical equations and the response to loud noise.

What are we seeing in this image?

First, what is LF (Low Frequency)/HF (High Frequency) ratio?

The LF to HF power (LF/HF ratio) has been used historically as a guide to estimate the ratio between the Sympathetic nervous system and Parasympathetic system activity.  A high ratio meant Sympathetic nervous system dominance and a lower ratio indicated high vagal tone. There is controversy in the medical community over testing parameters. While the LF/HF ratio is commonly used as a measure of Sympathovagal balance, it is primarily valid when used as a baseline.

In this graph image below, a patient had her neck put into a more stable position during the testing phase. This was during neck extension or chin pointing up. In this more stable position, her vagal tone increased drastically and dropped her LF/HF ratio.

Tests before and during treatments

Our treatments are based on restoring the cervical spine curve with Dynamic Ortho Neurologic Correction and Prolotherapy. During treatments we can test for changes, for instance, do certain neck motions or certain stressors still cause the jump in the HRV test? In many patients, we found that when you get the neck in proper alignment and you get the neck stabilized that the person’s overall physiology because their autonomic nervous system is stronger their vagal tone is stronger, the nerve flow through the vagus nerves are better able to handle all different kind of stressors better.

The caveat to that is if a person doesn’t get their neck curvature corrected and their neck into proper alignment and they have continued cervical spine instability, their ability to handle stressors is compromised.

Caring Medical measures both the time- and frequency-domain indices of HRV. Once baseline measurements are taken, they can be compared with those taken when with the patient under various stressors. As health improves, the changes in HRV from baseline lessen.

Many Caring Medical patients, especially those with systemic illnesses and/or cervical instability find monitoring and improving their HRV important to regaining their health. Typically, a finger probe is used which can measure the EKG and this is synced to a cell phone app.  Each morning it is checked, and trends noted.  A person then tests HRV doing various activities and to determine which ones lower and which ones raise their HRV. Just because you like a certain type of music, for instance, does not mean that your nervous system does. On a day when the HRV is low, it is helpful then to do something to raise it, like take a cold shower, meditate, pray or better yet, pray before you take that freezing cold shower! Obviously slowing down the breathing rate and increasing the depth of breaths always has a great effect on HRV. Mostly obtaining a high HRV involves getting adequate sleep and having an attitude of gratefulness.

In summary, dynamic or functional heart rate variability testing can be a valuable asset for somebody trying to overcome chronic health conditions.

Your “mysterious symptoms” and cervical spine problems

Heart Rate Variability has become a new and popular subject for longevity experts and advanced sports science. Simply if your heart is always racing, doesn’t “rest,” if it does not have slow beats with consistent heart rate variable, you are at higher risk for disease and premature death from cardiovascular events. This is not the subject of this article. This article deals with your “mysterious symptoms,” like those explained above. Dizziness, balance issues, panic attacks, loss of consciousness, possible problems with digestion, breathing, headaches, and other possible problems caused by cervical spine instability pressing on the vagus and cervical nerves.

The stories of racing hearts

I had bulging discs up and down my neck. But it is not significant enough to operate on. For now, I would just have to manage along with my neck pain, shoulder pain, and if my heart raced, I should find a quiet place to rest and avoid caffeine and sugary food.

I have been having neck and shoulder pain going on for one year now. I am young, 25, athletic, do a lot of working out in the gym. I woke up one morning, my arm left arm was numb and I had significant shoulder pain. I thought I slept on it wrong, but the numbness persisted, the pain came and went. After a few weeks, I went to the doctor, had an MRI. The doctor said, “nothing wrong here,” and that I should come back if things did not get better on their own.

Things did not get better. A started having significant muscle spasms, a lot of pain. One day when the muscle spasms hit, I started having difficulty breathing, my heart started to race. I do not know if I was having a panic attack or a heart attack but I had a friend get me to the emergency room. I had the x-ray, the chest scans, all the tests, and nothing came up except that I was prone to heart palpitations. Probably nothing to worry about but I should definitely get myself to a cardiologist.

At the cardiologist, they found the same thing, heart palpitations, and rapid heartbeat. Everyone was confused. Maybe I had hyperthyroid, I should see an endocrinologist.

I explained that I did not know if it was my thyroid or panic attacks, all I knew is that I had a problem breathing, spasms in my chest, and chest pain. I was given blood pressure medication, pills to reduce my heart rate, a referral to a thyroid doctor to get a blood work order to have my thyroid checked, and a referral to a cervical spine specialist. In all this, I barely mentioned to the doctor that I was developing not only significant shoulder pain but neck pain as well.

At the neck specialist, it was determined by MRI that I had bulging discs up and down my neck. But it is not significant enough to operate on. For now, I would just have to manage along with my neck pain, shoulder pain, and if my heart raced, I should find a quiet place to rest and avoid caffeine and sugary food. This was not enough for me. I needed to find out what was going on and get this fixed. If this is coming from my neck, I want it fixed.


Structural high blood pressure: hypertension due to atlantoaxial (C1-C2) instability

Ross Hauser, MD, and Brian Hutcheson, DC discuss the neurology behind cases of structural high blood pressure. In this video is a patient interview describing her condition and outcomes of treatment. The patient is very fit and does not meet the typical criteria for high blood pressure, poor diet, smoking, etc. Yet she had uncontrolled hypertension which can be puzzling to their doctors. By following the neurology of the symptoms, we see how upper cervical instability can impair proper vagus nerve input and restrict the blood flow that is necessary for blood pressure regulation. Our approach to cases like hers is to work on cervical curve correction as well as cervical stabilization with upper cervical Prolotherapy.

The results achieved by our patient in this video may not be typical results.

Video transcript summary

The problem for many people is that the neurological sensors for monitoring blood pressure are not working right.

What are we seeing in this image?

This image is referred to in the video above. It is a schematic showing key structures that regulate blood pressure and heart rate variable in the body.

Here we see the two main sensors:

The glossopharyngeal nerve / Carotid baroreceptors connection:

The Vagus Nerve / Aortic Baroreceptors

To briefly review:

The Squeeze / Pressure in the Carotid sheath

The carotid sheath is in the front and both sides of our neck. It lays close to your styloid process which connects to your hyoid bone and also to the anterior (front side) lateral part of your C1 or the first bone in your neck. If there is compression in this area, then the blood pressure is going to be off, and in some cases roller coaster.

We are going to refer to our article Cervical spine compression causes internal jugular vein stenosis for a summary understanding of compression to the carotid sheath, artery, and jugular vein.

Overcrowding in the carotid sheath. Compression in the carotid triangle – The cranial nerves

The carotid sheath is a wrapping of connective tissue or fascia that surrounds the vascular vessels of the neck. It also surrounds the cranial nerves. This is all one neat roll-up of arteries, veins, and nerves. It is also a very tight and compact roll-up packed into this protective tube. But the protective tube can only protect so far. Cervical instability can lead to compression of this tube and all the components within it. This can lead to an impact on the cervical nerves and conditions and symptoms thought to be neurologic in nature.

What are we seeing in this image? A visual description of how compression in the cervical spine can lead to problems with blood pressure.

Here we see that the carotid sheath and all its vital structures lays on top of the C1 Atlas. When the Atlas or C1 starts “wandering” out of place it takes the carotid sheath with it, stretching the arteries, veins, and the glossopharyngeal nerve and vagus nerve or compressing the arteries, veins, and glossopharyngeal nerve, and vagus nerve. When there is compression there can be high blood pressure signaling. When there is stretching, there can be high blood pressure signaling. The person is now suffering from “cardiovascular-like” symptoms.

A visual description of how compression in the cervical spine can lead to the problems of blood pressure.

The idea that upper cervical spine instability impacts heart rate variability and this may be a culprit of your symptoms, is not a new idea.

The idea that upper cervical spine instability impacts heart rate variability and this may be a culprit of your symptoms, is not a new idea. In our 27 years of helping patients with problems related to the cervical spine, we have seen these symptoms many times. Yet medical research is not yet that abundant. In our own peer-reviewed published studies we have been able to document cervical neck ligament damage as a possible cause of low HRV as to when cervical neck ligaments are damaged or weakened by wear and tear damage or injury, they allow the upper cervical instability that can impinge on the cervical nerves. We will be citing this research below. First, we will explore some independent research.

The first two studies, the first being from neurosurgeons, the second from chiropractors, both discuss the benefit of treatment, surgery, or chiropractic care.

In April 2011, in the medical journal Spine, (3) Doctors at the Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences in India examined patients with the suspected autonomic nervous system (ANS) and cervical compressive myelopathy. The researchers noted, “there are no studies on compressive myelopathies.”

So what does nerve compression do?

Study learning points:

The researchers found: “Patients with cervical compressive myelopathy have definite Autonomic nervous system dysfunction as compared to healthy age- and sex-matched controls. There is a significant improvement in the Valsalva ratio after (decompression) surgery.”

For some people, surgery can be an answer. This is not our answer. We will discuss our non-surgical treatments below.

Measurements in Heart Rate Variability as a means to show a treatment is working

Chiropractors in Sweden and Denmark are collaborating on a study (4) in which they can use Heart Rate Variability as a measure to detect if spinal manipulation, by reducing a patient’s pain, is impacting itself on the Autonomic nervous system.

The posterior-cervical sympathetic nervous system signals the sympathetic part of the autonomic nervous system that controls the head, neck, and face area. In cervical spine neck instability or cervicocranial syndrome, the posterior cervical sympathetic system is underactive because the vertebrae in the neck are pinching the sympathetic nerves.

Let’s let the researchers explain:

“The pain-reducing effects of (spinal manipulation therapy) on certain spinal pain conditions are well established, as are the normal reactions to such treatment. However, the mechanisms behind these effects are not well understood, although it is hypothesized that the pain-reducing effects could be mediated through the Autonomic nervous system”

In other words, spinal manipulation helps people by alleviating pain. But how does the manipulation do it? That is “not well understood.” So what the researchers hypothesized is that it must have something to do with the function of the Autonomic nervous system and that they may be able to show this by measuring Heart Rate Variability.

“Therefore, the study of Heart Rate Variability Responses to Spinal Manipulation Therapy as part of a short treatment plan and its relation to pain sensitivity and normal reactions to treatment will advance knowledge regarding the mechanisms involved in the specific effects of Spinal Manipulation Therapy.”

So here there is speculation that short-term pain relief achieved with chiropractic care can be shown by restoring normal heart rate variability.

Research on cervical instability and Prolotherapy treatments. A possible solution to the problems and challenges created by cervical spine instability and pressure on the vagus nerve on heart rate

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult-to-treat musculoskeletal disorders. We are going to refer to one of these studies as they relate to cervical instability and a myriad of related symptoms including the problem of a racing heartbeat, heart rate variability, and high blood pressure.

In our 2014 study (3) we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments.

This is what we wrote:

“There are a number of treatment modalities for the management of chronic neck pain and cervical instability, including injection therapy, nerve blocks, mobilization, manipulation, alternative medicine, behavioral therapy, fusion, and pharmacologic agents such as NSAIDs and opiates. However, these treatments do not address stabilizing the cervical spine or healing ligament injuries, and thus, do not offer long-term curative options.

To date, there is no consensus on the diagnosis of cervical spine instability or on traditional treatments that relieve chronic neck instability issues like those mentioned above. In such cases, patients often seek out alternative treatments for pain and symptom relief. Prolotherapy is one such treatment that is intended for acute and chronic musculoskeletal injuries, including those causing chronic neck pain related to underlying joint instability and ligament laxity. While these symptom classifications should be obvious signs of a patient in distress, the cause of the problems is not so obvious. Further and unfortunately, there is often no correlation between the hypermobility or subluxation of the vertebrae, clinical signs or symptoms, or neurological signs or symptoms. Sometimes there are no symptoms at all which further broadens the already very wide spectrum of possible diagnoses for cervical instability.”

What we demonstrated in this study is that the cervical neck ligaments are the main stabilizing structures of the cervical facet joints in the cervical spine and have been implicated as a major source of chronic neck pain and in the case of racing heartbeat, heart rate variability, and high blood pressure, cervical instability.

Prolotherapy treatments

Prolotherapy is an injection of simple dextrose into the unstable cervical spine. The concept is that these injections will strengthen the cervical ligaments thereby providing a stronger or more stable connection between the cervical vertebrae.

In our practice, we continue to see a large number of patients with a myriad of symptoms, like those described above, related to cervical neck instability. These people are often confused, many times frightened by recommendations to complicated cervical neck surgeries they don’t understand.

Many of these people have been told that their problem is a problem of degenerative cervical disc disease. After years of prolonged pain and conservative care options such as chiropractic, massage, physical therapy, anti-inflammatories, pain medications, cortisone injections, and cervical epidurals that eventually fail, the only recourse, these people are told, is neck surgery.

Surgical recommendations are described in a way that seemingly makes sense as the only solution to degenerative disc disease.

In this video, DMX displays Prolotherapy results as before and after treatments that resolved problems of a pinched nerve in the cervical spine

Surgical treatments for Cervical Instability may chase the wrong problem

In medicine, there are universally accepted equations. When pain cannot be controlled using conservative treatments including physical therapy, chiropractic, and pain medications, there has to be a surgical recommendation. 

In neck and spine surgery, doctors focus on degenerative disc disease and its treatment,   anterior cervical discectomy and fusion, and cervical decompression surgery to remove whole or part of the cervical vertebrae to allow space on compressed nerves and to fix the instability by fusing vertebral segments together. In the case of C1-C2 instability, these two vertebrae are fused posteriorly (behind) to limit their amount of movement.  The goal is to limit pressure on the nerves. To be clear again, for some people surgery is the only way. For many others, surgery can be realistically avoided.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and it helped answer many of the questions you may have surrounding cervical spine instability causing heart palpitations and blood pressure problems. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

References

1 Andani R, Khan YS. Anatomy, Head and Neck, Carotid Sinus. InStatPearls [Internet] 2020 Feb 19. StatPearls Publishing. [Google Scholar]
2 Pirahanchi Y, Bordoni B. Anatomy, Head and Neck, Carotid Baroreceptors. StatPearls [Internet]. 2021 Feb 7. [Google Scholar]
3 Srihari G, Shukla D, Devi BI, Sathyaprabha TN. Subclinical autonomic nervous system dysfunction in compressive cervical myelopathy. Spine. 2011 Apr 15;36(8):654-9. [Google Scholar]
4 Bakken AG, Axén I, Eklund A, O’Neill S. The effect of spinal manipulative therapy on heart rate variability and pain in patients with chronic neck pain: a randomized controlled trial. Trials. 2019 Dec;20(1):1-0. [Google Scholar]
5 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. Open Orthopaedics Journal. 2014;8:326. [Google Scholar]

This article was update April 16, 2021

 

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