ASSIGNMENT TITLE:
“THE EFFECT OF STRETCHING TO RELIEF SPASTICITY AND/OR
CONTRACTURE IN PEOPLE WITH STROKE ”
MODULE CODE: ADV 702
MODULE TITLE: APPLYING EVIDENCE TO PRACTICE
MODULE LEAD: KEITH WALKER
Student Number: 10566188.
Word Count: 4,327.
Evidence Based Practice is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients (Guyatt, 1991). It also requires that decisions about health care are based on the best available, current, valid and relevant evidence, these decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources (Sacket et al., 1996).
There is pressure to justify both the choices made for particular clients and patterns of practice “by reference to a body of evidence about efficiency and effectiveness” (Gomm and Davies, 2000). Consequently, evidence based practice has become a preoccupation for those therapist who seek to inform their interventions with a sound knowledge base (Hammel, 2001). Without recourse to research evidence, the reasoning process is dependent upon the intuition, trial and error and perpetuation of formerly fashionable routines (Ritchie, 1999).
Stroke is the leading cause of disability in the UK (Stroke association, 2014). Stroke is defined by the World Health Organization (WHO) as a clinical syndrome consisting of rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than twenty-four hours or leading to death with no apparent cause other than that of vascular origin. Stroke is the third leading cause of death after heart disease and cancer (Geyer et al., 2009; Truelson et al., 2000).People who have experienced a cerebrovascular accident (stroke) may exhibit an increased resistance to passive joint movement, decreased joint range of motion, and some exaggerated stretch reflexes. Researchers and clinicians have frequently described some of these symptoms as components of spasticity, defined as “a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes with exaggerated tendon jerks, resulting from hyper excitability of the stretch reflex (Lance, 1980). Some researchers have argued that changes in passive mechanical properties of muscle may be the additional mechanism responsible for symptoms observed in people with spasticity (Ibrahim et al., 1993).
Malhotra (2008) stated that spasticity normally occurs because of abnormal muscle activity that results from the disinhibition following a stroke. Lack of mobilization and prolonged spasticity may be accompanied by structural changes of muscle fibres and connective tissue, which may result in reduction on joint range of motion (ROM) and a clinical contracture (Rymer and Katz, 1994).Contracture are characterized by a reduction in joint range of motion or an increase in resistance to passive joint movement (Fergusson, 2007), both limiting joint mobility. Contractures are due to both neurally and non-neurally factors; neurally mediated factors refer to spasticity which directly limits the extensibility of the muscle-tendon unit while the non-neurally mediated factors is refered to structural changes in the muscle-tendon unit and other soft tissue structures overlying joints which together limit joint mobility (Lieber, 2004). Structural changes within the musculo-tendinous structures because of reduced use, disuse or fixed positioning of the limb segment in shortened position may therefore contribute to contracture (Malhorta, 2008).
Stretching include several types of muscle elongation procedures (Bovend et al., 2008), that can be applied by moving the joint through the range of motion (ROM) manually or by means of different mechanical devices, to normalize muscle tone, maintain or increase soft tissue extensibility, reduce contracture, pain and improve motor function (Selles et al., 2005). Stretching can be described as a constant force, variable force or a muscle contraction to produce a strain (change in length) in a muscle (Duong, 2001). Structures that are put under tension can consist of muscle, tendon, connective, vascular, dermal and neural tissues (Harvey et al., 2002).
Stretching techniques, irrespective of its form can be characterized by factors such as intensity i.e. the amount of tension applied to the structures(s) which can differ in the amount of force, and is kept either constant or varied (Sheard et al., 2009). The speed at which the elongation is occurring (i.e. velocity) and the number of replications of the stretch within one single session i.e. repetitions (Sheard et al., 2009). Duration is the time the structures are elongated within repetition while dose is the total end range time (Ryan et al., 2008). The periodicity of the stretch, which can vary from a single session to daily sessions for several weeks is referred to as the frequency of stretch (Wiart et al., 2008).
To state the literature review question in a PICO format: “The effect of stretching techniques on spasticity and/or contracture in people with stroke”.
To understand the effect of stretching on relief of spasticity and/or contracture of affected upper and lower limbs post stroke, a literature search was conducted. Electronic searches were conducted in the following computerized databases: Pubmed, Cumulative index to Nursing and Allied Health Literature (Cinahl), Cochrane Database of Systematic Reviews, Allied and Complementary Medicine Database (AMED) and Physiotherapy Evidence Database (Pedro) from 2010 to 2016. Reference list of included articles were also assessed as well as systematic reviews. Few potential articles were not available for on-line download; attempt was made through the university library to source for them. The following search terms were used – (stroke or cerebrovascular accident or cerebrovascular disease) AND (spasticity) AND (contracture or stiff*) AND (stretch).
Studies were included if they were in English and either publish randomized control trials (RCT), clinical trials or experimental or clinical cohort studies. Only studies involving human were included, with participant of both gender and adult age or above providing they had a confirmed stroke or cerebrovascular disease diagnosis and existing spasticity and/or contracture of either upper or lower limbs. The relevant studies to be discussed applied positioning procedure (preventive/therapeutic) for the upper limb while constant torque stretch, prolonged static and cyclic stretching with an intelligent device for the lower limb will be critically analyzed to determine the evidence base for their use. Studies that utilizes co-intervention such as anti-spasticity medication (e.g., baclofen, botulinum toxin type A etc.), electrical stimulation, use of cast and splints were excluded. Case reports, conference proceedings or protocols with no published date were also excluded.
A total of 117 articles was found. 77 was discarded because it does not address the topic thoroughly. 30 articles were further removed because they address spasticity/ contracture in other neurological conditions. On completion of a detailed search of the named databases, and removal of all articles that did not meet the inclusion criteria, key data was then extracted from all included articles. The information is presented as an experimental data extraction sheet that included information on the following: author, title and date of publication; number of participants, neurological condition; study design; stretching intervention; groups; outcome measure and study results (see appendix 1).
A total of 7 studies that was deemed relevant to the study at hand were selected, this consist of 2 Cochrane review, 4 randomized control trial and 1 clinical trial (see appendix 2). Other studies were discarded because they focused on pharmacological intervention, massage therapy and other forms of therapy that do not address the topic. Studies that emphasized on other neurological conditions were also excluded.
Critique
It is hypothesized that prevention of contracture and maintaining an optimal pain free range of joint motion around hemiplegic shoulder is an important therapeutic intervention in stroke rehabilitation (Carr, 2003). The study by Dejong et al., (2006) on contracture preventive positioning of the shoulder joint showed that positioning had no clear influence on motor performance of the arm and resistance to passive movement of elbow flexors spasticity. However, there was no solid evidence that a 5-week positioning procedure slowed down the development of shoulder abduction contracture. Also, small sample size was recruited which might underpowered the study. Because the positioning procedure was carried out by several different nurses, this might reduce the inter-tester reliability of the procedure. Therefore, outcome of their study should be interpreted with caution. Further verification with large sample size will be needed. The outcome of their study contradicts the findings from the study of Ada et al., (2005) that reported reduced development of contracture when the shoulder joint was put in maximum external rotation and 45° abduction in the afternoon as compared with the flexion positioning procedure carried out after participants had their shower in the morning. Their result might be generalized because large sample size were recruited from four rehabilitation clinic in an urban setting usually assessed by populace. However, positioning procedure been carried out at different time of the day might have some limitations on the study. Though, the responsiveness of spastic muscle with/without contracture to soft tissue temperature difference at various time of the day cannot be ascertained. However, a reduced muscle temperature by cooling have been discovered to inhibit monosynaptic stretch reflex and lowers the receptor sensitivity, this inhibit spastic muscle but the effect is short lived (Price et al.,1993) whereas increased temperature may increase the elasticity of the muscles there by causing relaxation of spastic muscle (Lehmann et al.,1982). The baseline similarity of subjects cannot be ascertained because the author did not state whether participants were prevented from activities that might involve stretching prior to receiving intervention in the afternoon. Conducting the external rotation positioning procedure in the afternoon, after the subject might have performed some daily activities involving stretching may be a contributing factor to the significant effect size recorded in the afternoon as compared with the flexion procedure carried out in the morning without any prior activities to warm up the soft tissues. This might have accounted for the short lived effect of stretching observed when stretching was done in the morning. Further studies on arm positioning procedure with baseline similarity between groups will be needed.
Although, stretching alone increased flexibility and range of motion as demonstrated by Ada et al., (2005). Combining stretching with deep heat technique e.g. pulsed short wave diathermy had a more significant cumulative effect when compared with stretching alone. This was demonstrated in the study by Draper et al., (2004). Though the intervention was clearly explained, only the participants were blinded in their study but assessors were not. This might have introduced assessor bias. Participants were also not properly randomized into groups. The long term effect of stretching and deep heat therapy cannot be verified because outcome measurement of the treatment effect was only carried out after a period of five days alone. Further research will be needed to determine the long term therapeutic effect of stretching and deep heat therapy.
It has been suggested that the effect of static stretching is proportional to the amount of time a stretch is held at its end range (Flowers et al., 1994). Mc Nair et al., (2001) examined the short term effect of a single 60seconds static calf stretch and cyclic calf stretch of the same duration; they reported a decrease in ankle joint stiffness after cyclic stretching and no difference in stiffness after static stretching. However, the clinical trial was carried out on people without any impairment. Their result cannot be generalized because the responsiveness to cyclic stretching by individuals without any neurological impairment might be different from stroke survivors with diverse result obtainable.
The effect of prolonged static and cyclic stretching on ankle joint stiffness among ten community dwelling stroke survivors was investigated by Bressel et al., (2002). Their study involved a small sample of participants not evenly distributed across both gender. This might have led to their study being underpowered. The essence of randomizing participants into two groups is not clear since there are no control groups for both stretching techniques. The author used 10minute walk test to measure the short and long term effect of stretching on gait in addition to measures of ankle stiffness / spasticity, the test might not be specific for its purpose because participants were ambulating stroke survivors who might have been accustomed to their gait/walking pattern with/without assistive device. This might have accounted for no difference in walking pattern observed after intervention. Two inclusion criteria of participants stated by the author seems contradictory- that participants were free from contracture and they had not been involved in a stretching program. It has been established that most stroke patient come down with stiffness or contracture as a result of reduced use or non-use of affected joint. Excessive and uncontrolled spasticity limits functional recovery, causes pain, and is associated with contracture (Barne, 2001). Majority of subject that participated in the study actually had stroke for some years, this does not agree with the inclusion criteria stated by the author of them having stroke 3 months before the start of their study. Outcome of the study should be interpreted with caution due to lack of baseline similarity in terms of participant’s stroke chronicity.
Furthermore, the author admitted not examining reliability of their measurement using the Kin-com dynamometer. The reliability of Kin-com dynamometer seems controversial, the author made reference to two previous studies that ascertained its reliability (Boiteau et al., 1995; Porter et al., 1996) but study by other researchers has also queried the gravity correlation features of this device. Finucane et al. (1994) observed that there was progressively greater discrepancy between measured forces (known weight of a limb) and predicted forces for the leg as the lever arm was moved from horizontal to 50° below the horizontal. The force recorded with the Kin-com dynamometer was greater when the subject knee was in full extension than when the lever arm was horizontal (which placed the subject knee in flexed position). A small difference was also noted between the measured forces with the lever arm horizontal when the subject was sitting compared with when the subject was positioned supine. This undermined the reliability of this equipment. This discrepancy may have affected the validity of the measured data .Verbal encouragement of the participants by the investigator during the measurement of maximum voluntary contraction (MVC) might have introduced fatigue without any period of rest in-between testing. This might have affected the outcome of the MVC recorded for both the ankle plantarflexors and dorsiflexors.
Mini-Mental State Examination (MMSE) used in their study has been faulted in its use for older adults who are illiterates, because of the unacceptably high miscalculation which has serious consequences for research and clinical practice in low and middle income countries where the proportion of illiteracy among older adults is high. However, this might have affected the result of this examination using this outcome tool because the author did not explain the level of literacy of the participants involved in their study. Further research that will involve a pilot study to determine the intra-rater reliability of Kin-com dynamometer as an intelligent stretching device for the lower limb prior to studies with a large sample size will be needed.
Yeh et al. (2007) studied the effects of sustained muscle stretching at constant torque, constant angle and cyclic stretch on hypertonic calf muscle in a single session of 30mins duration. An increase in passive range of motion (PROM) with both elastic and viscous component of reactive force decreasing significantly was reported. However, it decreased more in constant torque group. The result of the study by Yeh et al. (2007) supported the findings of Bressel et al. (2002) that constant angle and cyclic stretching increases range of motion (ROM) and reduced spasticity with modified ashworth scale (MAS) used as outcome measure, though there is no much significant difference in the effect of the two. Unlike the study by Bressel et al. (2002), the amplitude of the ankle movement was controlled to be +/-3° with respect to neutral ankle position with knee fully extended during the biomechanical assessment of joint stiffness. However, study by Yeh et al. (2007) had larger sample size which represents a reflection of what might be obtainable from the populace. Outcome of the research might be valuable because it clarified that constant torque sustained muscle stretching (which exploits the “creep phenomenon” whereby stretching force is maintained at a constant value but the stretching angle is continuously varied) might be more effective than both cyclic and constant angle stretch. Though, their study lacks a healthy control group, the precise mechanism responsible for the decrease of hypertonia after one sustained muscle stretch session could not be explained by the author. However, further research will be needed to determine the long term effect of constant torque stretch.
A systematic review by Katalinic et al. (2010) found out that stretch does not have clinically important effect on joint mobility in people with, or at risk of contracture if performed for less than 7 months. Though, they reported small improvement in joint mobility (mean difference= 3°, 95% CI=0° to 5°, p= 0.04) which was referred to as not clinically important. But an increase in range of motion by 3° can be improved upon by recommendation of functional splint to improve mobility and quality of life of patients. The result of this systematic review might be limited because they included studies with a pharmacological co-intervention (botulinum toxin).
Katalinic et al. (2010) also included studies with different neurological conditions including some non- neurological adult and pediatric conditions. Different condition might react to stretching technique in different ways and with diverse result obtainable. Their result might not be generally applicable to stroke survivors under review. Published and unpublished randomized control trials and clinical control trials were also included in their review.
Implication for Practice.
The aim of the literature review is to explore evidence base for therapeutic effect of stretching techniques in reducing spasticity and/or contracture in people with stroke. The lack of an established stretch guideline/model that encompasses considerable factors (e.g. frequency, duration and intensity) has undermined the effectiveness of stretching techniques. It has not yet been determined whether soft tissue structures are more responsive to passive movements administered through the hands of therapists. Most of the studies reviewed did not state when to introduce stretching technique as a form of therapy in neurological condition (e.g. stroke or cerebrovascular disease). It is not yet clear whether stretching approach will be more beneficial at the early or late stage of intervention because the short and long term effect of stretch cannot be ascertained.
Comprehension of spasticity phenomenon will facilitate therapeutic strategies to be developed. This will promote efficient treatment rather than relieve of symptom, thereby preventing secondary complication like contracture. An early multidisciplinary approach to spasticity is essential in order to obtain successful result in its treatment. The complexity and diversity of spasticity make the identification of its underlying mechanism and predisposing factors difficult.
A systematic review by Baker and Pereira (2013) reported a significant effect for Botulinum Toxin’s efficacy in reducing spasticity for both upper and lower limbs but with moderate quality evidence for lower limb outcomes. However, their review might be limited by the use of only one author to carry out the search and critique of articles. This might have increased the risk of rejecting relevant reports. Though, anti-spastic drugs like botulinum toxin A might not permanently relieve spasticity. However its pharmacological role combined with stretching technique might help therapist to reduce spasticity within the time limit.
In the treatment of spasticity, therapist make extensive use of inhibitory postures and manual stretching of the hypertonic muscles to reduce the muscle tone and, hence, improve the active range of motion (Tsai et al.,2001). Stretch has been extensively used in the clinics because it is considered to be safe, convenient and economical. Previous reports have suggested that the stretch reflex is modulated by motor activity, rather than load or passive stretch (Ibrahim et al., 1993). Consequently, it could be argued that physiotherapy interventions that promote voluntary motor activities would be superior to passive muscle stretch technique in reducing spasticity (Ibrahim et al., 1993). The recommendation of functional splints might be beneficial to promote motor activity.
Research on the long term effect of stretching is minimal and therefore requires more investigation. Because of insufficient recent and detailed spasticity management guideline. Literature reviewed has casted doubt on the potency of the therapeutic effect of stretching. Further clinical research will be needed to determine if stretching technique intervention is effective in rehabilitation of patient post stroke. It seems stretching only addresses the non-neural component of spasticity. Limited resources on how stretching technique relieves the neural component of spasticity makes treatment more complex.
Most of the study reviewed used Modified Ashworth Scale (MAS) as the main outcome measure for spasticity but recent researches have faulted the reliability of MAS. Resistance to passive movement is a complex measure that is influenced by many factors, only one of which could be spasticity. MAS cannot identify the cause of resistance because it measures both the neural and peripheral factors without differentiating their individual contributions, it can overestimate spasticity because it assumes that any increase in resistance felt is the result of abnormal reflex activity (Vattanaslip et al., 2010). However, the passive component also has viscoelastic properties i.e. the resistance increases with the speed of stretch.
The Ashworth Scale (AS) can be used as an ordinal level measure of resistance to passive movement, but not spasticity (Pandyan et al., 1999). Gracies et al., (2000) suggested that the reliability of the Modified Tardieu Scale (MTS) may be superior to that of the Modified Ashworth Scale at least for some joints. Modified Ashworth scale is confounded by contracture; Tardieu scale may be a better option to be used as outcome measure in spasticity because it differentiates spasticity from contracture (Gracies et al., 2000).
The clinical definitions of stretching and positioning in spasticity remain unclear, paradigm for stretching (duration, dose, intensity and frequency) in spasticity and the appropriate outcome measures for assessment remain unestablished. Although previous researches show many areas of agreement, disparity and inconsistencies of findings, it is evident that there is still a great deal that is unknown and requires further research. Subsequent studies will be needed to make clarification on the clinical importance of stretching, its short and long term effect, at what stage of disease should stretching be implemented?. This will serve as a guideline for further research on management of spasticity and/or contracture in people with stroke.
Barriers, Action Plan and Implementation.
The purpose of completing an in-depth literature review is to inform and change practice. Johns Reflective model (Johns, 2009) will be used as a guide to critical reflection, this model of structured reflection offers a set of cue question to tune practitioner into each of the ways of knowing within a reflexive and temporal context. The cue questions which includes; aesthetics, personal, ethics, empirics and reflexivity will serve as my guide.
From my experience of clinical practice as a physiotherapist using the “Bobath approach”, which is based on the reduction of spasticity and promotive postural reflexes prior to facilitating voluntary activity in paretic muscles through attention to trunk posture as well as controlled muscle stretch at the limbs (Bobath,1979).Passive movement coupled with a graded manual stretch is applied to the affected joint to overcome the hypertonicity and passively lengthen the muscle and other soft tissues surrounding the joint. Nonetheless, only a few studies showed that this technique is efficient to reduce spasticity in patients suffering from a stroke (Ansari, 2007)), and its effectiveness seems to be limited (Dias, 2007)
One major inconsistency in conventional muscle stretching is the lack of quantitative guidelines for clinical practitioners. The actual magnitude of the applied force cannot be quantified; it tends to depend on the particular therapist experience or on his/her own subjective preference. Though, spastic post stroke patient with/without contracture promptly referred for physiotherapy management improves with early intervention because it prevents disuse of affected limb and atrophy of surrounding muscles. However, it seems spasticity can only be minimized/reduced with stretching technique because spastic patients never recovered fully to their pre-stroke state when assessed after weeks of intervention on the spasticity “Ashworth scale” regularly used at our hospital. This may be due to the slow clinical development of spasticity being a release phenomenon characterized by lack of descending control over spinal cord inter-neuronal circuits (Wilson et al, 1999)
Constant torque sustained muscle stretching approach via an intelligent device might be more effective in inhibiting spasticity in stroke victims. This finding might be useful in establishing new standard for clinical prolonged muscle stretching. Intelligent stretching device may be an effective and safe alternative to manual passive motion treatment by therapists. Manual therapy effects may not be long lasting because of the limited and sometimes infrequent therapy. Manual stretching is laborious and the outcome may depend on the ability of the therapist to gauge the limits of the range of motion. The use of motors to deliver stretches have several advantages, an exact specified torque can be delivered and the motor can be used to assess range of motion and stiffness before and after intervention. Motor driven device also has the potential to be used repeatedly and regularly without daily involvement of the physical therapist. This will allow the therapist to incorporate other forms of treatment that will be beneficial to the patient.
Studies reviewed and earlier stated systematic reviews has proven that the use of functional splint to promote motor activity and stretching techniques coupled with administration of anti-spastic drugs prior to stretching will help in minimizing patient’s impairment and major functional implications, including difficulties with personal hygiene or dressing, positioning, and at times the inability to sit, which may lead to restricted community mobility and social isolation.
Knowledge gained from this study will be shared with other colleagues in form of workshop/seminar. This will familiarize us with recent trends in the management of spasticity/contracture in stroke patients. I will further liaise with the head of my department and the head of clinical services where I currently practice for a possibility of coupling a servomotor that can replicate the effect of the constant torque technique. This will be achieved through the works department of our institution, if procuring of a new one seems too expensive. Close monitoring and regular review of a stretch technique deployed will also be prioritized, this will improve our clinical practice thereby stimulating our desire for further research on stretching techniques.
Author/Year Title Participant characteristics Method Findings
Bressel et al.,
(2002)
The effect of prolonged static and cyclic stretching on ankle joint stiffness, torque relaxation and gait in people with stroke
10 community dwelling stroke survivors.
Prolonged Static
Stretch (PSS) – 5.
Prolonged Cyclic Stretch(PCS)- 5
A Randomized trial
30 mins static calf stretch
Subject foot moved at a rate of 5deg/sec from 10deg plantarflexion(neural) to a static hold at 80% of participant Maximal passive dorsiflexion angle(MPDA)
30 mins Cyclic Calf Stretch
Continuous passive ankle
joint motion between neutral ; 80% of MPDA at angular velocity of foot segment of 5°/sec
-Stiffness value decreased by 35% ; 30% after static and cyclic stretching respectively.
-Torque relaxation was 53% greater for static stretching than for cyclic stretching.
-Both has no main effect on mean walking times/speed.
Yeh et al.,
(2007)
Quantifying the effectiveness of the sustained muscle stretching treatments in stroke patient with ankle hypertonia
47 stroke survivors Before and After Design.
3 x 30 session: cyclic, constant angle ; constant torque.
Spasticity. MAS. (Modified Ashworth Scale).
ROM (Goniometer).
Ankle and Joint stiffness (dynamometer). Constant angle stretch
MAS; Pre:2 Post:1
ROM; Pre: 9.72
Post: 16.00
Cyclic stretch
MAS; Pre: 2 Post: 1
ROM; Pre: 9.56
Post: 14.81
Constant torque stretch
MAS; Pre: 3 Post:1
ROM; Pre: 9.19
Post: 18.29
Ada et al.,
(2007)
Thirty minutes of positioning reduces the development of shoulder external rotation contracture after stroke
31 stroke survivors
Treatment Group -15
Control Group- 16
A Randomized controlled trial.
4 weeks of participation in a shoulder positioning program.
(2 x30min/day, 5 days/week)
-Reduced development of contracture in 30min shoulder positioning at 45degree abduction ; in maximum external rotation.
-No significant difference in contracture when shoulder is in 90degree shoulder ; elbow flexion.
Dejong et al.,
(2013)
Combined arm stretch positioning ; NMES during rehabilitation does not improve ROM, shoulder pain or function in people after stroke.
46 stroke survivors A Randomized trial with concealed allocation.
EXG: Arm stretch positioning with NMES for (2x 45mins/day, 5days/wk for 8wks).
CG: Sharm arm positioning (no stretch) ; sham NMES (TENS with no motor effect) at similar frequency and duration.
No significant difference in arm contracture, shoulder pain and spasticity.
Dejong et al.,
(2006)
Contracture preventive positioning of the hemiplegic arm in sub-acute stroke patient
17 stroke survivors
Treatment Group – 9
Control Group- 8
A Randomized controlled trial.
Arm positioned in abduction, external rotation, elbow extension and supination for (2x 30mins/day, 5days/week for 5 weeks).
No solid evidence that a five-week positioning procedure slowed down the development of shoulder abduction contracture
APPENDIX 1: Articles assessing the effect of stretching to relief spasticity and/or contracture in people with stroke.
APPENDIX 2: PRISMA Flow Diagram showing how articles were searched.
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