Archive for category Gait Rehabilitation – Foot Drop

[ARTICLE] Effect of Exercise on Gait Kinematics and Kinetics in Patients with Chronic Ischaemic Stroke – Full Text

ABSTRACT

Introduction In 2014, American Heart Association and American Stroke Association (AHA/ASA) issued exercise guidelines for stroke patients.
Aim of the Study: To study the effects of an exercise programme based on AHA/ ASA guidelines, on gait kinematics and kinetics in patients with chronic ischemic stroke.
Materials and Methods: Twelve stroke patients, 67.33 ± 9.14 years old, followed an 8-week exercise programme, with 3 hourly sessions per week, consisting of strength, endurance and flexibility training, as well as neuromuscular activities. Patients’ gait kinematics and kinetics were evaluated before and after the intervention using a 3-dimensional gait analysis system.
Results: In most cases, patients in the intervention group showed significant increase or no change in gait kinematics, significant increase in joint moments at the anterior-posterior plane during support phase, and non-signi- ficant change in the frontal and transverse planes kinetics.
Conclusions: Exercise prevented further deterioration and/or led to improved walking pattern.

1. Introduction

It is estimated that one in 5 women and one in 6 men will sustain a stroke up to the age of 75 years [1] . The main purpose of rehabilitation in such patients is to achieve the maximum possible personal performance, physical and psychological, with the ultimate goal of regaining a level of functional independence that will allow them to be re-integrated into social life as much as possible [2] . However, stroke patients often adopt a sedentary lifestyle [3] [4] [5] [6] . This may be attributed to 1) factors associated with patients themselves, such as depression, lack of interest or motivation, decreased perception, decreased confidence, ignorance that exercise is possible and desirability and fear of falls, of a new stroke or other undesirable effects; 2) practical factors, such as lack of support from family or other social actors, inability to access exercise sites, inadequate public transport, health professionals’ ignorance of the availability of physical activity services; 3) financial cost [7] [8] [9] [10] [11] . Conversely, exercise in groups may improve patient motivation [12] .

In 2014, the council of the American Heart Association and the American Stroke association (AHA/ASA) revised the exercise recommendations for stroke patients at all stages of their recovery [13] . Therefore, the aim of this study was to assess the effect of an exercise programme based on these recommendations on gait kinematics and kinetics of ischaemic stroke patients in the chronic phase of recovery.[…]

 

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[Abstract] Stepping training with external feedback relating to lower limb support ability effectively improved complex motor activity in ambulatory patients with stroke: a randomized controlled trial

 

BACKGROUND: Lower limb support ability is important for steady and efficient mobility, but previous data commonly involved training during double stance positions, with or without external feedback, using a complex and costly machine.
AIM: To compare the effects of stepping training with or without external feedback in relation to the lower limb support ability of the affected limb on the functional ability necessary for independence in individuals with stroke.
DESIGN: A single-blinded, randomised controlled trial.
SETTING: Tertiary rehabilitation centres.
POPULATION: Ambulatory participants with stroke who walked independently over at least 10 meters with or without walking devices.
METHODS: Thirty-six participants were randomly arranged to be involved in a program of stepping training with or without external feedback related to the lower limb support ability of the affected limb (18 participants/group) for 30 minutes, followed by overground walking training for 10 minutes, 5 days/week over 4 weeks. The outcomes, including the lower limb support ability of the affected legs during stepping, functional ability and spatial walking data, were assessed prior to training, immediately after the first training session, and after 2- and 4- week training.
RESULTS: Participants demonstrated significant improvement in the amount of lower limb support ability, immediately after the first training with external feedback. Then, these participants showed further improvement in both the amount and duration of lower limb support ability, as well as the timed up and go data after 2 and 4 weeks of training (p < 0.05). This improvement was not found following control training.
CONCLUSIONS: The external feedback relating to lower limb support ability during stepping training effectively improved the movement stability and complex motor activity of ambulatory individuals with stroke who had long post-stroke time (approximately 3 years).
CLINICAL REHABILITATION IMPACT: Stepping training protocols and feedback can be easily applied in various settings using the amount of body-weight from an upright digital bathroom scale. Thus, the findings offer an alternative rehabilitation strategy for clinical, community and home-based settings for stroke individuals.

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via Stepping training with external feedback relating to lower limb support ability effectively improved complex motor activity in ambulatory patients with stroke: a randomized controlled trial – European Journal of Physical and Rehabilitation Medicine 2019 Oct 15 – Minerva Medica – Journals

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[Abstract] A Method for Self-Service Rehabilitation Training of Human Lower Limbs – IEEE Conference Publication

Abstract

Recently, rehabilitation robot technologies have been paid more attention by the researchers in the fields of rehabilitation medicine engineering and robotics. To assist active rehabilitation of patients with unilateral lower extremity injury, we propose a new self-service rehabilitation training method in which the injured lower limbs are controlled by using the contralateral healthy upper ones. First, the movement data of upper and lower limbs of a healthy person in normal walk are acquired by gait measurement experiments. Second, the eigenvectors of upper and lower limb movements in a cycle are extracted in turn. Third, the linear relationship between the movement of upper and lower limbs is identified using the least squares method. Finally, the results of simulation experiments show that the established linear mapping can achieve good accuracy and adaptability, and the self-service rehabilitation training method is effective.

via A Method for Self-Service Rehabilitation Training of Human Lower Limbs – IEEE Conference Publication

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[Abstract] The influence of virtual reality on rehabilitation of upper limbs and gait after stroke: a systematic review – Full Text PDF

Abstract

Stroke is the leading cause of functional disability in adults. Its neurovascular origin and injury location indicates the possible functional consequences. Virtual rehabilitation (VR) using patient’s motion control is a new technological tool for conventional rehabilitation, allowing patterns of movements in varied environments, involving the patient in therapy through the playful components offered by VR applications. The objective of this systematic review is to collect data regarding the influence promoted by VR in upper limb and hemiparetic gait. Full articles published between 2009 and 2015 in english were searched and selected in PubMed, Cochrane and Pedro databases. Eleven articles included (5 for VR and upper limbs; 4 for VR, gait and balance; and 2 for VR and neural mechanisms). The articles included demonstrate efficacy in VR treatment in hemiparetic patients in the variables analyzed.

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via The influence of virtual reality on rehabilitation of upper limbs and gait after stroke: a systematic review | Journal of Innovation and Healthcare Management

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[Abstract] A Preliminary Study of Dual-Task Training Using Virtual Reality: Influence on Walking and Balance in Chronic Poststroke Survivors

Abstract

BACKGROUND:

Stroke is a leading cause of death and disability in the Western world, and leads to impaired balance and mobility.

OBJECTIVE:

To investigate the feasibility of using a Virtual Reality-based dual task of an upper extremity while treadmill walking, to improve gait and functional balance performance of chronic poststroke survivors.

METHODS:

Twenty-two individuals chronic poststroke participated in the study, and were divided into 2 groups (each group performing an 8-session exercise program): 11 participated in dual-task walking (DTW), and the other 11 participated in single-task treadmill walking (TMW). The study was a randomized controlled trial, with assessors blinded to the participants’ allocated group. Measurements were conducted at pretest, post-test, and follow-up. Outcome measures included: the 10-m walking test (10 mW), Timed Up and Go (TUG), the Functional Reach Test (FRT), the Lateral Reach Test Left/Right (LRT-L/R); the Activities-specific Balance Confidence (ABC) scale, and the Berg Balance Scale(BBS).

RESULTS:

Improvements were observed in balance variables: BBS, FRT, LRT-L/R, (P < .01) favoring the DTW group; in gait variables: 10 mW time, also favoring the DTW group (P < .05); and the ABC scale (P < .01). No changes for interaction were observed in the TUG.

CONCLUSIONS:

The results of this study demonstrate the potential of VR-based DTW to improve walking and balance in people after stroke; thus, it is suggested to combine training sessions that require the performance of multiple tasks at the same time.

 

via A Preliminary Study of Dual-Task Training Using Virtual Reality: Influence on Walking and Balance in Chronic Poststroke Survivors. – PubMed – NCBI

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[Abstract] High Intensity Exercise for Walking Competency in Individuals with Stroke: A Systematic Review and Meta-Analysis

Abstract

OBJECTIVE:

To assess the effects of high intensity exercise on walking competency in individuals with stroke.

DATA SOURCES:

A systematic electronic searching of the PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL (EBSCOhost), and SPORTSDiscus (EBSCOhost) was initially performed up to June 25, 2019.

STUDY SELECTION:

Randomized controlled trials or clinical controlled trials comparing any walking or gait parameters of the high intensity exercise to lower intensity exercise or usual physical activities were included. The risk of bias of included studies was assessed by the Cochrane risk of bias tool. The quality of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system.

DATA EXTRACTION:

Data were extracted by 2 independent coders. The mean and standard deviation of the baseline and endpoint scores after training for walking distance, comfortable gait speed, gait analysis (cadence, stride length, and the gait symmetry), cost of walking, Berg Balance Scale , Time Up&Go (TUG) Test and adverse events were extracted.

DATA SYNTHESIS:

A total of 22 (n = 952) studies were included. Standardized mean difference (SMD), weighted mean difference (WMD), and odds ratios (ORs) were used to compute effect size and subgroup analysis was conducted to test the consistency of results with different characteristics of exercise and time since stroke. Sensitivity analysis was used to assess the robustness of the results, which revealed significant differences on walking distance (SMD = .32, 95% CI, .17-.46, P < .01, I2 = 39%; WMD = 21.76 m), comfortable gait speed (SMD = .28, 95% CI, .06-.49, P = .01, I2 = 47%; WMD = .04 m/s), stride length (SMD = .51, 95% CI, .13-.88, P < .01, I2 = 0%; WMD = .12 m) and TUG (SMD = -.36, 95% CI, -.72 to .01, P = .05, I2 = 9%; WMD = -1.89 s) in favor of high intensity exercise versus control group. No significant differences were found between the high intensity exercise and control group in adverse events, including falls (OR = 1.40, 95% CI, .69-2.85, P = .35, I2 = 11%), pain (OR = 3.34, 95% CI, .82-13.51, P = .09, I2 = 0%), and skin injuries (OR = 1.08, 95% CI, .30-3.90, P = .90, I2 = 0%).

CONCLUSIONS:

This systematic review suggests that high intensity exercise could be safe and more potent stimulus in enhancing walking competency in stroke survivors, with a capacity to improve walking distance, comfortable gait speed, stride length, and TUG compared with low to moderate intensity exercise or usual physical activities.

 

via High Intensity Exercise for Walking Competency in Individuals with Stroke: A Systematic Review and Meta-Analysis. – PubMed – NCBI

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[ARTICLE] Pharmacological Therapies for Motor Recovery After Stroke – Full Text

Abstract and Introduction

Abstract

Stroke is the most common serious neurological disorder. To date, the focus for research and trials has been on prevention and acute care. Many patients are left with serious neurological impairments and limitations in activity and participation after stroke. Recent preliminary research and trials suggest that the brain is ‘plastic’ and that the natural history of stroke recovery can be improved by physical therapy and pharmacotherapy. Motor weakness and the ability to walk have been the primary targets for testing interventions that may improve recovery after stroke. Physical therapeutic interventions enhance recovery after stroke; however, the timing, duration and type of intervention require clarification and further trials. Pharmacotherapy, in particular with dopaminergic and selective serotonin-reuptake inhibitors, shows promise in enhancing motor recovery after stroke; however, further large-scale trials are required.

Introduction

This review is a framework around an emerging and exciting area of stroke care – maximizing recovery after stroke. Stroke care is a continuum from prevention to hyperacute care to acute care to rehabilitation to community reintegration and back (Figure 1). The traditional medical model of care artificially divides care across multiple healthcare providers and locations. Prevention is most often in the hands of general and primary care medicine with the goal of maximizing stroke risk reduction strategies such as controlling hypertension. Hyperacute stroke care is in the hands of neurologists with a primary goal of providing thrombolysis to as many patients as possible and as quickly as possible. Acute stroke care is in the hands of neurologists and very often in the hands of internal medicine specialists who manage patients according to best practices on acute stroke units in acute care hospitals. Rehabilitation is under the care of physical medicine and rehabilitation physicians and allied health professionals usually in rehabilitation hospitals. Reintegration into the community is in the hands of home care and out-patient providers in the community. One patient, one neurological disorder and so many different care providers and locations.

Figure 1.The continuum of stroke care.

Recent research suggests that we are at the edge of major advances in post-stroke care. Animal and human studies show that the brain is ready to heal immediately after a stroke. The brain is ‘plastic’ and responds to external influences, such as physical therapy. The timing, the intensity and the exact external influence may all be important factors in maximizing recovery. Pharmacotherapy may influence how the injured brain recovers. This complex array of influences and recent research addressing these areas will be elaborated on in this review (Figure 2).

Figure 2.
Multiple factors may influence recovery after stroke.

via Pharmacological Therapies for Motor Recovery After Stroke

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[WEB PAGE] MEDRhythms Launches Trial of Post-Stroke Walking Device

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MEDRhythms Inc has launched a randomized controlled trial (RCT) at five top rehab hospitals and research centers across the country to examine the impact of a digital therapeutic device on stroke survivors who have post-stroke walking impairments, in support of the company’s eventual FDA submission.

“This clinical trial marks an important milestone toward MEDRhythms’ mission to make this high-quality intervention available to those who need and deserve to have it,” says Brian Harris, Co-Founder and CEO of Portland, Me-based MEDRhythms, in a media release. “As this new industry grows, it is important for digital therapeutics to demonstrate efficacy with the support of rigorous clinical trials, and this RCT is an integral step in MEDRhythms’ evidence generation strategy to do so.”

MEDRhythms’ clinical trial will be conducted at the Shirley Ryan AbilityLab in Chicago, the Kessler Foundation in New Jersey, Mt. Sinai Hospital in New York, Spaulding Rehabilitation Hospital in Boston, and the Boston University Neuromotor Recovery Laboratory in Boston. This trial was launched following completion of a successful feasibility study in the target population, which was conducted at the Boston University Neuromotor Recovery Lab. The results of this feasibility study will be announced at the American Physical Therapy Association’s annual Combined Sections Meeting in February 2020 in Denver, Colorado.

“Right now, the MEDRhythms digital therapeutic technology is a novel treatment for a subset of individuals that have few, if any, effective treatment options,” states David Putrino, the Director of Abilities Research Center (ARC) for the Department of Rehabilitation and Human Performance at the Mount Sinai Health System and the Principal Investigator at MEDRhythms’ Mount Sinai clinical trial site.

“The mission of the ARC is to identify and validate novel technologies that have the potential to significantly enhance the rehabilitation of people who are recovering from brain injuries and neurological conditions, including chronic stroke. The digital therapeutics industry has the potential to transform rehabilitation and disrupt healthcare, and it is imperative for companies in this space to run full-scale, multisite RCTs like MEDRhythms is doing.”

The digital therapeutic for post-stroke walking rehabilitation is one of a full pipeline of products that include therapeutics for indications such as Parkinson’s disease, multiple sclerosis, aging, and fall prevention, for which the company is actively exploring partnerships, per the release.

[Source(s): MEDRhythms, Business Wire]

 

via MEDRhythms Launches Trial of Post-Stroke Walking Device – Rehab Managment

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[ARTICLE] Robot-Assisted Stair Climbing Training on Postural Control and Sensory Integration Processes in Chronic Post-stroke Patients: A Randomized Controlled Clinical Trial – Full Text

Background: Postural control disturbances are one of the important causes of disability in stroke patients affecting balance and mobility. The impairment of sensory input integration from visual, somatosensory and vestibular systems contributes to postural control disorders in post-stroke patients. Robot-assisted gait training may be considered a valuable tool in improving gait and postural control abnormalities.

Objective: The primary aim of the study was to compare the effects of robot-assisted stair climbing training against sensory integration balance training on static and dynamic balance in chronic stroke patients. The secondary aims were to compare the training effects on sensory integration processes and mobility.

Methods: This single-blind, randomized, controlled trial involved 32 chronic stroke outpatients with postural instability. The experimental group (EG, n = 16) received robot-assisted stair climbing training. The control group (n = 16) received sensory integration balance training. Training protocols lasted for 5 weeks (50 min/session, two sessions/week). Before, after, and at 1-month follow-up, a blinded rater evaluated patients using a comprehensive test battery. Primary outcome: Berg Balance Scale (BBS). Secondary outcomes:10-meter walking test, 6-min walking test, Dynamic gait index (DGI), stair climbing test (SCT) up and down, the Time Up and Go, and length of sway and sway area of the Center of Pressure (CoP) assessed using the stabilometric assessment.

Results: There was a non-significant main effect of group on primary and secondary outcomes. A significant Time × Group interaction was measured on 6-min walking test (p = 0.013) and on posturographic outcomes (p = 0.005). Post hoc within-group analysis showed only in the EG a significant reduction of sway area and the CoP length on compliant surface in the eyes-closed and dome conditions.

Conclusion: Postural control disorders in patients with chronic stroke may be ameliorated by robot-assisted stair climbing training and sensory integration balance training. The robot-assisted stair climbing training contributed to improving sensorimotor integration processes on compliant surfaces. Clinical trial registration (NCT03566901).

Introduction

Postural control disturbances are one of the leading causes of disability in stroke patients, leading to problems with transferring, maintaining body position, mobility, and walking (Bruni et al., 2018). Therefore, the recovery of postural control is one of the main goals of post-stroke patients. Various and mixed components (i.e., weakness, joint limitation, alteration of tone, loss of movement coordination and sensory organization components) can affect postural control. Indeed, the challenge is to determine the relative weight placed on each of these factors and their interaction to plan specific rehabilitation programs (Bonan et al., 2004).

The two functional goals of postural control are postural orientation and equilibrium. The former involves the active alignment of the trunk and head to gravity, the base of support, visual surround and an internal reference. The latter involves the coordination of movement strategies to stabilize the center of body mass during self-initiated and externally triggered stability perturbations. Postural control during static and dynamic conditions requires a complex interaction between musculoskeletal and neural systems (Horak, 2006). Musculoskeletal components include biomechanical constraints such as the joint range of motion, muscle properties and limits of stability (Horak, 2006). Neural components include sensory and perceptual processes, motor processes involved in organizing muscles into neuromuscular synergies, and higher-level processes essential to plan and execute actions requiring postural control (Shumway-Cook and Woollacott, 2012). A disorder in any of these systems may affect postural control during static (in quite stance) and dynamic (gait) tasks and increase the risk of falling (Horak, 2006).

Literature emphasized the role of impairments of sensory input integration from visual, somatosensory and vestibular systems in leading to postural control disorders in post-stroke patients (Bonan et al., 2004Smania et al., 2008). Healthy persons rely on somatosensory (70%), vision (10%) and vestibular (20%) information when standing on a firm base of support in a well-lit environment (Peterka, 2002). Conversely, in quite stance on an unstable surface, they increase sensory weighting to vestibular and vision information as they decrease their dependence on surface somatosensory inputs for postural orientation (Peterka, 2002). Bonan et al. (2004) investigate whether post-stroke postural control disturbances may be caused by the inability to select the pertinent somatosensory, vestibular or visual information. Forty patients with hemiplegia after a single hemisphere chronic stroke (at least 12 months) performed computerized dynamic posturography to assess the patient’s ability to use sensory inputs separately and to suppress inaccurate inputs in case of sensory conflict. Six sensory conditions were assessed by an equilibrium score, as a measure of body stability. Results show that patients with hemiplegia seem to rely mostly on visual input. In conditions of altered somatosensory information, with visual deprivation or visuo-vestibular conflict, the patient’s performance was significantly lower than healthy subjects. The mechanism of this excessive visual reliance remains unclear. However, higher-level inability to select the appropriate sensory input rather than to elementary sensory impairment has been advocated as a potential mechanism of action (Bonan et al., 2004).

Sensory strategies and sensory reweighting processes are essential to generate effective movement strategies (ankle, hip, and stepping strategies) which can be resolved through feed-back or feed-forward postural adjustments. The cerebral cortex shapes these postural responses both directly via corticospinal loops and indirectly via the brainstem centers (Jacobs and Horak, 2007). Moreover, the cerebellar- and basal ganglia-cortical loop is responsible for adapting postural responses according to prior experience and for optimizing postural responses, respectively (Jacobs and Horak, 2007).

Rehabilitation is the cornerstone in the management of postural control disorders in post-stroke patients (Pollock et al., 2014). To date, no one physical rehabilitation approach can be considered more effective than any other approach (Pollock et al., 2014). Specific treatments should be chosen according to the individual requirements and the evidence available for that specific treatment. Moreover, it appears to be most beneficial a mixture of different treatment for an individual patient (Pollock et al., 2014). Considering that, rehabilitation involving repetitive, high intensity, task-specific exercises is the pathway for restoring motor function after stroke (Mehrholz et al., 2013Lo et al., 2017) robotic assistive devices for gait training have been progressively being used in neurorehabilitation to Sung et al. (2017). In the current literature, three primary evidence have been reported.

Firstly, a recent literature review highlights that robot-assisted gait training is advantageous as add-on therapy in stroke rehabilitation, as it adds special therapeutic effects that could not be afforded by conventional therapy alone (Morone et al., 2017Sung et al., 2017). Specifically, robot-assisted gait training was beneficial for improving motor recovery, gait function, and postural control in post-stroke patients (Morone et al., 2017Sung et al., 2017). Stroke patients who received physiotherapy treatment in combination with robotic devices were more likely to reach better outcomes compared to patients who received conventional training alone (Bruni et al., 2018).

Second, the systematic review by Swinnen et al. (2014) supported the use of robot-assisted gait therapy to improve postural control in subacute and chronic stroke patients. A wide variability among studies was reported about the robotic-device system and the therapy doses (3–5 times per week, 3–10 weeks, 12–25 sessions). However, significant improvements (Cohen’s d = 0.01 to 3.01) in postural control scores measured with the Berg Balance Scale (BBS), the Tinetti test, postural sway tests, and the Timed Up and Go (TUG) test were found after robot-assisted gait training. Interestingly, in five studies an end-effector device (gait trainer) was used (Peurala et al., 2005Tong et al., 2006Dias et al., 2007Ng et al., 2008Conesa et al., 2012). In two study, the exoskeleton was used (Hidler et al., 2009Westlake and Patten, 2009). In one study, a single joint wearable knee orthosis was used (Wong et al., 2012). Because the limited number of studies available and methodological differences among them, more specific randomized controlled trial in specific populations are necessary to draw stronger conclusions (Swinnen et al., 2014).

Finally, technological and scientific development has led to the implementation of robotic devices specifically designed to overcome the motor limitation in different tasks. With this perspective, the robot-assisted end-effector-based stair climbing (RASC) is a promising approach to facilitate task-specific activity and cardiovascular stress (Hesse et al., 20102012Tomelleri et al., 2011Stoller et al., 20142016Mazzoleni et al., 2017).

To date, no studies have been performed on the effects of RASC training in improving postural control and sensory integration processes in chronic post-stroke patients.

The primary aim of the study was to compare the effects of robot-assisted stair climbing training against sensory integration balance training on static and dynamic balance in chronic stroke patients. The secondary aims were to compare the training effects on sensory integration processes and mobility. The hypothesis was that the task-specific and repetitive robot-assisted stairs climbing training might act as sensory integration balance training, improving postural control because sensorimotor integration processes are essential for balance and walking.[…]

 

Continue —->  Frontiers | Robot-Assisted Stair Climbing Training on Postural Control and Sensory Integration Processes in Chronic Post-stroke Patients: A Randomized Controlled Clinical Trial | Neuroscience

Figure 1. The G-EO system used in the Robot-Assisted Stair-Climbing Training (Written informed consent was obtained from the individual pictured, for the publication of this image).

 

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