Vestibular Rehabilitation Inservice

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In-service project for clinical affiliation with Hingham PT, Inc. (Januay 2014-April 2014)
Review of vestibular system, common diagnosis and how to examine, evaluate and treat.
I also reviewed and supplied the clinic with the Four Step Square Test and Dynamic Gait Index in order to allow them to implement these outcome assessments into their clinic for individuals with balance/vestibular deficits

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  • Anterior: 45d anterior to coronal/frontal planePosterior: 45d posterior to coronal/frontal planeHorizontal: 30d superior to transverse plane
  • Lateral: stabilize body; input from otoliths & cerebellum via IPSILATERAL lateral vestibular nucleus-postural and LE musculatureMedial: stabilize head in space; input from SCC via CONTRALATERAL medial, superior, and descending vestibular nuclei- cervical musculatureReticulo: postural adjustments, balance reflexes; input from all vestibular nuclei, ipsi & contralateral componenets- allows for inputs from alternative sensory systems
  • Tinnitus- ringing in the ears
  • +Perilymph: extracellular fluid in the cochlea+Unknown cause, could be related to: circulation problems, viral infection, allergies, autoimmune reaction, migraine or possible genetic component
  • Most common: Viral, unilateral and acuteEndolymphatichydrops: abnormal fluctuations in endolymph, similar to MenieresDisease sx.
  • Vestibular-evokedmyogenic potentials (VEMP) testing of Pt. with migraine: test to determine the function of otolithic organs. After migraine- hyperresponsiveMeneires- hyporesponsive BPPV- latency response is typically prolonged
  • MEDS:Anithistamines and benzodiazepines: Meclizine, Lorazepam, Clonazepam, Dimenhydrinate, Diazepam, Amitriptyline.Other things you would check in typical head and neck pts: VBI etc.
  • Impulse test: unilateral- Unilateral vestibdeafferentation bilateral-often ototoxicity
  • Mastoid bone right behind ear
  • cold- 86F/30C degrees or belowWarm- 111.2F/44C or above
  • Active Stepping: the ability to change the BOS without balance loss then to reestabilish COG stability over the new BOS is a balance-dependent skill critical for functional activities
  • 6 conditions: 1. static EO, 2. staticEC, 3. sway-reference walls, 4.sway-reference floor, 5.sway-reference floor& EC, 6.sway-reference walls&floor -Ratios used to compare and identify impairments: SOM: 1/2, VIS 4/1, VEST 5/1, Visual Preference (3+6)/(2+5)
  • B-D exercises: 1. sit on the edge of your bed 2. lie down onto the side that causes your dizziness to increase, look towards the ceiling. Stay in this position for 2 mins. 3. sit upright and then wait for 30seconds. 4.Move rapidly to the opposite side for 2mins. 5. Repeat 4-5 times. 6. Do exercises 3x per day for 1 week or until you have been clear of dizziness for 3days.
  • Summarizes recent RCT’s- treatment effects between CRP and control Pts. Tended to diminish over time. Typically at 1wk, the CRP is very effective at providing symptom resolution for posterior canal BPPV
  • Also: Gufoni Maneuver & Vannucchi-Asprellaliberatory maneuver
  • +phobic postural vertigo: 1. dizziness&balance disturbances in upright static position & during motions 2. postural vertigo described as fluctuating unsteadiness 3.vertigo attacks that can occur spontaneously 4. anxiety & distressing vegetative symptoms accompanying & subsequent to the vertigo attacks 5. OCD that affect lability and mild depression 6. increased stress after illness, vestibular disorder
  • Vestibular Rehabilitation Inservice

    1. 1. Vestibular Rehabilitation Amy E. Rosen, SDPT
    2. 2. “I am dizzy”  Vestibular Disorders Association1 ◦ Recognizes 19 different types of vestibular disorders  “Dizziness” is one of the most common complaints to physicians by persons over 65 years of age2  Dizziness Definitions1,2 ◦ Vertigo: illusion of movement, rotation and/or spinning- either of the self or surrounding objects ◦ Disequilibrium: feeling of being unsteady, loss of balance; often accompanied by spatial disorientation ◦ Presyncope: a feeling of faintness, lightheadedness, or sense of falling; sudden decrease in BP
    3. 3. Balance3  “…a complex process involving the reception and integration of sensory inputs and the planning and execution of movement to achieve a goal requiring upright posture” ◦ Ability to control the COG over BOS in a sensory environment Choice of body movement Determination of body position Compare, select & combine senses Neck Muscle s Trunk Muscle s Thigh Muscle s Ankle Muscle s Somato- sensatio n Vestibula r System Vision Environmental Interaction Select & adjust muscle contractile pattern Generation of body movement
    4. 4. Dizziness and Fall Risk APTA Fact Sheet4  Those with a vestibular dysfunction & self reported dizziness were 12x more likely to fall (Yuri, 2010) ◦ Pt. with vestibular dysfunction alone was also shown to be at a higher risk for falling  Increased risk of fall & recurrent falls in those reporting dizziness. (Tromp, 2001)  Dizziness when standing correlates with falls & recurrent falls. (Grassfmans, 1996)  Pt. with bilateral vestibular dysfunction were shown to have significant increase in falls compare to general population (Herdman, 2000)  Dizziness & vertigo were found to be the leading cause of falls (Gananca, 2006) ◦ Indiivduals who fell due to dizziness/vertigo were more likely to experience 2 or more falls  Those with chronic dizziness were found to be at increased risk of fall (Tinetti, 2000)  Those reporting dizziness 2x more likely to fall (O’Loughlin, 1993)
    5. 5. ANATOMY REVIEW Image: greymattersjournal.com
    6. 6. Vestibular Labyrinth3  3 Semi- circular canals ◦ Anterior, Posterior & Lateral ◦ Angular Accelerations ◦ High Frequency  2 Otolith Organs ◦ Utricle & Saccule ◦ Sensitive to gravity ◦ Linear Accelerations ◦ Low Frequency
    7. 7. Processing3  CN 8: Vestibulocochlear Nerve ◦ Tonic firing  Deflections toward kinocilium cause depolarization  Deflections away from kinocilium cause hyperpolarization  Central Processing ◦ CN8 projects information ipsilaterally to 4 Vestibular nuclei in dorsal Pons & Medulla ◦ Vestibular nuclei send output to  Cerebellum to coordinate movements & monitor performance  CN3,4,6: contralateral CN6 then projects to Medial Longitudinal fasciculus (MLF) to contralateral Oculomotor Nucleus  Spinal Cord descending pathways to adjust limbs and trunk to regain balance  Reticular Formation to adjust circulation & breathing for new body position  Through the thalamus to Somatosensory Cortex for
    8. 8. Without you realizing…3  Motor Output Reflexes ◦ Vestibulo-ocular Reflex (VOR)  Allows for stable vision upon head movements  Eye movements in opposite direction of head in 1:1 ratio  CN3: Oculomotor, CN4: Trochlear, CN6: Abducens ◦ Vestibulo-spinal Reflex (VSR)  Stabilize the head and body  Lateral & Medial Vestibulospinal Tracts  Reticulospinal Tract  Nystagmus ◦ Involuntary, rhythmic oscillation of the eyes characterized by the direction of the fast phase ◦ Can derive from physiologic, pathologic, peripheral &/or central lesions ◦ Can cause reduced visual acuity and vertigo
    9. 9. Putting it all together Image: Reference 1
    10. 10. DISORDERS
    11. 11. General: Vestibular Disorders2,3 Peripheral Central  Nystagmus generally horizontal  Vertigo as severe as nystagmus ◦ Response typically fatigues or habituates  More intense feeling of vertigo  Hearing loss & tinnitus frequent  Long-tract sensory, motor involvement are unusual  Nystagmus can be horizontal, rotatory or vertical; multi-directional  Vertigo relatively mild or absent ◦ persistent  Hearing loss & tinnitus rare  Associated sensory, motor, cerebellar, & other CN involvement more common
    12. 12. BPPV1-3,5  Between 17-42% of dizzy patients diagnosed with vertigo  Benign Paroxysmal Positional Vertigo ◦ Form of Positional Vertigo  Spinning sensation produced by changes in head position relative to gravity  BPPV- characterized by repeated episodes of positional vertigo ◦ Canalithiasis: otoconial debris become free floating in the endolymph of SCC ◦ Cupulolithiasis: otoconial debris dislodged from otolithic organs deposits upon cupula of SCC  ~85% Posterior Canal & 10-15% Horizontal Canal  Most common in 5-7th decades of life ◦ Degeneration of cilia during natural aging  Characterized by: acute, discrete episodes of brief positional vertigo without associated hearing loss
    13. 13. Differential Diagnosis of BPPV5 Peripheral Central  Meniérès Disease  Vestibular neuritis  Labyrinthitis  Superior Canal dehiscence syndrome  Post-traumatic vertigo  Migraine-associated dizziness  Vertebrobasilar insufficency  Demyelinating diseases  CNS lesions Other: Anxiety or panic disorder, cericogenic vertigo, medication side effects, and postural hypotension
    14. 14. Meniérès Disease1-3,5  ~10% of Pt. presenting with vertigo  Chronic disorder due to abnormalities in quantity, composition &/or pressure of endolymph ◦ Mixing of endolymph & perilymph  Characterized by attacks: ◦ Attacks can last 20min- 24hrs ◦ Attack frequency: few per week to years between ◦ Early Stage: spontaneous & disabling vertigo, fluctuating hearing loss, ear fullness &/or tinnitus ◦ Between Attacks: fatigue, anxiety, LOB, headache, vision difficulties, vomiting/nausea, neck pain, sound sensitivity ◦ Late Stage: hearing loss, tinnitus, constant struggle with vision and balance  Any age, most common 40-60yo  Tx: medication, reduce- sodium diet, vestibular rehab, surgery
    15. 15. Neuritis/Labyrinthitis1-3,5  ~41% of Pt. presenting with vertigo  Inflammation of inner ear caused by viral or bacterial infection ◦ Vestibular hypofunction ◦ Unilateral or Bilateral ◦ Acute or chronic, lasting several wks.  Neuritis: inflammation of the nerve affecting vestibular ganglion  Labyrinthitis: inflammation of the labyrinth affecting both branches of CN8  Sx: very sudden attacks of severe dizziness, vertigo, nausea and imbalance lasting for hours or even days. ◦ Labyrinthitis- tinnitus &/or hearing loss  Secondary conditions: ◦ Neuritis: BPPV & Labyrinthlitis: Endolymphatic hydrops
    16. 16. Neuritis/Labyrinthitis1-3,5 Image: http://www.lookfordiagnosis.com/mesh_info.php?term=Neuritis&lang=1
    17. 17. Migraine-Associated Vertigo (MAV) 1-3,5  Migraine is one of the most debilitating chronic disorder in US ◦ ~40% of Pts with migraines have a vestibular component affecting balance &/or dizziness  Characterized by migraine with: ◦ Episodic vestibular symptoms  Dizziness, motion intolerance, spontaneous vertigo attacks, diminished eye focus with photosensitivity, LOB and ataxia ◦ Sound sensitivity & tinnitus, cervioalgia with muscle spasms, anxiety, confusion, spatial disorientation ◦ No other cause of vertigo  Cause: combinations of vascular events, neuritis of portion of vestibular nerve as result of migraine. ◦ Utricle is typically more affected  Difficult to diagnosis ◦ Vestibular-evoked myogenic potentials (VEMP) testing ◦ Common to also have true BPPV
    18. 18. Cervicogenic Dizziness1-3,5  A clinical syndrome of disequilibrium & disorientation in patients with neck problem, ie. cervical trauma, whiplash, cervical arthritis/denegerative, and others1  Characterized by: ◦ Dizziness worse during head movements or after maintaining one head position for prolonged time ◦ Dizziness after the neck pain ◦ May be accompanied by headache ◦ Dizziness can last minutes-hours ◦ Also complain of general imbalance, increasing with head movements  No diagnostic test to confirm ◦ Difficult to truly diagnose- rule out other conditions  Dizziness typically improves with conservative treatment of underlying neck issue.
    19. 19. CLINICAL EXAM
    20. 20. What to look for3,5,6  Take thorough history of symptoms ◦ Frequency, Duration, Severity & Description of Sensation ◦ Current vestibular suppressant medications?  Oculomotor Exam ◦ Test VOR  BPPV testing  Test for hearing loss  Caloric Testing  Assess static and dynamic balance  Assess routine postural transitions ◦ Sit-supine, rolling, forward leaning, history  Also assess for strength, ROM and functional limitations
    21. 21. Oculomotor Exam3  Gaze nystagmus ◦ Gaze at target 20-30° off midline for 20sec (R & L)  Look for nystagmus or change in characteristics of gaze  Smooth Pursuit ◦ Tracking H  Look for saccadic substitution  Saccades ◦ Jump gaze between 2 pts ~12in apart (Vertical & Horizontal)  Look for speed, accuracy and conjugate EOM  Alteration in oculomotor movements indicate central origin of vestibular dysfunction7 ◦ Electronystagmograph vs. MRI  83.3% sensitivity & 21.2% specificity  Severe alterations: 71.4% sensitivity & 50% specifity  MAV: saccadic eye motion testing generally normal1
    22. 22. Testing VOR2,3  Head Trust (Impulse) test ◦ Visual fixation on a target ◦ Rapid, passive rotation to one side  Perform slowly first & ensure adequate Cspine ROM ◦ Look for loss of fixation with saccadic reacquisition  Test function of ipsilateral ear to thrust  Head Shaking test ◦ Seated, with head tilted 30°, head shake @20Hz for 20 seconds ◦ Look for nystagmus after head shake  Peripheral Origin: fast phase of nystagmus toward stronger/intact labyrinth  Central Origin: prolonged nystagmus, dysconjugate nystagmus, or vertical nystagmus after horizontal stimulus
    23. 23. Testing for Posterior BPPV3, 5  Hallpike- Dix ◦ Head turned 45° to one side ◦ Quickly from seated position to supine, head 20° below horizontal ◦ Observe for latency, direction & duration of nystagmus  Latency: 5-20sec  Direction: mixed torsional & vertical components with fast phase (upper pole) toward dependent ear  Duration: should resolve within 60seconds ◦ Sit up & repeat contralateral ear, if necessary.
    24. 24. Testing for Horizontal BPPV3,5  Pagnini-McClure Maneuver ◦ aka: Supine Roll Test  Pt. supine with head in neutral  Quickly rotate head 90° to one side  Observe for nystagmus  Head returned to neutral then quickly rotated 90° to other side  Observe for nystagmus ◦ In most cases, Geotropic nystagmus is produced  Fast component toward the ground  Less common Apogeotropic nystagmus is toward upper ear ◦ Affected ear is thought to be the one to which the side of rotation produced the more intense nystagmus/vertigo
    25. 25. Exclusions for BPPV testing5  Pt with physical limitations including: ◦ Cervical stenosis ◦ Serve kyphoscoliosis ◦ Limited cervical ROM ◦ Down syndrome ◦ Severe rheumatoid arthritis ◦ Cervical radiculopathies ◦ Paget’s disease ◦ Morbid obesity ◦ Ankylosing spondylitis ◦ Low back dysfunction ◦ Spinal cord injuries
    26. 26. Tests for hearing loss2,3  Rinne Test ◦ Place vibrating tuning fork (512Hz) against Pt’s mastoid bone, ask Pt to tell you when sound is no longer heard ◦ Once sound is no longer heard, place still vibrating tuning fork 1-2 cm from the auditory canal, ask Pt to tell if they are able to hear tuning fork  Normal Hearing: Air conduction should be greater than bone conduction  Weber Test ◦ Place tuning fork (256Hz) in the middle of the Pt’s forehead, equidistant from each ear. ◦ Pt asked to report which ear the sound is heard louder  Normal Hearing: Equal in both
    27. 27. Caloric Testing2, 3, 8  To evaluate integrity of unilateral vestibular apparatus. ◦ Determine unilateral vestibular hypofunction, ie neuritis/labrynthitis  Performed irrigation to external auditory canal in supine with head elevated 30° ◦ Cold & warm water for 30secs ◦ 5mins between each condition  Normal: COWS ◦ Cold opposite, Warm same  Cooling- increase, Warming- decrease in the specific gravity of the endolymph  Measure time of onset of nystagmus from beginning irrigation, duration & direction of each side under each condition ◦ Approx. 20% different is considered significantly abnormal ◦ Ask Pt about sensation, intensity and any differences they experience  80% accurate at diagnosing nerve damage as a cause of vertigo ◦ Electronystagmograph  Central origin dizziness/vertigo
    28. 28. Outcome Measures3  Dynamic Gait Index9 ◦ Time to Administer <10min ◦ Assess ability to modify balance while walking in the presence of external demands ◦ Vestibular disorders, geriatrics, PD, po st-stroke, brain injury & MS  ≤19/24 increased fall risk ◦ Pt. with vestibular disorders scoring ≤19/24 are 2.58 times more likely to have a fall in last 6 months  Excellent test-retest reliability (ICC= 0.86)  Four Square Step Test10 ◦ Time to Administer <5min ◦ Active stepping for Functional Tasks ◦ Vestibular disorders, geriatrics, PD, post-stroke & transtibial amp.  Increased Risk of Falls ◦ Vestibular: >12s ◦ Geriatric: >15s ◦ Acute Stroke: >15s  Excellent test-retest reliability (ICC= 0.93)
    29. 29. Helpful Tools for Assessment3,5  Frenzel Goggles ◦ Video or optical ◦ Enlarge (and record) oculomotor function ◦ Help monitor performance & oculomotor function during testing (Nystagmus) Gordon College: Center for Balance, Mobility, and Wellness (Wenham, MA) http://www.interacoustics.es/com_en/Pages/Product/BalanceSystems/_in dex.htm?prodid=57249  “Balance Master”  Computerized Dynamic Posturography  6 conditions  Pt. relative reliance on visual, vestibular, an d somatosensory inputs
    30. 30. INTERVENTION
    31. 31. Treating the “Dizzy” Patient2,3,5,6  Vestibular Rehabilitation ◦ Goals:  to help retrain the ability of the body and brain to process balance information1  to allow free head movement without dizziness, especially during gait6  Enhace gaze stability, postural stability, improve dizziness/vertigo & activities of daily living ◦ Canalith repositioning exercises (CRP), postural control exercises, fall prevention training, relaxation training, strength conditioning exercises, functional skills retraining, education and…  Habituation ◦ Retrain brain to manage offending stimuli ◦ Conditioning  Adaptation ◦ Active head movements to compensate for retinal slip  Substitution ◦ Visual and somatosensory systems to compensation
    32. 32. Treating Posterior BPPV3,5  Epley maneuver  Pt in upright position with head turned 45° toward affected ear  Rapidly laid back to supine head-hanging position, held 20-30sec  Head turned 90° toward unaffected side, held 20sec  Head turned further 90° (switch Pt to s/l facing floor), held 20-30sec  Bring Pt to upright sitting position ◦ Most researched and most effective in short and long term treatment ◦ Canal switch occurs in 6-7% of those treated with CRP  Semont’s maneuver  Pt in upright position with head turned 45° away from affected ear  Rapidly moved to s/l position, looking up at ceiling, held 30sec  Rapidly move to opposite s/l position, looking at table, held 30s  Bring Pt to upright sitting position ◦ Less researched than Epley maneuver and possibly less effective long term  Brandt- Daroff Exercises ◦ Overall less effective but good for HEP as Habituation Exercises ◦ Self-administered CRP appeared to be more effective, 64% improvement, than self-treatment with Brandt-Daroff exercises, 23% improvement . (Radtke, 1999)
    33. 33. Effectiveness of Posterior Canal BPPV treated with Epley Maneuver5
    34. 34. Treating Horizontal BPPV3,5  Lempert Roll Maneuver ◦ ~75% effective in treating Lateral BPPV  Begin supine, turn head slowly toward unaffected side  Maintain each step for 15sec.  Complete maneuver, Pt brought to upright with head bowed 30° http://www.tinnitusjournal.com/detalhe_artigo.asp?id=
    35. 35. Therapeutic Intervention2,3,5,6  Pt’s with BPPV ◦ Evaluate & Treat, if positive, prior to beginning other treatment ◦ Should be re-evaluated after 1month from initial CPR ◦ Discuss safety and possible reoccurrence  Challenge the systems ◦ Reduce influence of dominant sensory systems, strengthen the weak  Visual  Somatosensory  Vestibular  Gaze stabilization ◦ Most common exercises for peripheral vestibular hypofunction  Work at tolerable level of dizziness ◦ Increase in symptoms should last no longer than 20mins following treatment  Frequency & Duration of treatment are dependent on Pt. & symptoms ◦ 2-3 times per week to 1 time every 2-3 weeks ◦ 1-2 weeks to several months
    36. 36. Activities3,6  Get Creative & Consider Real-Life Function ◦ Gaze stabilization: active head and eye movements  Adjust for distance, speed & frequency, plane of movement, BOS, posture, surface, etc. ◦ Static stance  EC/EO, change surfaces, change BOS, vary combinations ◦ Walking  head turns, change speed, change direction, change surface, change BOS, navigate obstacles, etc. ◦ Manipulate BOS for functional activities ◦ Reaching out of BOS ◦ Vary surfaces  Foam, Trampoline, Dyna Discs, balance boards, BOS  Transfers from one surface to another- stepping stones ◦ Physioballs for sitting balance  Add EC, add bouncing, add feet on foam ◦ Hurdles ◦ Cones ◦ Obstacle Course Do Not forget general strengthening, stretching & conditioning for functional activities.
    37. 37. Effectiveness of Vestibular Rehab11 Systematic Review of 71 articles dated until 2006  Strong evidence for vestibular rehab ◦ Vestibular hypofunction: Neuritis/Labyrinthitis ◦ Multisensory dizziness ◦ Meniérès Disease  Moderately strong evidence ◦ After vestibular surgery  Insufficient evidence ◦ BPPV ◦ PPV ◦ Neurological causes of dizziness ◦ Dizziness from whiplash-associated disorder ◦ Migraine- associated dizziness STRONG EVIDENCE: VESTIBULAR REHAB FOR VESTIBULAR DISORDERS
    38. 38. Practice Makes Perfect  Oculomotor testing  VOR testing  BPPV testing  Outcome Measures ◦ Dynamic Gait Index ◦ Four Square Step Test  Instructional Exercises
    39. 39. Vestibular Rehabilitation Gordon College: Center for Balance, Mobility & Wellness (Wenham,
    40. 40. References 1. Vestibular Disorders Association. Understanding Vestibular Disorders. Available at: http://vestibular.org/understanding-vestibular-disorder/types-vestibular-disorders 2. Reeves AG, Swenson RS. Disorders of the Nervous System. Dartmouth Medical School. Chapter 6, 14. Copyright 2008. Available at: http://www.dartmouth.edu/~dons/. 3. Umphred DA, Lazaro RT, Roller ML, Burton GU. Umphred’s Neurological Rehabilitation, Sixth Ed. Chapter 22. Elsevier, Inc. Copyright 2013. 4. Bloom M. Research Studies that Associate Dizziness and Falls: Fact Sheet. APTA, Section of Neurology. Available at: http://www.neuropt.org/docs/vsig-physician-fact-sheets/research-studies- that-associate-dizziness-and-falls.pdf?sfvrsn=2 5. Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo. Otolaryngology-Head and Neck Surgery 2008; 139, S47-S81 6. Hoffer M, Balaban C, Whitney S, Sparto P. Principles of vestibular physical therapy rehabilitation. Neurorehabilitation [serial online]. July 2011;29(2):157-166. Available from: CINAHL Complete, 7. Tirelli G, Rigo S, Bullo F, Meneguzzi C, Gregori D, Gatto A. Saccades and smooth pursuit eye movements in central vertigo. Acta Otorhinolaryngologica Italica: Organo Ufficiale Della Società Italiana Di Otorinolaringologia E Chirurgia Cervico-Facciale [serial online]. April 2011;31(2):96-102. Available from: MEDLINE 8. MedlinePlus. Caloric Stimulation. Last modified: 2/26/14. Available at: www.nlm.nih.gov/medlineplus/ency/article/003429.htm 9. Rehabilitation Measures Database. Rehab Measures: Dynamic Gait Index. Last modified 1/30/14. Available at: http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=898 10. Rehabilitation Measures Database. Rehab Measures: Four Step Square Test. Last modified: 1/31/14. Available at: http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=900 11. Hansson EE. Vestibular rehabilitation-For whom and how? A systematic review. Advances in Physiotherapy. 2007; 9: 106-116

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