Why I Choose To See A PT For Pelvic Health (And Maybe You Should Too)

Who speaks about personal stuff in public? And by personal, I mean: peeing, pooping, sex, pain in your… you know… privates! Once thought to be taboo, pelvic health and women’s health issues have gained increased attention over the last several years. Although sometimes not as much as most of us pelvic health therapists would hope for, but at least it’s something.

Just think about it. If you broke your arm, you would see an orthopedist or an orthopedic surgeon and possibly have therapy. If your hurt your knee, ankle or even had a hip replacement, it would be the same. If you had arthritis and were dealing with pain or difficulty performing your normal day to day activities, you would see a physician and possibly go to therapy ( I would hope) to get you moving better. So then why is it so difficult when people have pain in the pelvic region to know that there is someone who can address those issues to.

There are several muscles ‘housed’ in the pelvis and they have many functions including supportive and sexual. When there is dysfunction, whether it be muscles being “too tight” or muscles being “too weak” or even trauma whether from birth or otherwise, there are things that can be done to address this. A pelvic health therapist one who had had additional training to treat these issues and many others and techniques may include addressing the muscles internally as some of the muscles are not easily assessed otherwise. Education in breathing, postural, body mechanics are also key and integrated into functional and daily tasks.

Did you know pelvic health therapists also treat pregnant and post partum women… oh yeah… they have a pelvis too! And men… yup they have a pelvic too! And children… you guessed it… they have a pelvis!

Although women are known to be the ones who commonly have issues related to the pelvic region, many men suffer from pelvic girdle pain (pain in the penis, testicles, groin or even rectum), incontinence and erectile dysfunction issues. Children may have issues as well with incontinence, specifically bed wetting and everybody can have issues with constipation which is an issue that can often lead to other problems.

Many pelvic health therapists also work with patients, both male and female who may be dealing with or have dealt with diagnoses of cancer, including breast, ovarian/ cervical (especially after hysterectomies) and prostate.

So, if you have: dyspareunia, vulvodynia, endometriosis, pudendal neuralgia, bladder pain, dysmenorrhea, you are a male with penile, testicular, groin or rectal pain, back pain, interstitial cystitis, prostatitis, urinary or fecal incontinence, child birth, pelvic organ prolapse, hysterectomy, prostatectomy, laparoscopy, cesarean birth (to name a few) then a pelvic health therapist may be someone you might need to pay a visit to.

 

 

 

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The Deep Core

Every one speaks about the core, but typically are only referring to the abdominal muscles when they do so. But it is so much deeper than that… so much deeper!

Your core is made up of the transversus abdominus, which is the deepest abdominal muscle, the multifidus posteriorly (in the back), your diaphragm at the top and your pelvic floor muscles.

For a long time abdominals were trained in isolation but we know that there needs to be a greater move to integrate these muscles and help the “core” to truly function like the stabilizing unit that it is. If one of these groups is not working efficiently then it can translate to inefficient functional movements, the things that you do on a day to day basis.

In a properly functioning unit, the core is activated even before you do just about any task. This system is always working, and functions in coordination with your breath.

Typically when you breathe in the diaphragm descends and your pelvic floor relaxes and moves downward. When you breathe out, as the diaphragm moves back up to its original position, the pelvic floor recoils. Optimizing this has much to do with your posture and as such postural awareness while performing tasks is key to being as efficient as possible with those tasks.

If you want to know more about this phenomenon, check out Julie Wiebe, PT via: http://www.juliewiebept.com/video/how-should-you-breathe/ who has done significant research in this area.

Try this exercise:
Sit on a chair, making sure that you are sitting directly on your sit bones. Back erect and palms wrapped at the sides of your ribs almost as if wrapping from the back to the front. If you want, you can take a wash cloth or a face towel, roll it and place it length-ways at your perineum, running from the vagina to the anus. Take a deep breathe in, feeling your ribs expand to the sides and your abdomen forward. As you do so, also pay attention to the pelvic floor descending onto the wash cloth/ face towel. Now breathe out slowly, feeling the ribs recoil, the abdomen reduce and the pelvic floor recoil from the face towel/ wash cloth.
Now try this again, but with the pelvic tucked, the shoulders rounded and in a slouched posture and consider these things:
1. Can you feel the same amount of excursion of the ribs? Are you able to take in as much air?
2. Can you feel the descent and rise of the pelvic floor onto and off of the wash cloth/ face towel?

This is a nice quick way to easily see and feel the connection between posture and the pelvic floor. You can also try this is standing, assessing for quality of movement based on the postures that you assume.

Feel free to comment or ask questions.

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The 3rd Trimester…Home stretch!

The 3rd trimester. Hopefully you are feeling fine. You may be a little tired, or you could be full of energy and vibrant. Normal gestation is considered 38-42 weeks and you are more than likely counting down the days until you see this amazing baby or babies.

During this time:
1. Your OB appointments increase
2. You may begin to experience a little more discomfort as the baby continues to grow
3. It may start to get more uncomfortable at night, either finding a comfortable position to sleep or even just having difficulty sleeping in general.
4. For others there may be a feeling of constant fatigue
5. Heartburn/ Reflux

Things to remember:
1. Posture is important. Continue to be mindful of your posture.
2. Breathing is very helpful, not only for relaxation but being in tuned with your breath can help in future with your delivery process.
3. Eat smaller portions to accommodate for any heartburn or indigestion you may be feeling. Be cautious of foods that might exacerbate this (spicy foods, citrus foods)
4. Continue to be as mobile as possible. If you are tired, then rest, but on the days when you have a little more energy then go ahead and try to move as much as you can- walking, maybe cleaning with a little music on (I have had some of my best workouts dancing while cleaning).
5. Be mindful of breath holding and also “doming” at the abdomen with activity.

In a previous article I spoke about DRA (diastasis rectus abdominus), something that according to current research literature is present within 100% of pregnant women. This is a stretching of the connective tissue in the abdominal wall and makes sense as the abdomen is growing and needs to accommodate the baby. The important thing here is to be mindful of activity and the things listed above #3 and 4.

Now is a great time, if you haven’t already, to reach out to a pelvic floor therapist. Not only can they work on strengthening and mobility exercises and strategies to prepare you for delivery but also efficient positions for laboring in, especially in lieu of any orthopedic issues or pains that you may be having. They can educate you on any type of supports that may be helpful at this time to better alleviate pain and assist with keeping you as mobile as possible during this phase. In addition, they prepare you for the fourth trimester, or the phase immediately after labor, with exercises to strengthen the pelvic floor, education on proper posture for breast feeding, lifting/ carrying your baby and for functional tasks at home.

As with all the other phases of your pregnancy, your nutrition remains very important. Balance is key. For most persons, they are no longer nauseated at the site or the odor of food. If you feel that you are unable to eat adequately adding a nutritional shake can be helpful to ensure that you get the proper nutrients and calories needed.

As the countdown continues, continue to enjoy this time. Make some time for ‘mama’ because soon your focus will change somewhat and that is perfectly normal. Allow your ‘tribe’ to help where they can and take the opportunity to rest and rejuvenate.

Congratulations!!!!!!

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Diastasis Rectus Abdominus in the pregnant and post partum woman

Commonly referred to as DRA, this is a separation of the rectus abdominus muscle or “6-pack muscle” of the abdomen. Although it can occur in men and children (for varying reasons) it is commonly seen in women in the 3rd trimester of pregnancy and the post-partum period. Some reports state that at least 75% of women in the 3rd trimester have a diastasis, which is not surprising considering that the connective tissue has to stretch to accommodate for the growing fetus. Post-partum however it remains common in approximately 35% of women and this is where it can be concerning.

For some, they are concerned with the aesthetics. However, for pelvic health therapists, we are concerned with not only function but the associated issues that may be common in a persistent DRA such as, but not limited to, back pain, incontinence, prolapse, abdominal doming, abdominal hernias and failure to return to prior level of activity as a result of any or all of the above.

Again, this post is not to scare but to offer information. While some persons may have a DRA that resolves without intervention during the post partum period, there are others who may have a greater separation and as such greater compromise to the strength and integrity of the tissues and would need to be evaluated and treated for that.

How do we test for DRA?

A diastasis is determined at the level of the belly button, slightly above and also slightly below if the separation is greater than 2 finger widths or approximately 16mm.

To test, you lie on your back with the knees bent (feet flat). Relax your body and place your fingers, palm facing towards your abdomen slightly above the belly button.

Lift your head and neck slightly from the floor- no need to lift your shoulders- as if doing a slight curl up.

If you feel a gapping or separation, then that is a diastasis. Repeat at the level of your belly button and slightly below.

You may also note bulging or doming through the separation.

Why do we need therapy to help?

Often times when there is a DRA, women use strategies that can make it worse, including over-using other muscles and holding their breath. Since this can increase the pressure within the abdomen, it can also negatively impact the DRA.

A women’s health therapist can assess your DRA, not only in the position described above, but in other functional positions and would therefore be able to customize a program to address this and any other concurrent issues with the focus of returning you to prior function and activities without pain, leaking, to fitness related activities and not adding further insult to the region.

It should be noted that in some instances, the diastasis will not fully close. The key here is to remember that the integrity of the tissue is what is important with the goal of improving tensile strength and ability to transfer loads t/o the muscles thereby promoting improved function.

 

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The 2nd trimester…What’s in store?

Congratulations! You have passed the infamous 13-week mark. You are excited because maybe your morning sickness has ended (or maybe not). In a few weeks you get to find out the sex of your baby- how awesome!

The 2nd trimester is interesting because your body continues to undergo many changes but here is where some of those changes become visible. As such, there are a few things that we need to be mindful of.

  1. Your posture. Due to the growing weight of the fetus, your center of gravity shifts. Why is this important you ask? It’s because one of the most common complaints for many women during pregnancy is back pain. The weight of your breasts and stomach start to pull you forward and your body tries to counter. This results in an increase low back “arch”, which is usually the location of most people’s pain. While back pain is certainly common because of the changes that your body undergoes, know that it is not normal and there are ways to alleviate this.
  2. Difficulty breathing. Your stomach is getting so much bigger and it is not uncommon for some women to say they feel slightly winded. One of the ways to address this is to try to maintain some level of cardiovascular fitness throughout. Know that pregnancy does not mean that you have to be inactive. You can continue to work out at the same intensity as prior to your pregnancy. Strength training can be performed, but it is advised that you do so under the eye of a trainer or therapist who specializes with the pregnant population- be cautious with new programs or increasing weight if this is not something you partook of prior to pregnancy as we want to avoid straining. Walking is a wonderful exercise when pregnant, start with a few minutes at a comfortable pace- maybe 10 minutes daily and increase as tolerated. Do not over exert yourself. If you can hold a conversation while participating in activity then you likely are not over doing it.
  3. You may start noticing, depending on the size of your stomach, that your belly button is more prominent. In addition, you may feel some separation just above or below your belly button. This separation is one of the connective tissue, or the linea alba that is located between your rectus abdominus muscles (otherwise known as the ‘6 pack’ muscles). This is known as diastasis rectus abdominus and is more noticeable (when present) in the 3rd trimester and post-partum. Please note that the stretching of the tissues is needed to accommodate the growing fetus. The key here is being mindful of postures and to avoid “bearing down” or valsalva maneuvers which could exacerbate this and cause “doming” as well (more on this in future posts).
  4. Aches and pains! During this time a lot of women begin to notice pain at the lateral and lower aspects of the abdomen. This is more than likely round ligament pain, stemming from the stretching of this ligament due to the growth of the fetus and subsequently the abdomen. Other complaints may include but are not limited to: back pain, groin pain, headaches, jaw pain, neck pain.

Other things to consider include:

  1. Your positions. Usually it is recommended by most OBs to avoid the supine position (lying on your back) for sleeping at least by mid-second trimester. The reason for this is because the growing weight of the baby can press on the vena cava or main vein bringing blood from your extremities. Left side lying is preferred. In addition, when exercises, be mindful of positioning and as your start to grow in size you will need to modify exercises to avoid supine. There are plenty of exercises and modifications you can do, so no worries.
  2. Be mindful of what you eat. Wholesome and nutritious foods- fresh fruits and vegetables are always recommended. Smaller portions are preferred as it can be uncomfortable to eat larger meals at this time.
  3. One of the things that can help during this and really any other time is meditation and breathing exercises. As your body undergoes these changes, it can be a bit overwhelming for some and that is ok! You are not alone!

What can PT do to help?

  1. Education and increasing awareness of what occurs during this time, especially for new mothers who may be unaware of what to expect.
  2. Many women are not in tuned to their breathe, nor are they aware of its connection to the pelvic floor. Education related to this is important and linked to postural training for not only relaxation but also for increased awareness of the pelvic floor muscles and optimization of function.
  3. Postural Training. A lot of the time improved postural awareness and corrections can improve some of the issues that women deal with at this time.
  4. Exercises including strengthening and stretching to improve mobility and function and help with preparation for labor.
  5. Manual techniques, taping and belts/ braces and other therapeutic interventions as needed and as appropriate, depending on the client.

As always, talk to your health professional. Although many women report discomfort when pregnant, they may or may not be referred to physical therapy or a pelvic health/ women’s health specialist. Know that although some things are common, this does not mean they are normal. There are many resources out there for you and solutions to address any issues that you may have during this time.

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Round Ligament Pain

The round ligament is a ligament that attaches the uterus to the pelvis.

As pregnancy progresses and the fetus grows, so does the uterus, causing stretching of this ligament and discomfort usually at either side of the abdomen and underneath. This typically occurs from the 2nd trimester.

Pain typically lasts only for a short time but can persist even longer in some cases. It can be felt when rolling or changing positions, such as when attempting to get out of bed, with coughing, sneezing or quick movements.

How can therapy help?

There are several interventions that can be performed to address round ligament pain. These include:

  • Manual Therapy
  • Taping/ bracing either with the use of tape or with the use of maternity belts. It is best that you speak to a women’s health therapist who can recommend what belt is best, if one is needed as there are several on the market and this can save you both time, money and the possibility of no relief from having the wrong belt.
  • Exercises to address the muscles within the surrounding areas for improved support.
  • Moist heat to decrease discomfort as tolerated
  • Strategies to improve pain when present including proper movement techniques
  • Therapy may also be necessary to distinguish this pain from something else.

As always if you are pregnant and have any concerns, speak to your health professional. There is no such thing as a silly question and it is best that any concerns be addressed.

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The 1st Trimester… What do I do??????

Yeahhhhhh! You just found out that you are pregnant. Maybe you were planning. Maybe you weren’t. Maybe you have been trying for a while. Irregardless… Congratulations!

Your body is about to experience the miracle that is pregnancy and I will say- it is pretty awesome! Some may beg to differ and to be honest, now that I am not pregnant, looking back I still think it is, although while I was pregnant (especially with my first) I am not sure I felt that way).
Your body is about to undergo some interesting changes and for some of you, you may not even have a clue! You may not have missed a menstrual cycle, you may not be having any symptoms, you may feel like “normal” like you always do. For some of us though it is not that easy. When that ‘all-day’ …I mean ‘morning sickness’ kicks in, it can kick your butt! Know that for every woman the symptoms can be different, so let’s look at a few:

  1. Morning sickness (for some of you, you may be sick all day). In severe cases some women have hyperemesis gravidarum which is more or less very severe morning sickness. Talk to your medical professional and let them know what is going on.
  2. Fatigue. You could very well feel like a walking narcoleptic
  3. Insomnia. Even though you are tired, you just can’t seem to sleep
  4. Frequent bathroom trips
  5. Tender breasts
  6. It may feel like you are having a period that doesn’t go away, so for some of you that have headaches, tender breasts, nausea with your cycles, you may very well feel the same.
  7. Decreased sex drive (well if you’re throwing up all the time I am pretty sure sex is not that high on your list).

This can make it very difficult to do much of anything…and I do mean anything. But what are some things that you can do to help during this time?

  1. Rest. Rest as much as you need to. Your body is going through changes so allow it time to recover each day.
  2. Try to stay active. I know this may seem like a contradiction to the first, but it isn’t, I promise. Yes, you may feel awful, but even if all you can do is walk, then do that. Try to incorporate at least 30 minutes of activity into your day. Now that being said, if your symptoms are really severe, then listen to your body and don’t try to over do it.
  3. Be mindful of what you eat and consider smaller portions. If you are having morning sickness or persistent nausea, you are not really in the mood to eat much. Consider more shakes, with nutrient dense ingredients (greens, fruit, protein) or consider snacking, smaller meals throughout your day. Also travel with snacks at all time. Have a few go to snacks that you keep handy at all times. If scents are a trigger of your nausea, then try bland foods.
  4. Don’t feel as though you have to do EVERYTHING! Utilize your community. For all of you super women out there, this will serve you well. It is okay to ask for help and call in the ‘cavalry’ if needed.

Some other things to consider are:

  1. The use of essential oils
  2. Meditation and breathing activities (we will highlight some of those in the next article)
  3. Support groups. No man is an island and there are many who have gone through something at least similar to what you are experiencing. Consider community groups or online groups such as meetups or Facebook groups. Talk to the healthcare professionals you see (OB, PT, Midwife, Doula) and ask for information.

It goes by faster than you think. Really! I know it may not feel that way when all you do is run to the bathroom to throw up but “this too shall pass”.

Congratulations and let’s prepare for this amazing little person(s) who is on the way!

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Post-partum SEX…The Elephant in the room


There is a myriad of things that happen to you and your body as you go through pregnancy. Besides physical changes, of which there are many, there are also hormonal and emotional changes. You may or may not have been sexually active during your pregnancy and you have been told you need to wait those 6 weeks before your doctor will give you the go ahead for most things, including sex.

Your 6 weeks have come… you had your appointment and you got the green light…but why can’t you have sex? Or why is it so uncomfortable or even painful? And why does no one talk about this?

So much has happened to your body!

  • First of all, there are the emotional and hormonal changes that you may be going through… You just may not have the urge and that is ok! If you are breastfeeding, that can cause decreases in estrogen which often leads to vaginal dryness.
  • You may be sleep deprived. The little darlings are adorable, but waking every couple of hours is tiring and leaves you fatigued without much energy to do anything, let alone have sex.
  • What the heck has happened to my body! Sometimes, many women have a hard time with the physical changes in their body. They may not feel “sexy”. Stuff doesn’t fit the same way. We may have gained a few pounds. We may now have stretch marks. These things are all normal and nothing to be ashamed of.
  • You may be hurting. There are quite a few reasons why you are in pain with sex. Let me put it into perspective for you…you just birthed a person!!!!That’s right. A living, breathing, squirming and wiggling person just exited your body. During that process muscles, ligaments and connective tissue can be stretched and depending on the type of birth you may have had and how stressful, there could be some serious trauma or injury to some of these tissues. You may have had an episiotomy or might have torn naturally and this can happen to varying degrees. In some cases there could also be significant muscle tightness. Yup! I said it! You have muscles “down there” and they are affected by trauma, just like your quads, hamstrings or any other muscle.

So, what can you do?

  • Use of lubricants can be helpful
  • Seek counseling if necessary. There are lots of resources available to assist. This may be helpful for those persons who are having issues communicating with or relating to their spouse.
  • Talk to your healthcare providers, especially if there are other issues such as post-partum depression that may be affecting you.
  • Seek out a pelvic health physical therapist. Did you know that a pelvic health physical therapist can assess you both externally and internally to address issues with pain, trigger points, muscle weakness as well as providing strategies for improving your overall function post birth whether it may your normal daily activities, posture, returning to sport, dealing with incontinence, sexual issues etc.

This doesn’t have to be a troubling time. Know that you are not alone and there are resources and clinicians available to assist you with whatever you may be dealing with post birth. In many states, you can go directly to your women’s health physical therapist through a process called direct access where they act as primary providers of healthcare without a referral first from an MD, OB or GYN.

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Why Post-partum Physical Therapy Should Be The New Standard of Care

So… you had a baby. Congratulations!

You got pregnant and watched your body go through these AMAZING changes over a period of 9 months. There were even changes that you did not see. These included:
– the stretching of the linea alba as the abdominal muscles and connective tissues stretches to accommodate your growing stomach
– the relaxation of pelvic ligaments to accommodate for growth of the baby by also labor
– stretching of muscles to accommodate for the above
– slight separation of your pubic bones, up to which 2-4mm is considered normal, to accommodate for passage of the baby during labor
– orthopedic issues including SI jt dysfunction, lumbosacral, thoracolumbar and even sometimes cervical issues due to postural changes.
– decreased muscle tone based on your ability to remain active throughout your pregnancy. Remember not everyone is able to actively participate in some type of fitness although it is highly recommended. There are women on bedrest with precautions and there are many more who don’t have access to or know where to find good instruction for safe activity during pregnancy and as a result opt to “be safe rather than sorry” and not do anything. Then there are those who continue their sedentary lifestyle throughout.

Now depending on the type of birth you might have had, whether you labored for a long time, whether you had a vaginal or a cesarean, there might have been even more changes. These may include: tearing of your perineum (the area between the vaginal entry/ introitus and the anus; disruption of pelvic floor muscles depending on forcefulness, speed of birth and length of labor; disruption of connective tissues if a cesarean and sometimes even with a vaginal birth.

So how does one check at 6 weeks help?!!?!?!?! A peek at the uterus and a papsmear. Maybe you had a physician who asked about breast feeding and or asked a few questions to screen for post-partum depression (or maybe you didn’t). It all seems insufficient as far as postpartum care goes. Somehow the focus post birth seems to be on the baby… and don’t get me wrong, it should… but you know the saying “If momma ain’t happy, ain’t nobody happy!” and I think that has never been truer. If moms are in pain, unable to move and function, have diastasis recti, have abdominal pain, adhesions due to scarring, unable to control urine and feces, unable to have sex, fractures of tailbones and so on, we are not only talking about physical implications, but we are now talking about a lot of psychosocial issues that impact this female and by extension her family and can as a result have an impact of her ability to function optimally even as a mom in some cases.

Research has shown that approximately 50% of women have diastasis recti after giving birth which goes unresolved after 8 weeks. Among American women, about 1 in every 4 have some type of pelvic floor dysfunction. Among new mothers, 58% of moms who delivered vaginally have a pelvic floor dysfunction, as well as 42% of those who have delivered via cesarean.

So, talk to your OB/GYN today. In many states in the US physical therapists (PT) have direct access which means that they can evaluate you and even treat you for a specific period of time without a prescription from your MD. In some states direct access is such that there is no time restriction. Find a PT near you that specializes in pregnancy, post-partum and women’s health that can help you address any issues you may be having as a result of pregnancy.

Let’s take care of ‘momma’!

Take a look at this article from an American living in France with access to post-partum therapy. In France, as a part of their care, women get 10-20 customary post-partum visits with a therapist to ensure that they can address any issues they may have.

http://www.slate.com/articles/life/family/2012/02/postnatal_care_in_france_vagina_exercises_and_video_games.single.html

References:
Benjamin DR, van de Water ATM, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014;100(1):1-8.

Sahakian J, Woodward S. Stress incontinence and pelvic floor excercises in pregnancy. Br J Nurs. 2012;21(18):S10-S15.

Yamaguchi M, Morino S. Comparison of Pelvic Alignment among Never-Pregnant Women,Pregnant Women, and Postpartum Women (Pelvic Alignment and Pregnancy). J Women’s Health Care. 2016;05(01). doi:10.4172/2167-0420.1000294.

Madill S. Differences in pelvic floor muscle activation and functional output between women with and without stress urinary incontinence. September 2009.

Miller JM, Low LK, Zielinski R, Smith AR, DeLancey JOL, Brandon C. Evaluating maternal recovery from labor and delivery: bone and levator ani injuries. Am J Obstet Gynecol. 2015;213(2):188–e11. doi:10.1016/j.ajog.2015.05.001.

Larson-Meyer E. The effects of regular postpartum exercise on mother and child: review article. Int SportMed J. 2003;4(6):1-14.

Norman E, Sherburn M, Osborne RH. An Exercise and Education Program Improves Well-Being of New Mothers: A Randomized Controlled Trial. Phys Ther. 2010;90(3):348-355.

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