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See discussions, st ats, and author pr ofiles f or this public ation at : https://www .researchgate.ne t/public ation/225060894
Comparison of Effectiveness of Su pervised Exercise Program and Cyriax
Physiotherapy in Patients with Tennis Elbow (Lateral Epicondylitis): A
Randomized Clinical T rial
Article    in  The Scientific World Journal · May 2012
DOI: 10.1100/2012/939645  · Sour ce: PubMed
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The Scientific W orld Journal
V olume 2012, Article ID 939645, 8pages
doi:10.1100/2012/939645The cientific WorldJOURNA L
Research Article
Comparison of Effectiveness of Supervised Exercise Program and
Cyriax Physiotherapy in Patients with T ennis Elbow(Lateral Epicondylitis): A Randomized Clinical Trial
Rajadurai Viswas,1Rejeeshkumar Ramachandran,1and Payal Korde Anantkumar2
1BCF College Of Physiotherapy, Indo American Hospital Campus, Kottayam District, Kerala State, Vaikom 686143, India
2Physiotherapist, Rudraksh Physiotherapy Clinic, Kandivali (West), Maharashtra State, Mumbai 400 067, India
Correspondence should be addressed to Rajadurai Viswas, [anonimizat]
Received 1 November 2011; Accepted 4 December 2011
Academic Editor: G ¨ul Baltaci
Copyright © 2012 Rajadurai Viswas et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and repro duction in any medium, provided the original work is properly
cited.
Objective .T oc o m p a r et h ee ffectiveness of supervised exercise program and Cyriax physiotherapy in the treatment of tennis elbow
(lateral epicondylitis). Design . Randomized clinical trial. Setting . Physiotherapy and rehabilitation centre. Subjects . This study was
carried out with 20 patients, who had tennis elbow (lateral epicondylitis). Intervention .G r o u pA( n=10) had received supervised
exercise program. Group B ( n=10) was treated with Cyriax physiotherapy. All patients received three treatment sessions per
week for four weeks (12 treatment sessions). Outcome measures . Pain was evaluated using a visual analogue scale (V AS), and
functional status was evaluated by completion of the T ennis Elbow Function Scale (TEFS) which were recorded at base line andat the end of fourth week. Results . Both the supervised exercise program and Cyriax physiotherapy were found to be significantly
effective in reduction of pain and in the improvement of functional status. The supervised exercise programme resulted in greater
improvement in comparison to those who received Cyriax physiotherapy. Conclusion . The results of this clinical trial demonstrate
that the supervised exercise program may be the first treatment choice for therapist in managing tennis elbow.
1. Introduction
The syndrome of persistent disabling pain in the elbow, pre-
dominantly in the radio humeral joint, is called as tennis
elbow, lateral epicondylitis, or lateral epicondylalgia [ 1–5].
The definite cause of tennis elbow is not yet known. It is apainful and debilitating musculoskeletal condition that af-fects health care industry [ 6]. It is very common in indi-
viduals whose jobs necessitate frequent rotary motion of theforearm (e.g., tennis players and carpenters) [ 7]. It is com-
monly due to more quick, monotonous, cyclic eccentric con-tractions and wrist griping activities [ 8]. The commonly
affected arm is the dominant arm, with a prevalence of 1–3%
in the general population, but the incidence rapidly increasesto 19% between 30–60 years of age and seems to be moresevere and long-standing in women [ 9,10]. The average
period of an episode of lateral epicondylitis ranges between6 months and 2 years [ 11]. In tennis elbow, microscopicand macroscopic lesions can be found in the Extensor Carpi
Radialis Brevis (ECRB) [ 12].
The main clinical presentation and the chief complaints
in tennis elbow are decreased grip strength, decreasedfunctional activities, and increased pain, which may havesignificant impact on activities of daily living. The diagnosisof tennis elbow can be made simple, and it may be confirmedby test which would elicit the pain, tenderness over on thefacet of the lateral epicondyle on palpation, resisted wristextension, resisted middle finger extension, and passive wristflexion [ 13].
Even though tennis elbow has well-defined clinical feat-
ures, no proper treatment intervention has emanated [ 14].
In literature, more than 40 di fferent methods have been doc-
umented for the treatment of tennis elbow [ 15]. Conven-
tional treatment [ 16] for tennis elbow has focused primarily
on the pain management by anti-inflammatory medication,ultrasound, phonophoresis [ 17], or iontophoresis. Various

2 The Scientific W orld Journal
treatments have been attempted for tennis elbow including
corticosteroid injection [ 18], drug therapies, laser [ 19–22],
electrical stimulation [ 23,24], ergonomics [ 25,26], coun-
terforce bracing [ 27], acupuncture [ 28,29], and splintage
[2]. Surgical treatment is indicated in 5–10% [ 30]o fp a t i e n t s
who did not improve from their symptoms with conservative
treatment approach. The theoretical mechanism of actions
of these treatment interventions di ffers widely, but the entire
treatments’ goal is to improve function and reduce pain [ 14].
Even though numerous studies have been conducted ontreatment of this clinical condition, till date the most e ffective
management strategy is not agreed [ 31]. For the treatment
of tennis elbow, both medical and physiotherapeutic inter-ventions have been reported in research literature [ 32]. Cy-
riax and Cyriax suggested the use of deep transverse fric-tion massage in combination with mill’s manipulation forthe treatment of tennis elbow [ 33]. In order to label the treat-
ment intervention as Cyriax physiotherapy, both the treat-ment components mentioned above must be used jointly inthe sequence specified. In this protocol, person must adhereto this intervention 3 times a week for duration of 4 weeks[34]. However, the number of research studies analysing the
effectiveness of this treatment intervention is less, the reason
being that most of them do not have proper randomization,blinded outcome measures, and accurate functional outcomequestionnaires [ 35–37]. For the above-mentioned reasons,
further research is warranted to find out the e ffectiveness of
Cyriax physiotherapy intervention.
The conventional treatment intervention of tennis elbow
is most often accompanied by exercise program which may
include strengthening, flexibility, or endurance training exer-
cises. For instance, Stasinopoulos et al. [ 38] recommended
the use of static stretching of the Extensor Carpi RadialisBrevis (ECRB) and eccentric strengthening exercises for thewrist extensors in treating lateral epicondylitis. Even thoughvarious treatments exist in the management of tennis elbow,optimal treatment intervention is not agreed upon till date.Hence, further research is necessary to find the most e ffective
treatment option in the management of patients with tenniselbow [ 33]. The purpose of the study was to compare the
effectiveness of Cyriax physiotherapy and supervised exercise
program in the reduction of pain and improving functionalstatus in patients with tennis elbow.
2. Methods
A randomized clinical trial was conducted between March2011 and September 2011 in an outpatient department,Physiotherapy and Rehabilitation centre, Alleppey, Kerala,India. Patients were referred by orthopaedic consultant,health care providers, and also self-referral to the centre.Patients were included if they were between 30 to 45 yearsof age and had been diagnosed with tennis elbow, and theduration of symptoms was between 8 and 10 weeks.
2.1. Inclusion Criteria
(1) Pain with gripping.
(2) Pain with resisted wrist extension.(3) Pain with passive wrist flexion with the elbow exten-
sion.
(4) T enderness on palpation over the lateral epicondyle
of humerus.
2.2. Exclusion Criteria
(1) Cardiovascular diseases.
(2) Neurological impairments.(3) Aversion to manual contact.
(4) Neuromuscular diseases.
(5) Previous trauma to the elbow region.(6) Elbow pain.
(7) Previous surgery to the elbow region.
(8) Peripheral nerve entrapment.(9) Cervical radiculopathy.
(10) Corticosteroid injection within 6 months.
(11) Previous therapy for elbow joint (minimizing expec-
tation bias).
All patients signed the written consent form prior to part-
icipation. The recruited patients had also completed a stand-ard health questionnaire which encompassed details relatingto patient demographics, duration of symptoms, any previ-ous treatment undertaken, and job status.
2.3. Treatment. Patients assigned to Group A received super-
vised therapeutic exercise program which included staticstretching of the Extensor Carpi Radialis Brevis followedby eccentric strengthening of the wrist extensors. Staticstretching was performed in the seated position with elbowextension, forearm pronation, and wrist flexion with ulnardeviation. According to the patient tolerance stretch forcewas applied. This stretch position was held for duration of30–45 seconds and was performed 3 times before and 3 timesafter the eccentric exercise portion of the treatment for atotal of 6 repetitions [ 14]. There was a 30-second rest interval
between each bouts of stretching.
Eccentric strengthening exercise was performed in the
seated position with full elbow extension, forearm pronation,and maximum wrist extension. From this position, the
patient slowly lowered wrist into flexion for a count of 30,
using the contralateral hand to return the wrist to maximumextension. Patients were instructed to continue the exerciseeven when they experience mild discomfort and to stopthe exercise if the pain worsens and becomes disabling. Forwhom the eccentric exercise could be performed withoutminor discomfort or pain, the load was increased using freeweights based on the patients 10 RM (Repetition Maximum).Three sets of ten repetitions were performed during eachtreatment, with a one-minute rest interval between each set.Patients were also provided with education manual regardingergonomics and activity modification technique to avoidaggravation of symptoms.

The Scientific W orld Journal 3
Figure 1: Deep transverse friction massage.
Figure 2: Mill’s Manipulation.
Patients in Group B received Cyriax physiotherapy, which
consists of 10 minutes of deep transverse friction massageimmediately followed by a single application of Mill’s manip-ulation. The hand placement is shown in Figure 1 .D e e p
transverse friction for tennis elbow is applied as follows [ 34,
39]. The patient should be positioned comfortably with the
elbow fully supinated and in 90
◦of flexion. After palpating
the anterolateral aspect of the lateral epicondyle of humerus,the area of tenderness was mapped. Deep transverse frictionis applied with the side of the thumb tip. The pressure wasapplied in a posterior direction on the tenoosseous junction.It was applied for ten minutes after the numbing e ffect has
been attained, to prepare the tendon for Mill’s manipulation[33].
For the technique of Mills manipulation, patients were
positioned comfortably in the seating position with theaffected extremity in 90
◦of abduction with internal rotation
enough so that the olecranon faced up. The therapist stabi-lized the patient’s wrist in full flexion and pronation with onehand, while other hand was placed over the olecranon [ 14].
While assuming full wrist flexion and pronation position, thetherapist should apply a high-velocity low-amplitude thrustat the end range of elbow extension ( Figure 2 ).
2.4. Outcome Measures. Outcome measures used in the study
includes pain intensity and functional status which wererecorded at base line (pretest) and at the end of 4 weeks. Anindependent observer, who was blinded to the patient groupallocation, assessed the outcome measures. Pain intensity was
measured using the visual analogue scale (V AS). The V ASconsists of a 10 cm horizontal line with two ends labelledas 0 cm representing the “least pain imaginable” and 10 cmthe “worst pain imaginable” . Patients were given instructionsto intersect this V AS scale with a vertical line depending on
their current level of pain. The V AS assessment tool has been
found to be a valid and also a reliable method of measuringpatients perceived pain [ 40,41].
Patients functional status was assessed by completion of
the T ennis Elbow Function Scale (TEFS) [ 42]. In TEFS scale,
the patients were instructed to perform certain set of task thatcan be di fficult in performing as a result of their problem and
were informed to accordingly rate the intensity of their pain.Higher scores are indicative of greater levels of disability.The TEFS assessment tool has been found to have high test-retest reliability (ICC 0.92) and moderate construct validity(Pearson’s correlation coe fficient 0.47) [ 42].
3. Data Analysis
Thirty-five patients, 20 male and 15 female, were initially
assessed for eligibility for this study. 15 patients wereexcluded for the following reasons: not meeting inclusioncriteria ( n
=7), declined to participate ( n=7), and other
reason ( n=1). The remaining 20 patients (10 males and
10 females) randomly allocated into 2 groups. Participantflow through the study is illustrated in Figure 3 . Patients in
Group A received supervised exercise program while patientsin Group B received Cyriax Physiotherapy treatment. Allpatients were seen 3 times a week for 4 weeks for a total of12 treatment sessions.
Data analysis was performed with SPSS version 16.0. Sta-
tistical analysis including mean and standard duration wascalculated for all measurement. The mean di fferences with
standard deviation for outcome measures of pain intensityand function scale were calculated before the treatment andalso the end of 4 weeks. Mann Whitney Utest, Wilcoxon
Signed Rank test, and two sample t-test are the statistical tests
used in this study.
4. Results
At the time of initial evaluation, statistical analysis did not
reveal any significant di fferences for any of the variables
between Group A (supervised exercise program) and GroupB (Cyriax physiotherapy).
4.1. Age Distribution. Statistical tool used is the two sample
ttest. For Group A, the age of the subjects ranged between
30 and 45, while for Group B it ranged between 31 and45. The mean age for Group A was 37 .40
±4.881 and
Group B was 38 .20±4.341 as shown in Figure 4 and Ta b l e 1 .
The intergroup comparison of mean age did not show anysignificant di fference between the ages of the two groups.
4.2. Gender Distribution. Group A consisted of 10 patients
(n
=10), with a gender distribution of 4 males (40%) and

4 The Scientific W orld Journal
Assessed for eligibility ( )
Excluded ( )
♦Not meeting inclusion criteria ( )
♦Declined to participate ( )
♦Other reasons ( )
Randomized ( )
Analysed ( n 10)Lost to follow-up ( n 0)
Discontinued intervention ( n 0)Lost to follow-up ( n 0)
Discontinued intervention ( n=0)Allocated to supervised exercise ( )
♦Received allocated intervention ( )Allocated to cyriax physiotherapy ( )
♦Received allocated intervention ( )
Analysed ( n 10)n=15
n=7
n=7
n=1n=35
n=20
n=10
n=
=
=
= =10
==n=10
n=10
Figure 3: Participants flow chart.
Table 1: Mean, standard deviation (SD), & standard error (SE) of age.
Age comparison n Mean SD Standard error mean Pvalue Result
Group A 10 37.40 4.88 1.5431.000 P> 0.05 (not significant)
Group B 10 38.20 4.34 1.373
204060
37.4 38.2AgesComparison of the ages of the two groups
0
Group A Group B
Figure 4: Comparison of the ages of the two groups.
6 females (60%). Group B also consisted of 10 patients ( n=
10) and a gender distribution of 6 males (60%) and 4 females
( 4 0 % ) .T h e s ed a t aw e r ep r e s e n t e di n Figure 5 and Ta b l e 2 .
4.3. Duration of Symptoms. T h em e a nd u r a t i o no fs y m p t o m s
(in weeks) for Group A was 9 .1±0.88 and for Group B wasTable 2: Percentage of distribution of gender in both groups.
Male Female
Group A 4 (40%) 6 (60%)
Group B 6 (60%) 4 (40%)
8.8±0.91 weeks. There is no significant di fference between
the duration of symptom of the two groups at 5% level ofsignificance as shown in Figure 6 and Ta b l e 3 .
4.4. Visual Analogue Scale (V AS). VA S s c o r e s w e r e f o u n d t o
be similar between groups at baseline (Pretest). Statisticaltool used is the Mann-Whitney Utest. There is no significant
difference between the pre-V AS scores of the two groups at
5% level of significance ( Ta b l e 4 ).
4.4.1. Tennis Elbow Function Scale (TEFS). TEFS scores were
found to be similar between groups at baseline (Pre T est).Statistical tool used is the Mann-Whitney Utest. There is no
significant di fference between the pre-TEFS scores of the two
groups at 5% level of significance ( Ta b l e 5 ).

The Scientific W orld Journal 5
Table 3: Duration of symptoms (in weeks) in both groups.
Duration of symptoms in
weeksMean SD Pvalue Result
Group A 9.1 0.881.000 P> 0.05 (Not Significant)
Group B 8.8 0.91
0123456
Male FemaleGroup A
Group B
Figure 5: Distribution of gender in both groups.Duration
05101520
9.1 8.8Duration of the symptoms (weeks)
Group A Group B
Figure 6: Duration of symptoms (in weeks) in both groups.
Table 4: Comparison of Pretest V AS score of Group A and B.
(a) Ranks
Group n Mean rank Sum of ranks
VA S P r eGroup A 10 10.50 105.00
Group B 10 10.50 105.00
To t a l 2 0
(b) T est statistics
VA S P r e
Mann-Whitney U 50.000
Exact significance 1.000
4.4.2. Pre-Post Test Comparison of V AS Scores in Group A.
The intragroup comparison of pain intensity as measuredTable 5: Comparison of Pretest TEFS scores of Groups A and B.
(a) Ranks
Group n Mean rank Sum of ranks
TEFS PreGroup A 10 10.50 105.00
Group B 10 10.50 105.00
To t a l 2 0
(b) T est statistics
TEFS Pre
Mann-Whitney U 50.000
Exact significance 1.000
Table 6
(a) Ranks
nMean rank Sum of ranks
VA S p o s t – VA S
preNegative ranks 10 5.50 55.00
Positive ranks 0 .00 .00
Ties 0
To t a l 1 0
(b) T est statistical
VA S p o s t – VA S p r e
Z −2.889
Asymp. significance ( 2-tailed) .004
by V AS at the end of treatment intervention in Group A,
presented in T ables 6(a) and 6(b), shows that there was a
definitive reduction in the pain intensity at the end of 4 weeksof supervised exercise program. The statistical test used isWilcoxon signed-rank test.
4.4.3. Pre-Post Test Comparison of V AS Scores in Group B. The
intragroup comparison of pain intensity as measured by V ASat the end of treatment intervention in Group B, presentedin T ables 7(a) and 7(b), shows that there was a definitive
reduction in the pain intensity at the end of 4 weeks of Cyriaxphysiotherapy treatment. The statistical test used is Wilcoxonsigned-rank test.
4.4.4. Posttest Comparison of V AS Scores between the Groups.
The results of the posttest intergroup comparison of painintensity as measured by V AS are presented in T ables 8(a)
and 8(b). Though both groups showed significant reduction
in pain when compared to the pretest score, the intergroupcomparison of V AS scores showed a higher reduction in V ASscores in Group A than Group B, which was statistically

6 The Scientific W orld Journal
Table 7
(a) Ranks
NMean rank Sum of ranks
VA S p o s t – VA S
preNegative ranks 10 5.50 55.00
Positive ranks 0 .00 .00
Ties 0
To t a l 1 0
(b) T est statistics
VA S p o s t – VA S p r e
Z −2.919
Asymp. significance .004
Table 8
(a) Ranks
Group n Mean rank Sum of ranks
VA S Po s tGroup A 10 7.10 71.00
Group B 10 13.90 139.00
To t a l 2 0
(b) T est statistics
VA S Po s t
Mann-Whitney U 16.000
Exact significance .009
Table 9
(a) Ranks
nMean rank Sum of ranks
TEFS Post-TEFS
PreNegative ranks 10 5.50 55.00
Positive ranks 0 .00 .00
Ties 0
To t a l 1 0
(b) T est statistics
TEFS Post-TEFS Pre
Z −2.859
Asymp. significance .004
significant. The statistical tool used is Mann-Whitney Utest
(Figure 7 ).
4.4.5. Pre-Post Test Comparison of TEFS Scores in Group A.
The intragroup comparison of functional status as measuredby TEFS at the end of treatment intervention in Group A,presented in T ables 9(a) and 9(b), shows that there was a
definitive improvement in the functional status at the end of
4 weeks of supervised exercise program. The statistical testused is Wilcoxon signed-rank test.
4.4.6. Pre-Post Test Comparison of TEFS Scores in Group B.
The intragroup comparison of functional status as measuredby TEFS at the end of treatment intervention in Group B,Table 10
(a) Ranks
nMean rank Sum of ranks
TEFS Post-TEFS
PreNegative ranks 10 5.50 55.00
Positive ranks 0 .00 .00
Ties 0
To t a l 1 0
(b) T est statistics
TEFS Post-TEFS Pre
Z −2.889
Asymp. significance .004
Group A
Group BV AS pre V AS post097.9 7.9
4.35.6
36
Figure 7: Comparison of V AS scores of two groups.
p r e s e n t e di nT a b l e s 10(a) and 10(b), shows that there was a
definitive improvement in the functional status at the endof 4 weeks of Cyriax physiotherapy treatment. The statisticaltest used is Wilcoxon signed-rank test.
4.4.7. Posttest Comparison of TEFS Scores between the Groups.
The results of the posttest intergroup comparison of func-tional status as measured by TEFS are presented in T ables11(a) and 11(b). Though both Groups showed significant
improvement in the functional status when compared tothe pretest score, the intergroup comparison of TEFS scoresshowed a higher reduction in TEFS scores in Group A thanGroup B, which was statistically significant. The statisticaltool used is Mann-Whitney U test ( Figure 8 ).
5. Discussion
The results of this study demonstrate that both the super-
vised exercise program (Group A) and Cyriax physiother-apy treatment (Group B) groups experienced significantimprovements in pain and function following 4 weeks treat-ment sessions. The supervised exercise and static stretchinggroup experienced greater outcomes for all variables in com-parison to those receiving Cyriax physiotherapy treatment.The reported success of supervised exercise program in thisstudy is consistent with previously published research studies

The Scientific W orld Journal 7
Group A
Group BTEFS pre TEFS post01020304050
33.2 33.2
23.925.8
Figure 8: Comparison of TEFS scores of two groups.
Table 11
(a) Ranks
Group n Mean rank Sum of ranks
TEFS PostGroup A 10 6.65 66.50
Group B 10 14.35 143.50
To t a l 2 0
(b) T est statistics
VA S Po s t
Mann-Whitney U 11.500
Exact significance .002
[12,36,37]. Pienim ¨aki et al. compared a six-to-eight-week
exercise programme of stretches and exercises (isometricand isotonic) with a treatment of pulsed ultrasound acrossthe same time span and showed that the SMD for painvisual analogue scale at rest was 0.97 (95% CI 0.30 to1.63) and 0.66 (95% CI 0.01 to 1.31) for pain visualanalogue scale under strain. Maximum grip strength was notsignificantly di fferent between groups [ 12]. This suggests a
favourable e ffect in that exercise may improve pain in lateral
epicondylalgia but not maximum grip strength [ 12]. V erhaar
et al. compared the e ffects of corticosteroid injections with
Cyriax physiotherapy in treating patients with tennis elbow.The results showed that the corticosteroid injection wassignificantly more e ffective on the outcome measures (pain,
function, grip strength, and global assessment) than Cyriax
physiotherapy at the end of the treatment, but at the follow-up, one year after the end of treatment, there were no sig-nificant di fferences between the two treatment groups [ 37].
Stasinopoulus et al. compared the e ffectiveness of supervised
exercise, Cyriax physiotherapy, and treatment with poly-chromatic noncoherent light in managing tennis elbow.They concluded that supervised exercise consisting of staticstretching and eccentric strengthening produced the largesteffect in reducing pain and improving function [ 36].
T h ee a r l yr e t u r no ff u n c t i o n a ls t a t u si sv e r yu s e f u lf o r
a sports person, as it will facilitate his/her return to sportsin less duration. This improvement in functional status willalso prevent disuse atrophy or muscle weakness resulting
from less or no activity due to pain and disability causedby tennis elbow. It has been assumed that the underlyingmechanism of pain relief secondary to friction massage maybe due to modulation of pain impulses at the spinal cord level[43]. At present, no published evidence exists to support the
proposed mechanism as to what actually occurs during and
following manual treatment with Cyriax physiotherapy [ 33].
The hypothesized mechanism of Mill’s manipulation is thelengthening of scar tissue following the rupture of adhesionsdue to the manipulation [ 33]. In comparing the results of
these trials to those experienced by the supervised exercisetreatment group in the present study, two points must beconsidered. First, none of the above-mentioned trials useda true control group, thereby not controlling for the naturalcourse of the disorder or spontaneous recovery. Second, thepresent study did not assign patients to receive supervisedexercise as an isolated treatment. Therefore, comparisonsbetween our results and those of previous trials should bemade with caution as it is not possible to determine whichintervention made the greatest contribution to the treatmenteffect.
6. Limitations of This Study
(i) No follow-up data was collected; therefore, the long-
term e ffects of the interventions in the present study
remain unknown.
(ii) Absence of true control group a ffects the internal
validity of the study.
7. Conclusions
W e rejected the null hypothesis that no di fference would be
seen in pain intensity and functional status after 4 weeks ascompared with Cyriax physiotherapy treatment. The groupsthat performed supervised exercise program for 4 weeksshowed significantly greater improvement in reduction ofpain and functional status than the Cyriax physiotherapytreatment. The favorable results in the present study indicatethe need for future research examining the incorporationof supervised exercise program into multimodal treatmentregimens.
Conflict of Interests
The authors declare that there is no conflict of interests.
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