Aerobic exercise is a core component of cardiac rehabilitation (CR). Exercise Prescription for Athletic Cardiac Rehabilitation Patients Thomas P. Olson, Ph.D., FACSM, FAHA Consultant – Department of Cardiovascular Medicine Associate Professor of Medicine – … We kindly ask you to call to notify us and reschedule any individual appointment or missed workshop. Wherever possible, this prescription should be bas … Exercise … Some reasons BP was monitored during exercise included if BP was high during aerobic exercise and if the patient was hypertensive. RPE is a standardized subjective measurement of effort that matches verbalized statements and visual cues with an individual's perception of how hard they feel they are working. Evolving role of exercise testing in contemporary cardiac rehabilitation. We found that all CR facilities used standard thresholds specified within FITT-VP guidelines. Your program will be personalised to your needs, including medicines education, exercise programs, and other support.The aim is to help you make long-term lifestyle changes to improve your wellbeing, but also reduce your risk of future heart or stroke events. A commonly described endpoint for CR programs that did not set functional capacity goals was cited as “just improvement.” However, the methodology on how “improvement” was assessed was never definitively elucidated, instead suggesting that functional capacity was a benchmark. Among the centers that conducted resistance exercise sessions with patients, we found that they all monitored HR during sessions. Cardiac rehabilitation (cardiac rehab) is a program of exercise, education and counselling designed to help you recover after a heart attack or other heart conditions.This personalized program will help you regain your strength, prevent your condition from getting worse and reduce your risk of having heart problems in the future. The most challenging and least well-defined aspect of the exercise prescription … -. Most patients can begin a formal exercise prescription program after consultation with a HCP. Leading organizations recommend that the exercise prescriptions should be based on a symptom limited baseline graded exercise test (GXT). Consequently, exercise prescriptions including exercise … High use of this variable as a measurement tool could be due to its ease of use with patients. The goal is to lower your risk of future heart problems. The prescription of exercise, either as a part of a formal exercise training program or as a means to increase physical activity in general, has been and will remain a primary component of cardiac rehabilitation and secondary prevention programming. Cardiovascular fitness and mortality after contemporary cardiac rehabilitation; pp. Of the centers that performed resistance training, the most cited techniques for intensity was trial and error, followed by RPE. Clipboard, Search History, and several other advanced features are temporarily unavailable. This critical handbook delivers scientifically based standards on exercise testing and prescription to the certification candidate, the professional, and the student. Services by Location We offer a range of … Wherever possible, this prescription … Most patients are given a prescription … 3 – 38 In patients with chronic CAD, cardiac rehabilitation may be as effective as drug treatment and catheter intervention in terms of the improvement of prognosis. Prediction of long-term prognosis in 12,169 men referred for cardiac rehabilitation. Many cardio-protective benefits and positive adaptations to aerobic training are further emphasized in cardiac patients who have engaged in a high intensity interval training program as compared to moderate intensity continuous training (12–17). Elsevier; Amsterdam, The Netherlands: 2013. Cardiac Rehabilitation and Intensive Cardiac Rehabilitation – JA6850 . An exercise program should be designed to maximize an individual's increase in functional capacity; therefore, functional capacity goals should be set to assess the effectiveness of the exercise prescription. Introduction: Cardiac rehabilitation (CR) is a primary prescribed treatment for a variety of cardiovascular disease states, including: coronary artery disease, percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), myocardial infarction (MI), and heart failure. The core element of cardiac and pulmonary rehabilitation programs is aerobic exercise. ... You must inform the cardiac rehab staff when you are checking-in if: • You have forgotten to take your medication. 1Central Michigan University, School of Health Sciences, College of Health Professions, Mt. However, it is unclear how these guidelines are being administered at cardiac rehabilitation centers. Exercise training in patients with cardiovascular disease increases exercise capacity, 1–3 reduces cardiac ischemia, 1,2 delays the onset of or eliminates angina pectoris, 4,5 and improves endothelial function. Selected high-risk patients, specifically those with pre-existing coronary artery disease (CAD), may require … min−1 above resting HR, ≥85% of age predicted maximal heart rate, blood pressure, common sense, and trial and error were being used. These can be used to create an exercise prescription based on the FITT (F requency, I ntensity, T ype, T ime) principles. J. Various types of equipment were utilized during resistance exercise sessions, with free weights being the most commonly used. The Vision for Program Certification 19901990s’s – Widespread acceptance of cardiac rehabilitation – Increased number of programs opening – Widespread variability in program processes and quality State experience in certification – Driven by reimbursement – Process tem plate existe d – Request for national oversite 1995 - Clinical Practice Guidelines for Cardiac There are two common methods of exercise prescription, an effort based exercise prescription and target heart rate based exercise prescription. Cardiopulmonary Rehabilitation Guidelines August 2018 5. We found that all CR programs applied continuous aerobic exercise training sessions with their patients. Often, the intensity of resistance exercise training sessions is based on using a resistance equivalent to a certain percentage of a patient's 1RM or upon repetitions of a certain weight until voluntary fatigue. Exercise Prescription – Cardiac Rehab Setting CPA will provide information on patients: Heart rate (HR), Blood Pressure (BP), Rate of perceived Exertion (RPE), Expired Gases, Anaerobic …  |  Monitoring of hemodynamic responses from resistance exercises may be especially important for patients with CVD as postural changes, resistant hypertension, irregular breathing patterns (Valsalva maneuver), and poor exercise techniques can contribute to elevated hypertensive or hypotensive responses. to the cardiac rehabilitation centre for any onsite appointments (including exercise classes). Additional educational efforts should be made to ensure future clinical exercise physiologists can clearly explain the RPE scale. Heart rate is used for exercise intensity assessment and prescription based on its linear relationship with both V. o2 and work load during incremental exercise in cardiac disease (29). Cardiac rehabilitation is a program designed for people with heart problems. RPE can also be used as an effective intensity-monitoring tool for resistance exercise sessions. Consequently, exercise prescriptions including exercise progression in CR are not following standard exercise prescription guidelines. However, recent evidence suggests that only ~30% of CR clinics perform baseline GXTs. We also found that all the CR centers prescribed repetitions within this range, and the most frequently reported was 10 repetitions. Prev. Cardiac Rehab programme Exercise prescription Following a cardiac event or surgery, it’s important that you return to normal activities of daily living, incorporating physical activity. Blood pressure was monitored by all the centers both before and after sessions, but only 20% measured BP during sessions. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Cardiol. We found that the majority of CR programs use more than one measurement to prescribe intensity; the most frequently used measurement is RPE. Physical activity guidance and exercise prescription 3736Appendix B Use of heart rate and determining target heart rates 3737Appendix C ... AHA Exercise guidelines (2004) Bethesda Conference 36 (2005) USA.gov. Guideline documents for cardiac rehabilitation typically contain recommendations for exercise training common to all cardiac patients, with there being little variation in exercise prescription … You can leave yourself one to two days each week without exercise or for an easy walk if you want. There is an all new section on performance measures. Coll. The Cardiac Rehabilitation Service can help you through this stage. Cardiol. A joint position statement of the European Association for Cardiovascular Prevention and Rehabilitation, the American Association of Cardiovascular and Pulmonary Rehabilitation, and the Canadian Association of Cardiac Rehabilitation recommends that exercise prescription for cardiac patients must be based on the ‘threshold concept’ as compared with the ‘relative percent concept’. Patients are encouraged to be self-directed throughout the Exercise definitions: Current guidelines state that to gain health benefits we all need to do physical activity on most days of the week, at a moderate intensity level for 30 to 45 min. We found that all the CR centers fell slightly below this recommendation, with the majority of centers prescribing 6 exercises per session. 6 Meta-analyses of exercise-based, cardiac rehabilitation studies have suggested that exercise training reduces cardiac mortality in coronary artery disease (CAD) patients. Am Heart J 2011; 162:571. Therefore, the purpose of this review is to provide clinicians with evidence-based techniques for prescribing exercise in the absence of a baseline GXT. Our questionnaire found that only 44% of the programs set functional capacity goals for their patients with no clear, consistent benchmark. This section was adapted from the Cardiac Rehabilitation booklet from the Wellness Institute at Seven Oaks Hospital in Winnipeg, Manitoba, 2009. COVID-19 is an emerging, rapidly evolving situation. In chronic heart failure … Exercise training in cardiac rehabilitation should be medically supervised and led by an experienced exercise therapist (or physiotherapist). Exercise and heart failure: a statement from the American Heart Association Committee on Exercise, Rehabilitation, and Prevention. The more information you have from your cardiac rehab sessions, the better to help you plead your case to your doc about safe exercise guidelines. Leading organizations recommend that the exercise prescriptions should be based on a symptom limited baseline graded exercise test (GXT). Recipient(s) will receive an email with a link to 'Exercise Prescription Techniques in Cardiac Rehabilitation Centers in Midwest States' and will not need an account to access the content. doi: 10.1097/HCR.0000000000000176. This site needs JavaScript to work properly. Despite the difficulty for clinicians to manipulate resistance exercise among this population, we found that all CR programs progressed their patients by increasing resistance and by RPE. However, recent evidence suggests that only ~30% of CR clinics perform baseline GXTs. You can … In addition, this study demonstrates the application of research-based exercise prescription among disease patients as outlined by professional organizations such as ACSM and AACVPR. There are two common methods of exercise prescription, an effort based exercise prescription and target heart rate based exercise prescription. Training Techniques in Cardiac Rehabilitation Human Kinetics : Leeds • Squires, R.W (1998) : Exercise Prescription for the High – Risk Cardiac Patient • American College of Sport Medicine (ACSM) (1991) Guidelines for Exercise testing and Prescription … You are scheduled to exercise at Cardiac Rehab Monday, Wednesday, and Friday, and we encourage you to exercise on the days you are not here (Tuesday, Thursday, Saturday or Sunday). Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Exercise Prescription The following is a guide only; all exercises must be individualized to the patient’s presentation and current ability. aerobic exercise; cardiac rehabilitation; cardiovascular disease; graded exercise testing. Am. The prescription of exercise, either as a part of a formal exercise training program or as a means to increase physical activity in general, has been and will remain a primary component of cardiac rehabilitation and secondary prevention programming. We note that 89% of the programs conducted resistance exercise training sessions with their patients. The current observational study highlights the variability and complexity of prescribing exercise to CVD patients. III.  |  455–463. HHS That said, using higher intensity exercise prescriptions carry a potential risk for the occurrence of cardiac events in high-risk cardiac patients (19). Various strategies are used to monitor exercise training prescriptions, often based on frequency, intensity, duration (time), type, volume, and progression—also known as FITT-VP principle (9). The current concept of cardiac rehabilitation includes a specific exercise prescription [“the exercise prescription should include intensity (dose), frequency, duration, and the often forgotten, progression” (Pina, 2010)], behavioral and lifestyle risk factor reduction, health education, and personal counseling. Cool-down: activity after exercise such as an easy walk and stretching to help bring the body back Exercise training is a prominent and critical component of early outpatient cardiac rehabilitation (CR), providing impressive patient benefits for cardiorespiratory and metabolic indices, quality of life, and cardiovascular disease management as shown in Table 1. Note: JA6850 was revised to add a reference to MLN Matters® article MM7113 ... • Physician-prescribed exercise - This physical activity includes aerobic exercise combined with other types of exercise … The ACSM recommends that patients progress by increasing the resistance being performed, increasing the number of repetitions performed, or by setting decreased rest periods between performed sets. Subject: Exercise Prescription Techniques in Cardiac Rehabilitation Centers in Midwest States, (Optional message may have a maximum of 1000 characters.). This emphasizes the importance that academic programs place on training students across all prescription techniques. 8–10 Current guidelines for exercise prescription are commonly based on heart rate (HR): … 2002;40:1531–1540. Circulation. Healthy eating. High-intensity interval training has also been associated with greater patient satisfaction (18). 4.1 Effectiveness of exercise only or exercise as part of a comprehensive cardiac rehabilitation program on all-cause mortality and cardiac mortality (According to Jolliffe et al. Circulation. CR is shown to reduce mortality, hospital readmissions, costs and to improve exercise capacity, quality of life and psychological well-being[2-5], and is recommended in international guidelines for patients with a ST-elevation acute myocardial infarct… However, whether these interval training sessions were specifically regarded as high-intensity interval training was not assessed and should be investigated further. doi: 10.1016/j.jacc.2003.07.028. Cardiac Rehabilitation (CR) is an effective exercise-based lifestyle therapy for patients with cardiac disease. ACSM’s Guidelines for Exercise Testing and Prescription is the flagship title from the American College of Sports Medicine, the prestigious organization that sets the standards for the exercise profession. Methods: Guidelines, position statements and policy documents for cardiac rehabilitation, available internationally in the English language, were identified through a search of electronic databases and government and cardiology society websites. Cardiac rehabilitation (rehab) typically includes an outpatient program. During the initial phase after an acute event, the exercise … Initial loads should allow a patient to be able to comfortably complete 10–15 repetitions (9). All CR programs prescribed exercise sessions 3 times per week. ACSM’s Guidelines for Exercise Testing and Prescription is the flagship title from the American College of Sports Medicine, the prestigious organization that sets the standards for the exercise profession. You can notify your physiotherapist by phone if you are going to miss multiple exercise classes. Relationship Between Exercise Workload During Cardiac Rehabilitation and Outcomes in Patients With Coronary Heart Disease. The authors declare no conflict of interest. Brawner CA, Abdul-Nour K, Lewis B, et al. Peak oxygen intake and cardiac mortality in women referred for cardiac rehabilitation. We might assume that students are learning different techniques than their colleagues performing internships at other clinics; however, the procedures taught may be different but not incorrect. Keywords: 2003;42:2139–2143. Your doctor will let you know when it is the right time to begin an exercise program. We note that 66% of the CR programs follow this guideline. Intensity indicators (e.g., heart rate, perceived exertion) are reviewed, along with special exercise considerations for various disease states (e.g., heart failure, peripheral artery disease, and coronary artery disease). At cardiac rehab, you learn about your heart condition and your treatments. […] From our findings, patients progressed through their aerobic programs in a variety of ways; 85% of the centers surveyed their patients' progress through their exercise programs by using a combination of the components of the FITT principle. Search for other works by this author on: Address for correspondence: Micah Zuhl, PhD, Department of Health, Exercise, and Sports Sciences, University of New Mexico, 1 University, Albuquerque, NM 87131; (505) 277 3243; e-mail: Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews, Longterm exercise training in patients with advanced chronic heart failure: sustained benefits on left ventricular performance and exercise capacity, Exercise training programs in Dutch cardiac rehabilitation centres, Decision memo for coverage of cardiac rehabilitation (CR) programs for chronic heart failure (HF), Centers for Medicare and Medicaid Services, Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery, Temporal trends and factors associated with cardiac rehabilitation referral among patients hospitalized with heart failure: findings from get with the guidelines-heart failure registry, Increasing cardiac rehabilitation participation from 20% to 70%: a road map from the Million Hearts Cardiac rehabilitation collaborative, Guidelines for exercise testing and prescription, Wolters Kluwer Health/Lippincott Williams and Wilkins, Perceived exertion as an indicator of somatic stress, Exercise performance and perceived exertion in patients with coronary insufficiency, arterial hypertension and vasoregulatory asthenia, High-intensity interval training improves peak oxygen uptake and muscular exercise capacity in heart transplant recipients, Cardiac rehabilitation in chronic heart failure: effect of an 8-week, high-intensity interval training versus continuous training, Aerobic interval training versus continuous moderate exercise after coronary artery bypass surgery: a randomized study of cardiovascular effects and quality of life, Superior cardiovascular effect of aerobic interval training versus moderate continuous training in heart failure patients: a randomized study, High intensity aerobic interval exercise is superior to moderate intensity exercise for increasing aerobic capacity in patients with coronary artery disease, Greater improvement in cardiorespiratory fitness using higherintensity interval training in the standard cardiac rehabilitation setting, High-intensity interval running is perceived to be more enjoyable than moderate-intensity continuous exercise: implications for exercise adherence, Cardiovascular risk of high-versus moderate-intensity aerobic exercise in coronary heart disease patients, Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis, Copyright © 2018 Clinical Exercise Physiology Association, Garett Griffith, MS, MPH, ACSM-CEP, Badeia Saed, BS, Tracy Baynard, PhD, Cemal Ozemek, PhD, FACSM, ACSM-CEP, RCEP, Ross Arena, PhD, PT, FACSM, Dennis J. Kerrigan, PhD, RCEP, Clinton A. Brawner, PhD, RCEP, Steven J. Keteyian, PhD, RCEP, David C. Murdy, MD, Jonathan K. Ehrman, PhD, RCEP, Ali E. Wolpern, MS, Johanna D. de Gennaro, MS, Timothy A. Brusseau, PhD, Wonwoo Byun, PhD, Marlene J. Egger, PhD, Robert W. Hitchcock, PhD, Ingrid E. Nygaard, MS, MD, Xiaoming Sheng, PhD, Janet M. Shaw, PhD, Stefanie K. Whalen, MS, Alexis King, MA, Kenneth Wilund, PhD, Michael J. Germain, MD, Samuel A. E. Headley, PhD, RCEP, Cassandra Herman, PhD, Teneasha Washington, PhD, Allison Tubbs, MS, CHES, Penny Edwards, M.Ed, Rebecca Cline, MPH, Cara Williams, MPH, Leona M. Dowman, PhD, Anthony K. May, PhD, This site uses cookies. Therefore, it is essential to train exercise clinicians in a variety of prescription techniques in the absence of a baseline stress test. CVD patients are deconditioned when beginning CR programs, so it may be wise for the exercise prescription to train major muscle groups initially with one set and progressing to multiple sets as tolerated by the patient. -, Martin B.-J., Arena R., Haykowsky M., Hauer T., Austford L.D., Knudtson M., Aggarwal S., Stone J.A., Investigators A. Mayo Clinic Proceedings. Common strategies in aerobic exercise training to measure relative exercise intensity includes using heart rate max (HRmax), heart rate reserve (HRR), metabolic equivalents (METs), oxygen uptake reserve (VO2R), and the Borg rating of perceived exertion scale (RPE). The most commonly reported frequency of resistance training sessions per week was 3 days per week, falling into the prescribed 2–3 days per week recommended by the ACSM (9). We found that interval training was applied in 69% of CR programs. 6, 57 Page 3 2/28/19 Words to Know Aerobic activity: physical exercise of low to moderate intensity performed for a period of time. By continuing to use our website, you are agreeing to, POINT: An Argument in Favor of This Model, Multiple Sclerosis: Treadmill Versus Cycle Ergometry Maximal Exercise Test Responses, Professional Doctorate in Clinical Exercise Physiology, Weight Change During a Clinical Weight Management Program: An Observational Cohort Study, Relationship of Heart Rate, Perceived Exertion, and Intra-Abdominal Pressure in Women, Finding The Clinical Exercise Physiologist's Collective Voice During the COVID-19 Pandemic, Karlman Wasserman, MD, PHD, Physiologist and Physician-Scientist: 1927–2020, The Pathway to Inclusion: Improving the Health of All Americans, Best Practice Approach for Interstitial Lung Disease in the Rehabilitation Setting. -, Gibbons R.J., Balady G.J., Bricker J.T., Chaitman B.R., Fletcher G.F., Froelicher V.F., Mark D.B., McCallister B.D., Mooss A.N., O’Reilly M.G. You will receive information and tools to make lifestyle changes, such as: Not smoking. Link Google Scholar; 60 Smart N, Marwick TH. doi: 10.1016/S0735-1097(02)02164-2. ACC members also highlighted the importance of cardiac rehab … Exercise can and should be prescribed with enough detail to allow the patient, either alone or with the aid of non-physician staff (e.g., cardiac rehabilitation), to engage in an exercise … Cardiac rehabilitation (CR) is a multi-factorial and comprehensive intervention in secondary prevention, designed to limit the physiological and psychological effects of cardiovascular disease, manage symptoms, and reduce the risk of future cardiovascular events. Exercise training has been demonstrated to improve the physical effects listed in Table 2. Rehabil. 2016;36:309–319. The application of resistance exercise training has been shown to be safe for patients with cardiac conditions. Please enable it to take advantage of the complete set of features! Anderson L, Oldridge N, Thompson DR, et al. This program is one part, or phase, of your cardiac rehab. Exercise Prescription – Cardiac Rehab Setting CPA will provide information on patients: Heart rate (HR), Blood Pressure (BP), R ate of perceived Exertion (R PE), Expired Gases, Anaerobic Threshold, O2 saturation, VO2max. Guidelines for the prescription of aerobic and resistance exercise training for patients with cardiovascular diseases have been developed and widely disseminated. Exercise training for patients with heart failure: a systematic review of factors that improve mortality and morbidity. Variability exists due to multitude of patient types (e.g., CABG, MI, PCI), characteristics (e.g., age, health history), and condition (e.g., exercise tolerance, exercise history). Typically, aerobic capacity is diminished following a cardiac event or development of symptoms of CVD, making daily living and leisure activities much harder for the patient to accomplish, which often leads to further sedentary behavior. With a cap on duration due to fixed session lengths, intensity may be the best progression variable. RPE can be a relative intensity monitoring tool for both aerobic and resistance exercise training, and it has been validated against several physiological markers (10,11). Responding to a key recommendation made by the ACC and other stakeholders, the Centers for Medicare and Medicaid Services (CMS) used emergency rulemaking authority to add cardiac rehabilitation (rehab) and intensive cardiac rehab services to the list of approved telehealth services outside the annual rulemaking process. - Core components rehab A - Core components rehab B - Exercise prescription - Risk classific exercise class A - Risk classific exercise class B - Risk classific exercise class C - Risk classific exercise class D - Contraindications to exercise treadmill testing - NYHA and other classifications of cardiovascular disability - Contraindications for cardiac rehabilitation 2) Regarding the 45 lbs you gained, this could probably be explained by your being less physically active due to the heart issues. Exercise-Based Cardiac Rehabilitation … Coll. Baseline exercise testing remains the gold standard approach for prescribing exercise among heart disease patients, however, clinicians must be prepared to safely develop and monitor patients when a baseline GXT is not performed. For this reason, exercise prescription guidelines for cardiac … Am J Med. The Vision for Program Certification 19901990s’s – Widespread acceptance of cardiac rehabilitation – Increased number of programs opening – Widespread variability in program processes and quality State experience in certification – Driven by reimbursement – Process tem plate existe d – Request for national oversite 1995 - Clinical Practice Guidelines for Cardiac Angina: discomfort caused by lack of blood flow to the heart muscle.This may feel like pressure, tightness, or heaviness in the chest, arm, neck, jaw or back. Pleasant, MI 48858 USA, 2University of New Mexico, Health, Exercise, Sports Sciences, College of Education, Albuquerque, NM 87131 USA, Conflicts of Interest and Source of Funding: None. The cost-effectiveness of cardiac rehabilitation in 1995 dollars was $4900 per year life saved Compares favorably with other preventive therapies used in the post-myocardial infarction setting, such as pharmacologic lipid lowering, beta- adrenergic blocking medications, and thrombolysis Exercise rehabilitation … doi: 10.1161/01.CIR.0000024413.15949.ED. Includes guidelines for the treatment of lipids, hypertension, smoking cessation, diabetes, physical activity, stroke, CHF, as well as nutrition, stress testing, exercise prescription, psychological services, program management, in-and-out-patient services and much more. Cardiac rehab programmes last for up to 10-12 weeks and the sessions usually run for approximately 2 hours at a time. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error, Multidisciplinary Digital Publishing Institute (MDPI), Kavanagh T., Mertens D.J., Hamm L.F., Beyene J., Kennedy J., Corey P., Shephard R.J. Defining the optimal dose of exercise to maximise health outcomes is now considered a priority. Cardiac rehabilitation is a multi-factorial intervention recommended by international guidelines to patients with coronary artery disease. Thus, it remains unclear if cardiac rehabilitation facilities prescribe high-intensity interval exercise prescriptions to their patients. The most frequent combination used to progress patients through their aerobic exercise programs was an intensity/duration combination. -, Kavanagh T., Mertens D.J., Hamm L.F., Beyene J., Kennedy J., Corey P., Shephard R.J. 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