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Cryotherapy and Exercise Recovery: Part 1

Today's guest post comes from Tavis Bruce. A while back, I asked Tavis to pull together an article examining the literature on cryotherapy with athletes, and as you'll see below, he really overdelivered. Enjoy! -EC

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Sports and ice go together like peanut butter and jelly (or steak and eggs, if you’re into Paleo). From ice packs to ice baths, various forms of “cryotherapy” have long held a sacred place in sports medicine to treat acute injuries and facilitate recovery from training or competition. But despite its popularity and widespread use, the evidence in support of cryotherapy remains equivocal.

More recently, cryotherapy—particularly the use of ice baths, or cold water immersion—has come under increasing scrutiny from both the scientific community and the strength and conditioning industry at large...and rightfully so! However, in the process, we may be swinging the pendulum too far in the other direction, indicated by those who have come to the conclusion that “ice baths are a complete waste of time for every athlete in every sport in every possible situation.” Now, others may disagree with me on this one; but, the evidence (or lack thereof) for cryotherapy appears to be a little more nuanced than that.

I guess what I’m trying to say is: I’m not so sure I’m ready to throw the ice out with the bathwater just yet. Perhaps, instead of pondering black-and-white questions like, “to ice or not to ice?” we should be asking:

                         “When is ice appropriate?”

I’d like to examine why.

A quick note before we get started: this article will not discuss the use of cryotherapy for the management and/or rehabilitation of acute soft tissue injuries. I am NOT a medical professional; I just play one on Facebook.

As such, this article will only cover the efficacy of cryotherapy as a post-exercise recovery strategy.

Is there a Physiological Rationale for Cryotherapy?

Note: I’m not going to spend much time discussing the physiological rational (the “why”) behind cryotherapy for two reasons. First, the mechanisms are still quite hypothetical. Second, and more importantly, it’s a bit outside the scope of this article to convey practically relevant and actionable information for my fellow coaches and athletes. We can debate the mechanistic stuff until the cows come home, but in my humble opinion, the gold standard measurement for post-exercise recovery is the measurement of performance variables. And, I like to think that most athletes, coaches, and sports scientists would agree with me. That being said, I do think it’s always a good idea to establish if there is at least a physiological rationale for any method we may use with ourselves and/or our athletes. With that said…

Cryotherapy results in various physiological changes (most of which are temperature-dependent) that have long been proposed to exert a therapeutic effect post-exercise. Although the most cited physiological change is a blunted inflammatory response, there exists a range of other effects through which cooling the body after exercise may accelerate the recovery process. Of note, cryotherapy may:

• Improve tissue oxygenation1 and removal of metabolic waste (2) by reversing exercise-induced muscle edema (3,4).
• Reduce reactive oxygen species (ROS)-mediated muscle damage (5) by reducing local metabolism (1).
• Induce analgesia by decreasing nerve conduction velocity (6) in addition to directly activating sensory afferents (7).
• Restore parasympathetic tone by increasing vagal tone (8,9).

In addition, cold water immersion (or “ice baths”), a popular form of cryotherapy, may have additional benefits resulting from the compressive forces experienced during water immersion, but I won’t be covering them in this article (see Wilcock et al. [10] for a good review). For more information on the physiological effects of cold water immersion and other forms of cryotherapy, I encourage you to check out this (open access!) review by White and Wells.

The Effects of Cryotherapy on Recovery from Sport or Exercise

Perceptual Measures of Recovery

Cold water immersion reduces perceptions of fatigue (11-16) and increases perceptions of recovery (17,18) and physical readiness (19) between training sessions; however, it doesn’t seem to have much of an effect on ratings of perceived exertion (RPE) during subsequent training bouts (20-23).*

*Except for when CWI is used as a precooling strategy before exercise. (More on precooling later.)

Delayed-Onset Muscle Soreness

Though it’s pretty well accepted that cooling injured tissue can temporarily reduce or relieve pain (24), it’s not really clear if post-exercise cooling has any effect on delayed-onset muscle soreness (DOMS): the type of soreness you feel in the days following a bout of intense or novel exercise.

There is some evidence that cold water immersion (CWI) alleviates DOMS better than passive recovery (25), particularly when CWI is used following exercise that involves a large degree of metabolic stress (26) (e.g., running, cycling, or team sports). However, this effect is less clear when CWI is compared to warm (27), thermoneutral1 (4,28), or contrast (27,29,30) immersion, and recent evidence suggests that CWI may be no more effective than a placebo (19) for relieving DOMS. Collectively, these findings highlight the perceptual nature of muscle soreness and the importance of athletes’ perceptions of cryotherapy (or any recovery method, for that matter).

Icing and cold water immersion may help reduce delayed-onset muscle soreness after running or team sports, but the effect likely depends on the athlete’s belief in cryotherapy as a method of recovery.

Range of Motion

There is conflicting data on the effect of cooling on range of motion (ROM). Cooling alone does not appear to improve ROM (28,31-38), but it may enhance the effects of stretching (39-43) by increasing stretch tolerance (44). On the one hand, this increased tolerance to stretch does not appear to translate into long-term improvements in ROM (45-47). On the other hand, heat combined with stretching may have more lasting effects than stretching alone (44).

If your goal is to restore lost ROM following exercise, combine heat (not cold!) with stretching.

GoodHFStretch

Strength

The short-term effects of post-exercise cooling on recovery of strength characteristics are mixed and seem to depend on the type of exercise stress from which you’re trying to recover before you hit the weights.

There is some evidence that CWI may reduce or recover losses in maximal voluntary contraction (MVC) following simulated team sports (48-50) or intermittent sprint exercise (51-53), but not after downhill running (54) or cycling (55,56). And, in the only study of its kind, Broatch et al. found that CWI following high-intensity sprint intervals recovered MVC no better than a thermoneutral placebo (19).

Roberts et al. demonstrated that CWI was effective for restoring submaximal (but not maximal) strength between two lower body training sessions within the same day (57). Vaile et al. found both cold and contrast water immersion were effective at restoring strength up to three days after heavy eccentric strength training (27)*, but most studies show no or non-significant improvements over this time period (28,58-62). However, it’s important to note that all of these studies used (potentially) “less effective” cooling methods (such as when only the exercised muscle is cooled) compared to more therapeutic methods such as whole-body CWI.

*I highlight the study by Vaile et al. because it is the only study that compared multiple hydrotherapy modalities in trained males, and in a cross-over design with a “washout” period between treatments of sufficient duration to eliminate any residual effects of the repeated bout effect. Thumbs up for study quality!

Cold water immersion may help recover muscle contractile properties following running or team sports. Benefits following resistance training are less clear and may require the use of cold water immersion over local cooling of exercised tissue.

Jump Performance

Most studies show significant recovery of jump performance within 24-48 hours post-exercise with no clear additional benefits to CWI (18,49,53,63,64). Furthermore, CWI may impair jump performance within the first two hours (57) possibly due to the acute effects of cold exposure on force production (65).

Here’s the deal: jump performance seems to recover just fine on its own. However, there is some evidence that CWI may maintain jump performance in scenarios of accumulated fatigue, such as during tournament play in team sports. One study of basketball players found that the CWI maintained jump performance better in players who saw more playing time throughout a 3-day tournament (66).

iceb

Sprint Performance

Like jump performance, many studies report that sprint performance returns to baseline within 24 hours after exercise, regardless of treatment intervention (18,49, 61). Accordingly, most studies do not find a benefit in favor of CWI compared to other recovery interventions because the initial exercise bout was not sufficiently intense to elicit a significant 24-hour performance decrement.

However, when exercise was sufficiently intense to affect 24-48 hour sprint performance, CWI maintained repeat-sprint performance (a measure of speed-endurance) better than thermoneutral immersion (67), contrast water therapy (12,13,48), and passive recovery (12,13,48,67).

The effect of CWI on absolute speed is less clear. Of the two studies I found, one found no benefit to CWI over passive recovery on immediate and 24-hour recovery of 50-m dash time (68), while the other showed that CWI maintained 20-m speed better than compression or stretching over a 3-day simulated basketball tournament (66).

There’s not a lot of data on the effects of CWI on same-day recovery of sprint performance, but one study showed no significant differences in repeat-sprint performance between CWI and passive recovery immediately and up to two hours after intermittent sprint exercise in the heat (61). This ties in well with the research in sprint cycling that shows neutral—or even detrimental—effects on 30-second Wingate performance following CWI when sufficient re-warming does not occur (69,70). This makes sense: reduced muscle temperature will negatively affect muscle contractile properties (71), impair energy metabolism (72), and slow nerve conduction velocity (6,73), which collectively will negatively affect the force- and power-generating capabilities of muscle. Thus, caution should be taken when using CWI between or prior to exercise that requires a high-degree of muscular force (sprinting, jumping, etc.). Athletes should allow sufficient time to rewarm following CWI and make sure to include a dynamic warm-up before their next event, which has been shown to offset the negative effects of cold exposure on power production in the vertical jump (65).

When exercise is sufficiently intense, CWI may help restore short-term (<48 hour) sprint and jump performance. However, reduced muscular temperatures negatively affect the force-generation capacities of muscle. Thus, when using ice baths between two training sessions or events within the same day, it is important to allow the body sufficient time to re-warm and/or to include an extensive dynamic warm-up.

Endurance Performance

Given the number of endurance athletes that use ice baths to recover between workouts or events, it was somewhat surprising that very few studies looked at endurance performance following recovery periods of 24 hours or longer. Two of those studies showed that CWI improves endurance performance following a 24-hour recovery period (17,74), and two other studies demonstrated similar recovery benefits across 3-day (75) and 5-day (23) training blocks.

Paula_Radciffe_NYC_Marathon_2008_cropped

Most studies that looked at the effects of CWI on recovery from endurance exercise utilized recovery periods of <60 minutes between exercise bouts. But here’s the thing: When an athlete takes an ice bath between two bouts of exercise with a short (<1 hour) duration between bouts that ice bath creates a “precooling” effect for the second bout. Precooling is proposed to increase performance (particularly in hot conditions) by increasing heat storage capacity, reducing thermal strain, and decreasing perceived exertion by reducing core body temperature prior to exercise (76).* And, based on the abundance of data showing a benefit to precooling on endurance performance** (particularly in hot conditions), this is probably why we see such an immediate recovery of endurance performance following CWI (56,77-81). This effect diminishes with longer recovery periods (82), presumably as core body temperature returns to baseline.

*If you’re interested in learning more about precooling check out this (open-access!) systematic review as well as the results of two recent meta-analyses here and here.

**Just to reiterate: the beneficial effect of precooling likely does not hold true for short-duration, maximal efforts (see above).


Ice baths may be useful for recovering endurance performance, particularly when an athlete has to compete in multiple games or events in one day.

The Effect of Regular Cold Water Immersion on Long-Term Training Adaptations

Very few studies have looked at the effects of ice baths on long-term training adaptations. But, the evidence-to-date paints a pretty clear picture:

Strength Training

The evidence is pretty clear on this one: regular use of CWI impairs long-term gains in muscle mass and strength (83-86) at least in part by blunting the molecular response to resistance exercise (84). This seems to apply to both trained (84) and untrained (85,86) individuals.

Ice baths blunt the acute molecular response to resistance training and impair long-term gains in muscle mass and strength. Athletes should reconsider using ice baths after strength training, particularly in the off-season or preparatory period when the focus is on adaptation rather than performance.

Endurance Training

The evidence for the effects of CWI on adaptations to endurance training is not so clear. One study in competitive cyclists found that regular CWI neither enhanced nor interfered with cycling performance over a three-week training block (87). Furthermore, recent evidence suggests that regular CWI may actually enhance molecular adaptations to endurance training (88). However, it’s important to interpret these results with caution, as molecular adaptations do not always reflect functional outcomes and the study did not measure changes in performance. Of note, there is some evidence that regular CWI at very cold temperatures (5ᵒC) for very long durations (>30 minutes) may disrupt local vascular adaptations and attenuate improvements in VO2max to endurance training in untrained subjects (85).

There is no direct evidence to suggest that ice baths enhance nor interfere with endurance training adaptations. In trained athletes, ice baths can be used sparingly after endurance training, but regular use is not recommended, particularly during the preparatory period when the focus of training is on adaptation. Finally, ice baths of excessive duration or at extremely cold temperatures should be avoided.

Major Take-Aways

The evidence for cryotherapy is pretty mixed, but there are some patterns that seem to emerge from the literature:

• Cold water immersion and other forms of cryotherapy reduce exercise-induced inflammation.
• This reduction in inflammation may lead to reduced perceptions of fatigue and muscle soreness and increased perceptions of recovery which may benefit performance in the short-term.
• Importantly, the short-term recovery benefits of cryotherapy may depend considerably on the mode exercise (i.e. the type of stress), the physiological and perceptual qualities one is trying to restore, and (as I will discuss further in Part 2) the athlete’s belief in cryotherapy as a recovery modality.
• Meanwhile, a growing body of evidence indicates that inflammation is a necessary process for tissue regeneration and, as such, regular use of cold water immersion may impair long-term muscular and vascular adaptations to exercise.
• As such, cryotherapy should be used sparingly, particularly in the off-season when the goal is to maximize training adaptations.

In Part 2, I will address:

• whether baseball pitchers should ice their arms
• whether there an optimal cooling method, temperature, or duration
• whether cryotherapy is just one big fat placebo
• practical recommendations for athletes and coaches

Stay tuned for Part 2!

Note: the references for this entire article (including the upcoming part 2) will be posted as the first comment below.

About the Author

A native of the Great White North, Tavis Bruce (@TavisBruce) is no stranger to the effects of cold on athletic performance. He holds a Bachelor of Kinesiology and Health Science from the University of British Columbia, where he pitched for the Thunderbirds baseball team for three seasons. Tavis is currently the Director of Education for the Baseball Performance Group, where he integrates his passion for sports science with his love of baseball. He can be contacted at tavis.bru@gmail.com.
 

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Strength and Conditioning Stuff You Should Read: 11/11/14

First off, Happy Veterans Day - and a big thank you to all those out there who have served our country and protected our freedom.

Second, here are some recommended reads for the holiday:

Elite Training Mentorship - In this month's update, I have a webinar entitled, "8 Things I've Learned About Core Training," along with two new exercise demonstration videos and an article.

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Mike Roncarati Interview - Mike Robertson interviewed Golden State Warriors Strength and Conditioning Coach Mike Roncarati, DPT, who happens to be a former Cressey Sports Performance intern. Roncarati brings some awesome thoughts to light on assessment, rehabilitation, monitoring, and managing a busy NBA calendar. He's is a super bright guy and this is "must-read" material if you're an aspiring strength and conditioning coach (or desire to work in professional sports in any capacity).

5 Resistance Training Myths in the Running World - This article is over seven years old now, but it warranted "reincarnation" in light of a conversation I had the other day with a friend who is an avid endurance athlete/distance runner.

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Stuff You Should Read: 8/10/09

A few good reading recommendations for this week... Sucker Punch: Alwyn Cosgrove - This is a fantastic interview at T-Muscle with one of my best friends and mentors in the industry.  Alwyn calls it like he sees it (which is sadly becoming less and less common in this industry).  He even gives some schmuck named "Cressey" a shout-out in the interview. The Influence of Strength and Power on Muscular Endurance Test Performance - This recent study from the Journal of Strength and Conditioning Research confirms what we already know - but also gives a quantifiable number for which we can shoot when training for something like the 225 bench test - or even in dealing with endurance athletes.  Here are the sentences I like the most: "...the current research suggests that the initial goal of a training program to enhance muscular endurance should be to increase maximum strength to a point that the specific load being lifted during repeated actions is less than 40% of the individuals' 1RM. Subsequent training should then focus on maintaining maximal strength levels and improving local muscular endurance in the specific task." So, if your goal is to get better on the 225 bench press test, unless you've got a 562.5-pound bench press, it's still going to help you to train for maximum strength. And, more significantly to what we see on a daily basis, you need to get fit to run, not run to get fit.  A 200+ pound woman who takes up jogging as her initial form of exercise to lose weight is just asking to get hurt because she is far too weak for the load (at least 800 pounds of ground reactive forces) that is imposed on each leg with each stride. Someone like this would be better off focusing on programs like Afterburn or Warp Speed Fat Loss - which focus on using resistance training, interval training, and nutritional modifications to get unwanted weight off folks.

warpspeedfatloss

It's impressive how I brought this entire blog post back to Alwyn in a big circle, huh?
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Stuff You Should Read: 3/24/09

This week's "worth checking out" list: Five Resistance Training Myths in the Running World Bill Hartman Tips Part 1 Bill Hartman Tips Part 2
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Ask EC: Installment 1

By Eric Cressey

Q: I know that you're a proponent of DB Isometric Split Squats for extended periods of time. I can only manage 15 seconds on both legs with no weights. I feel that this is pretty pathetic in light of my performance on other exercises, which tends to be quite good. So, to get that time up more and to start using weights, should I simply hold the position as long as I can and look to get up to 60 seconds? Or would I be better off doing ski-squats against the wall more often until the hold strength builds up?

Also, when I'm doing the exercise, I feel the exercise more in the elevated leg in the quads. It's not up that high ,but I am sinking pretty low to get the required angle. I'm 6' 2". A: Definitely stick with the Bulgarian EQIs; your endurance will pick up in no time. Remember, although muscular endurance is an added bonus of the exercises, this is more about working on active flexibility. I work with several guys each week that are 7-feet tall or very close to it, and they can all get it done; at 6-2, you shouldn't have a problem once you find the right position. You should feel it in your hip flexors on the elevated leg; if you're feeling it in the quad of that leg, it means that you're exerting too much force on the foot on the bench instead of allowing your hips to sink down while keep the back leg extended (or close to it). Drive your front heel into the ground and contract your glutes hard, pulling the chest up and shoulder blades back and down. Make sure that your knee is directly above your foot and your weight is on the heel. Q: Thanks to your advice on taking care of primary subacromial impingement, my pain is gone and I'm ready to get back to work on my pressing strength. I'm not sure how to reintegrate benching and overhead pressing. I definitely don't want to reaggravate the injury; any suggestions? A: You're correct that it isn't a good idea to jump right back into things with full range of motion and loading. I favor the following progession (although slight medications in rapidity of progression are always made based on symptoms): Body Weight Push-up > Weighted Push-up > Cable Crossover from Low Pulley > Cable Crossover from Hip Height > Neutral Grip DB Floor Press > Neutral Grip Decline DB Press > Pronated Grip Decline DB Press > Barbell Floor Press > Decline Barbell Press > Flat DB Press > Incline DB Press > Barbell Bench Press > Barbell Incline Press > DB Military Press > Barbell Military Press/Push Press > Behind the Neck Presses Note: Some trainees don't even need to go as far as the end, as the cost:benefit ratio for loaded behind-the-neck exercises is way out of whack for some people post-injury. The rationale for these progressions are: a) The scapular and humeral stabilizers are most effective in closed chain positions.(justifying the push up). b) Impingement symptoms are most likely to be aggravated with flexion and/or abduction of the humerus beyond 90-degrees. c) Traction (pulling the humeral head away from the glenoid fossa, as with a cable crossover) is less traumatic to the previously injured muscles than approximation (forcing the humeral head into the fossa). d) Internal rotation (as seen with pronated grips) mechanically decreases the subacromial space, increasing the risk of re-injury.

With this progression, I like to start recovering trainees off with long eccentrics in the 6-8 rep ranges. In many cases, high-speed movements like speed benches and push jerks can be the most problematic, so I avoid these early on. It's important to pay attention to not only how the shoulder feels during the exercise, but also what you feel in the 12 or so hours afterward. If you're hurting, you've likely jumped the gun on your rehabilitation. During this time, keep up working hard to strengthen your scapular retractors and depressors and the external rotators of your humerus. In fact, your volume on these exercises should still be greater than that of internal rotations and protractions. Ice post-exercise and don't do too much too soon, and you'll be back on track in no time. Q: I'm working my back from a shoulder injury, and wanted to know if you think it would be feasible to do a little external rotation and scapular retraction work each day? While I'm not feeling any pain, I can still tell that my stabilizers are pretty weak. I have been alternating between rowing movements and face pulls each day as of late along with doing some sort of RC work each day (external rotations, 90 degree prone rotations, prone trap raises, band work, etc). Is this too much in your opinion or is it fine? I'm talking like 3x15 of rowing/face pulls and maybe 3 exercises of 3-4x15 of RC work per day (light weight obviously). Or would it be better to just do everything 3-4 times per week. I just figured I would divide the volume up throughout the entire week. A: I think it would definitely be advantageous to do some every day, although your loading and set/rep parameters could use some revisions. Try loading the movements in the 6-10 rep range once a week, and then hitting them with lighter weights in the 12-15 rep range on another day. On the other five days, just do some work with the theraband and/or light dumbbells to get the blood flowing. These are really small muscles, so you have to go out of your way to promote bloodflow and, in turn, healing. It certainly won't hurt to get them "activated" so that they're firing on all cylinders when you get back to your compound movements down the road. Q: After reading your article in the October issue in Rugged, I have a question or two. In healthy individuals, are you saying you do NO "direct" local (deep) ab work. i.e. plank, "thin tummy?" It seems as if the trainee gets plenty of local ab work w/ exercises like the DL, squats etc, but I don't know if "direct" ab work is mandated. I am still confused about this, even know I've read countless articles relating to this topic. A: Be careful with your classification scheme; I wouldn't classify tummy sucking with plank exercises. The cues I give to my athletes on plank exercises are to brace as if someone is about to kick them in the stomach (much like you would push out when squatting and deadlifting). The training effect is markedly different with this approach than with sucking in the tummy. In short, bracing makes you strong, and tummy sucking makes you look and perform like a wanker. You are, however, correct in saying that I think attempting to isolate the TVA in healthy individuals is a bad idea from both a training economy and potential harm standpoint. This training time would be better spent on other things, most notably multi-joint exercises and mindlessly gawking at gorgeous women in sports bras and spandex shorts. Q: First of all, let me tell how much I enjoy your no-nonsense, information filled articles. It's great that people like you are writing about various posture related, biomechanics issues. I have a problem to which I have not been able to find a solution here in India. I have over-pronation in both feet, resulting in low reactive force output plus patello-femoral pain if I run long distances. Aside from getting orthotics, is there anything else I can do about this over pronation. A: It really depends on whether the cause is structural or functional. You state that you have over-pronation in both feet, but don't allude to whether the feet have been flat for your entire life or if it's something that's kicked in as a result of movement dysfunction. From a structural standpoint, orthotics are really your only bet; the structural abnormality will dictate how the orthotic is shaped. From a functional standpoint, you need to determine if you have weakness in a decelerator elsewhere that's forcing the extra pronation in order to compensation. The external rotators of the hip (especially the gluteus maximus) and quadriceps are notable possibilities. Don't forget the dorsiflexors, either.
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Five Resistance Training Myths in the Running World

To some, resistance training is the Rodney Dangerfield of the running community; it gets no respect. To others, it’s like Tom Cruise; runners think it might be useful, but it just doesn’t make any sense to them. And then, there are those to whom resistance training is like Abraham Lincoln; it’s freed them from being slaves to ineffective programming. As a performance enhancement specialist who has a lot of “Abe” endurance athletes under my tutelage, I’d like to take this opportunity to bring the Rodney and Tom runners in the crowd up to speed. With that in mind, let’s look at the five most prominent myths present in the running community with respect to resistance training Continue Reading...
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Weight Room Workouts for Cyclists: Part 2

As we learned in part one, cyclists can gain an advantage by training off the bike. The corrective exercises presented here work toward increasing performance strength, allowing you to deter injuries and stay in the saddle longer. Continue Reading...
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Weight-Room Workouts for Cyclists: Part 1

Cyclists spend thousands of dollars on precise training and nutrition protocols, seek out the best equipment and supplements, and look to find the best training groups to push them to the next level. However, in spite of their enthusiasm and commitment, very few cyclists are taking advantage of valuable training off the bike. This three-part series outlines six key exercises that not only optimize performance, but will keep you healthy for the long haul, as well. Continue Reading...
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