A multi-component training program improves motor, but not respiratory parameters, in Parkinson’s disease patients

GIUSEPPE D’ANTONA1,2, MATTEO FORTUNATI1,3, CHIARA PIETRAROIA1, STEFANIA SOZZI4, PATRIK DRID5, VENERE QUINTIERO1, MICAELA SCHMID4, GIULIA MARIA STELLA6,7, OSCAR CRISAFULLI1,5

1CRIAMS-Sport Medicine Centre, Voghera, University of Pavia, Voghera, Italy; 2Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy; 3Department of Industrial Engineering, University of Roma “Tor Vergata”, Rome, Italy; 4Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy; 5Faculty of Sport and Physical Education, University of Novi Sad, Novi Sad, Serbia; 6Department of Internal Medicine and Medical Therapeutics, University of Pavia Medical School, Pavia, Italy; 7Unit of Respiratory Disease, Cardiothoracic and Vascular Department, IRCCS Policlinico San Matteo, Pavia, Italy.

Summary. Introduction. Parkinson’s disease (PD) can impair both motor and respiratory functions (MFs and RFs), reducing physical efficiency and quality of life. While various exercise modalities have shown benefits on either MFs or RFs, it is unclear whether a multi-component training program (McTP), combining different exercise types, can improve both concurrently. Methods. Ten PD patients (age: 75.1 ± 7.1 years; 9 males, 1 female), all at Hoehn & Yahr stage 2, completed a 3-month bi-weekly McTP. Each 1-hour session included 20 minutes of aerobic exercise (AE) at 14-17 on the Borg scale (targeting RFs), followed by lower-limb resistance and balance exercises (both at Borg level 15) to improve MFs. Training parameters were based on literature in PD or, when unavailable, age-matched healthy cohorts. RFs were assessed via spirometry, 12-second forced inspiration/expiration, and maximal inspirations. MFs were evaluated with the 6-Minute Walking Test (6MWT), Timed Up & Go (TUG), and Short Physical Performance Battery (SPPB). Pre/post comparisons used Wilcoxon signed-rank and paired t-tests. Results. No significant changes (p>0.05) were observed in RFs or TUG. However, 6MWT (p<0.01) and SPPB (p≤0.05) scores improved significantly. Conclusions. These findings suggest that McTP effectively improved MFs, but no statistically significant changes were observed in RFs. Modifying AE frequency and/or duration may be necessary to target respiratory adaptation.

Key words. Respiratory function, pulmonary function test, spirometry, exercise therapy, adapted exercise.

Un programma di allenamento multicomponente migliora i parametri motori, ma non quelli respiratori, nei pazienti con malattia di Parkinson

Riassunto. Introduzione. La malattia di Parkinson (MdP) può compromettere sia le funzioni motorie (FM) sia le funzioni respiratorie (FR), riducendo l’efficienza fisica e la qualità della vita. Sebbene varie modalità di esercizio abbiano mostrato benefici sulle FM o sulle FR, non è chiaro se un programma di allenamento multicomponente (McTP), che combini differenti tipi di esercizio, possa migliorare entrambe contemporaneamente. Metodi. Dieci pazienti con MdP (età: 75.1±7.1 anni; 9 maschi, 1 femmina), tutti allo stadio 2 di Hoehn & Yahr, hanno completato un McTP bisettimanale della durata di 3 mesi. Ogni sessione di un’ora includeva 20 minuti di esercizio aerobico (EA) a 14–17 della scala di Borg (mirato alle FR), seguiti da esercizi contro resistenza degli arti inferiori e di equilibrio (entrambi a livello 15 di Borg) per migliorare le FM. I parametri di allenamento si basavano sulla letteratura nella MdP o, quando non disponibile, su coorti sane di pari età. Le FR sono state valutate tramite spirometria, inspirazione/espirazione forzata di 12 secondi e massime inspirazioni. Le FM sono state valutate con il 6-Minute Walking Test (6MWT), il Timed Up & Go (TUG) e lo Short Physical Performance Battery (SPPB). I confronti pre/post hanno utilizzato il test dei ranghi con segno di Wilcoxon e i T-test appaiati. Risultati. Non sono stati osservati cambiamenti significativi (p>0,05) nelle FR o nel TUG. Tuttavia, i punteggi del 6MWT (p<0,01) e dello SPPB (p≤0,05) sono migliorati significativamente. Conclusioni. Questi risultati suggeriscono che il McTP ha migliorato efficacemente le FM, ma non sono stati osservati cambiamenti statisticamente significativi nelle FR. Modificare la frequenza e/o la durata dell’EA può essere necessario per puntare all’adattamento respiratorio.

Parole chiave. Funzione respiratoria, test di funzionalità polmonare, spirometria, terapia dell’esercizio, esercizio adattato.

Introduction

Parkinson’s Disease (PD) is a progressive neurodegenerative disorder characterised by typical limitations in motor function (MF) such as gait impairments1 and postural instability2, and non-classical symptoms such as weakened respiratory function (RF)3, which include both restrictive and obstructive types4. In particular, from the early stages of the disease, it reduces several MFs, including gait speed and step length, impairs rhythmicity, and increases interlimb asymmetry5. Moreover, it leads to abnormal dynamic postural control and dysfunctional proprioceptive mechanisms, which in turn compromise static and dynamic balance and increase the risk of falls6. Regarding RFs, compared with values expected in age-matched healthy individuals, PD reduces the forced vital capacity (FVC), the forced expiratory volume in the first second (FEV₁), and the Tiffeneau index (FEV₁/FVC)7.

In these patients, compromission in RF, alongside limitation in MF, interfere with the activities of daily living8 and discourage PD patients from performing highly metabolic-dependent tasks9, thereby contributing to increased disability10 and a higher risk of developing comorbidities. Several forms of physical exercise (PE) have demonstrated favourable outcomes in PD patients, ameliorating either MFs11 and RFs12-15. However, since the clinical manifestations of PD can impact both domains1-3, identifying a PE modality that effectively addresses the various detrimental adaptations of the disease represents an important clinical challenge.

In this context, a multi-component training program (McTP), also known as multimodal, multidomain or functional training protocol, is a PE intervention that combines multiple types of exercises targeting specific physical functions within a single session (such as aerobic exercise (AE), resistance training (RT), balance, mobility, etc.)12,13,15-17. The McTP is theoretically designed to deliver broad-spectrum improvements, which may simultaneously enhance the various physical functions impaired in PD. Several studies have investigated the effectiveness of McTP in PD patients. Some focused exclusively on MFs16,18, others on RFs12,13, while only two works have evaluated a combination of both domains14,15. Interestingly, the results of these studies are not consistent. In the first investigation, there was an improvement in some RF parameters, but not in MF (i.e., distance walked)15, whereas in the other one, ambulation capacity and only one of the RF parameters showed improvement14. The paucity and contradictory nature of the available data highlight the need for further research to identify the most effective composition of this type of PE protocol to achieve optimal improvements in both functions.

Hence, in this brief report, the main objective is to investigate the preliminary effectiveness of an McTP intervention composed of a balance and lower-body RT domain, focused on improving MF, and an AE component aimed at improving RF in PD patients. The hypothesis is that the 3-month McTP will lead to significant improvements in both MFs and RFs.

Materials and methods

Research design

The study is a quasi-experimental, non-randomised, single-group, pilot study with a 3-month treatment. The length of the intervention was selected based on its expected sufficiency to induce adaptations in MFs and RFs in PD patients14,15. Participants underwent baseline RF and MF tests 3 days before the start of the intervention, while post-intervention assessments were performed 3 days after the end of the training protocol.

Participants

A convenient sample of 10 PD patients was recruited for the study (mean ± SD age: 75.1±7.1 years old; height: 1.65±0.09 m; body mass: 73.7±12.1 kg; nine male, one female). All participants completed the training and underwent post-intervention tests. All participants, were non-smokers. None of the patients reported previous respiratory diseases, such as pneumonia, pulmonary fibrosis, or bronchitis. Notably, all PD participants were afferent to the Hoen & Yahr (H&Y) stage 2. PD patients were included if they had the usual pharmacological treatment for at least 4 weeks before entering the study. Exclusion criteria were cardiovascular, musculoskeletal, respiratory diseases, and other neurological conditions. Moreover, patients were excluded if they had signs of cognitive impairment, i.e., score < 21 on the Mini-Mental State Examination. Patients recruited in this study did not receive any physical therapy or other type of treatment in parallel with the intervention. They attended all sessions of the intervention protocol (100% adherence rate). The medication regimen of all PD patients remained stable over the intervention period. All the participants signed an informed consent. The study was approved by the Ethics Committee of the Faculty of Sport and Physical Education, University of Novi Sad, Serbia, (Ref. no: 49-03-02/2023-1) and was conducted in accordance with the Declaration of Helsinki19.

Outcome variables

Primary outcome variables: respiratory function tests

The RFs were evaluated through three tests. First, a spirometric evaluation was conducted using the Cosmed Pony spirometer (Cosmed®, Roma, Italy), with participants sitting comfortably wearing a nose clip. Tests were repeated three times after a self-paced rest period (but not less than 2 minutes) to allow full recovery from acute inspiratory and expiratory muscle fatigue. Direct measurements included FVC (litre), FEV1(litre), Peak Expiratory Flow (PEF, litre/minute), Peak Inspiratory Flow (PIF, litre/minute), Tiffeneau index (FEV1/FVC%), mean Forced Expiratory Flow 25%-75% (FEF25-75%, litre/minute), and Forced Expiratory Time (FET100%, seconds). Second, during a 12-second continuing forced inspiration and expiration through the spirometer, Maximum Voluntary Ventilation (MVV, litre/minute) and Tidal Volume during MVV (TVMVV, litre) were measured. Third, using an inspiratory pressuremeter PONT-FX (Cosmed®, Roma, Italy), three maximal inspirations and three maximal exhalations, maintaining constant pressure, were executed to assess respiratory muscle strength. During this test, Maximum Inspiratory Pressure (MIP, centimetres of water) and Maximum Expiratory Pressure (MEP, centimetres of water) were monitored. All the measurements were performed following the American Thoracic Society and European Respiratory Society Technical recommendations20 and percent predicted values were calculated using GLI 2012 reference equations with ethnicity-specific adjustments. All RF tests were conducted during the optimal on period after medication administration.

Secondary outcome variables: motor function tests

Six-Minute Walking Test (6MWT). The 6MWT is a recommended test by The Movement Disorder Society to evaluate walking capacity in PD patients21.

Time Up & Go test (TUG). The TUG is a common and reliable test for measuring functional capacity in PD21, as well as other basal ganglia disorders22. The test was repeated three times, and the mean value in seconds of these measurement trials was entered for analysis. Of note, each participant had one familiarisation trial as an attempt to avoid learning effects and ensure that volunteers understood the instructions.

Short Physical Performance Battery (SPPB). The SPPB is widely used to evaluate physical function in neurological patient cohorts, and has been recently utilised in a cohort of PD patients23. It comprises three main sub-items that assess balance, gait, and lower body strength through, respectively, a sequence of static equilibrium in different standing positions (feet together, semi-tandem, and tandem), a gait speed evaluation on a distance of 4 meters, and a strength tasks through the chair stand test, in which the subject need to stand up and sit down five times as quickly as possible. Each sub-item is scored from 0 to 4, with a higher score indicating better performance, while the total SPPB value is the sum of each sub-item’s points. After familiarisation with the tasks, subjects performed the test and the score was stored.

All MF tests were conducted during the optimal on period after medication administration.

Multi-component training protocol

The McTP was a biweekly training of 60 minutes for 12 weeks (24 sessions) and was designed to target MFs and RFs. It comprised three domains: AE, lower-limb RT, and balance exercises. A qualified kinesiologist, with 10 years of experience in PE for PD patients, led the session by physically demonstrating and orally explaining each task, while PD patients were grouped in front of the instructor. The intervention was delivered to two small groups of 5 participants.

Specifically, the 20-minute AE component was delivered as a continuous walking task incorporating rhythmic variations and gait training, performed at a perceived exertion level of 14–17 on the 20-point Borg scale, consistent with current PD exercise guidelines24 and previous studies showing RF improvements12-15. The RT and balance domains, each lasting 20 minutes, were both performed in a circuit format at an RPE of 15 on the 20-point Borg scale, previously indicated as well-tolerated in PD patients12-13. Notably, to the authors’ knowledge, there are no guidelines on the AE weekly dose requested to ameliorate RFs in PD patients; hence, for the present training prescription, we proposed a dose suggested to ameliorate peak of oxygen consumption (V̇O2peak) in community-based elderly25, since V̇O2peak values have been reported as associated with RFs in a large cohort of age-matched elderly26. RT was prescribed to reach the suggested minimum weekly dose reported for patients at moderate H&Y stage in order to ameliorate functional strength24. Similarly, balance was designed to accumulate 40 minutes per week, a duration recently identified by a network analysis as effective for improving this capacity in PD patients27. Table 1 outlines the McTP protocol and the progression of exercises throughout the intervention. No adverse events were identified during the intervention. The intervention was delivered in the gym of the Faculty of Sport and Physical Education, University of Novi Sad, Serbia.




Statistical analysis

Data are presented as mean ± standard deviation (SD). Normality was assessed using the Shapiro-Wilk test. Depending on the distribution, either the Wilcoxon signed-rank test (for non-normally distributed data) or the two-tailed paired samples Student’s t-test (for normally distributed data) was used to compare baseline (T0) and post-intervention (T1) values. For parametric paired measures, the effect of the intervention was quantified using Hedges’ g, calculated from the paired t-test values and corrected for small sample sizes. For non-parametric measures, a rank-biserial effect size (r = Z/√N) was calculated from the Wilcoxon test to estimate the magnitude of the effect on the ranked differences between pre- and post-intervention. The statistical significance level was set at p≤0.05. Analysis was performed using the software JASP (V. 0.18.1, Jasp Team 2023).

Results

Baseline and post-intervention mean values of RF and MF parameters are presented in table 2.




Overall, there were no statistically significant differences (p>0.05) between T0 and T1 for all the RF parameters considered, and for the results of the TUG. Instead, there were significant improvements in 6MWT (p<0.01) and SPPB (p≤0.05).

Discussion

This is the first study to evaluate RF and MF parameters after a 3-month McTP in a cohort of homogeneous (H&Y=2) PD patients. Overall, after the proposed intervention, no statistically significant improvements in RF parameters and TUG were found, while ameliorations in walking capacity (i.e., 6MWT) and the multidimensional physical function score of the SPPB were observed.

Respiratory function

Overall, our PD cohort showed a baseline condition of impaired RFs compared to the reference values, as denoted by the marked reduction in several indicators, such as MIP, MEP, MVV, and PEF (table 2).

Our McTP was based on a weekly quantity of AE suggested to ameliorate V̇O2peak in community-based elderly25, since V̇O2peak values have been reported as associated with RFs in a large cohort of age-matched elderly26. However, we did not observe such effects, even if there was a trend toward normalisation of FVC and FEV-1. On the contrary, other McTP interventions on PD patients reported significant improvements in some, but not all, RF parameters12-15. Specifically, among them, MEP improved in three studies12,14,15, while only one study found amelioration in, respectively, MIP15, and FVC13.

When contextualising our non-significant findings in light of previous studies12-15, it appears plausible that discrepancies in RF outcomes may stem from differences in the weekly frequency and session duration of the AE component. Specifically, our protocol involved a lower weekly frequency than those used by Duarte et al.12 and Silveira et al.13, and a shorter session duration than that reported by Barretto et al.15 and McMahon et al.14. The potential contribution of these two factors is underscored by the observation that the perceived exercise intensity used in our protocol aligned with values across all the aforementioned investigations12-15. This interpretation is further supported by studies conducted on healthy older adults, which suggest that AE-induced improvements in RFs are dose-dependent, highlighting the crucial role of both session duration and training frequency in eliciting such adaptations28,29. However, given the small sample size and the resulting limited statistical power, the findings should be considered preliminary and interpreted with caution.

Motor function

Walking distance significantly improved after McTP (table 2), suggesting that it may have had a positive impact on participants’ ambulatory capacity. Noteworthy, the increase in 6MWT exceeded the minimal clinically important difference in people with pathology30, potentially contributing to real-world ambulation performance31 and promoting a greater autonomy in carrying out essential activities of daily living.

The improvement in 6MWT performance appears consistent with findings from several studies evaluating the effectiveness of a McTP on MF parameters closely associated with walking capacity (i.e., gait speed and stride length16,32), as well as with the increase in ambulation capacity reported in a study involving an integrative PE approach14. However, as previously reported, the latter study implemented a combination of three training types (McTP, HIIT, and Tai Chi), which limits its comparability with our protocol.

On the contrary, our findings are in contrast with those observed in cohorts of PD patients trained with an McTP, in which 6MWT remained unchanged15,17. The differences between the present study and Gryfe et al.17 may be attributed to the dissimilar distribution of H&Y stages, since they recruited patients ranging from stages I to III. In fact, recent guidelines on PE for PD suggest offering group activities by categorising patients into early (H&Y 1–2.5) and moderate (H&Y 2–4) disease stages24. Combining patients with such varied disease severity17 may have affected the results, making the proposed McTP too challenging for some and too easy for others, potentially limiting physical improvements. Besides, in Barretto et al.15, PD patients did not receive balance training, a motor capacity known to influence walking ability, as reported in several PD cohorts33,34, which may have constrained their walking capacity. Moreover, performing AE training on a cycle ergometer15, a stationary device, could have a limited training effect on balance, as it requires a lower level of postural control compared to that requested during walking or gait training.

Regarding overall SPPB, results show that the score significantly improved after the McTP, indicating an overall better MF. This could be thanks to the protocol’s threefold design, in which there was a component related to each of the scale’s evaluation (functional movement, balance, and gait). Interestingly, to the author’s knowledge, this is the second study to use the SPPB as an outcome measure following a PE intervention in PD patients, and the first to do so after a McTP. This multifunction test has been recently utilised to measure the effectiveness of two forms of unimodal PE intervention in I to III H&Y PD patients. One group (n=8) performed 16 sessions of twice-weekly 60-minute strength training, while the other (n=9) a power training with the same characteristics23. Results show that the SPPB score significantly ameliorated from pre- to post-intervention; however, if compared to our findings, by a reduced overall score (our study, T0: 9.60±2.37 pts; T1: 11.30±1.06 pts, do Amaral Felipe et al.23, strength training, T0: 9.2±1.5 pts; T1: 10.1±1.3 pts; power training, T0: 8.4±2.2 pts; T1: 9.2±2.0 pts). This interpretation would suggest that a McTP intervention may be superior in increasing multiple impaired MFs in PD.

More specifically, regarding each SPPB’s sub-items, the improvement in the chair stand test may be attributed to the lower-limb strength exercises prescribed in the McTP, which included sitting and standing from a chair or box, as well as body-weight partial lunges. Thus, supporting the effectiveness of lower-limb RT on functional mobility in older patients35.

On the contrary, the absence of a significant improvement in gait speed, despite the observed enhancement in the 6MWT, which would suggest an increase in walking velocity, may be explained by the already near-optimal baseline score on the SPPB gait speed subscale (T0: 3.80±0.42 pts out of a maximum of 4.00 pts). Consequently, the SPPB gait speed component, being close to its upper limit, might have lacked sufficient sensitivity to detect further improvements, a limitation commonly referred to as the ceiling effect36. Therefore, the apparent absence of change could be attributed more to the restricted sensitivity of the assessment tool than to the lack of an actual improvement in performance.

Regarding the balance sub-item, its score improved, but not significantly. However, the baseline score was 3.10±1.20 pts (table 1), which is indicative of a moderate-to-high mean level of residual balance capacity. Once again, this leaves only a limited margin for significant improvement, and it seems that the reduced sensitivity of the SPPB score system could be behind the non-significant amelioration at post-intervention.

Finally, the time to perform the TUG decreased, but the difference between T0 and T1 did not reach significance (table 2), despite other MF parameters showing a significant amelioration after the intervention. However, it must be considered that, at pre-intervention evaluation (T0: 9.60±4.82 sec, table 2), our cohort performed in line with the reference time values for healthy elderly individuals aged 70-79 years (9.2 sec (8.2-10.2 sec, 95% CI))37, this suggests that the margin for improvement may have been minimal, as this task was likely not impaired enough to demonstrate significant gains due to the ceiling effect. In fact, other studies have reported a positive effect of McTP on TUG performance in patients with PD16,18, but, in line with the proposed explanation, their baseline performance was lower (Tollár et al.18, T0: 16.1±3.7 sec; Zhang et al.16, T0: 11.8±2.1 sec), which may have allowed for significant improvement. Notably, their post-intervention scores are comparable to the baseline values observed in our sample (Tollár et al.18, T1: 9.9±2.7 sec; Zhang et al.16, 9.7±2.0 sec). Another possible explanation for the lack of improvement in TUG performance is that this test reflects not only mobility but also dynamic balance. Our training protocol, however, focused on static balance exercises and did not specifically target dynamic balance components. This discrepancy may have limited the transfer of training effects to TUG outcomes. Future studies should therefore consider including both static and dynamic balance exercises to comprehensively address balance impairments in PD.

Summary of McTP effectiveness

Regarding McTP, the few data currently available would suggest that the observed improvements are dose and domain-related specific. For example, enhancements in the distance walked, as in the 6MWT, appear to require the inclusion of exercises specifically targeting gait, walking, and balance, as observed in our study as well as in other investigations16,32. This seems further supported by evidence indicating that when McTP did not include balance or gait training, improvements in ambulation did not occur15. On the other hand, if an improvement in RFs is required, without a specific PE intervention (i.e. not utilising respiratory muscle training devices), it seems that a minimum dose of AE (in terms of frequency and duration) must be reached. This is suggested by the comparison between our non-significant results and the significant ameliorations of studies that implemented higher weekly frequency12,13 and longer session durations14,15, despite comparable exercise intensity. From a clinical perspective, our findings highlight the importance of carefully tailoring multicomponent training in PD. In particular, dynamic balance training should be incorporated alongside AE, RT, and static balance exercises, since this component is crucial for mobility, fall prevention, and functional independence in daily activities.

Limitations and future directions

Being this brief report, a quasi-experimental pilot study, it does not include a PD patient control group and randomisation. Both these characteristics are essential for reducing bias and establishing causal relationships between the intervention and observed outcomes. Moreover, as it lacks an appropriate sample size, the results presented here are only suggestive and must not be generalised. Therefore, future studies with larger sample sizes comprising both genders, different H&Y stages, appropriate control groups, and randomised designs are warranted to confirm or disprove these preliminary findings. Additionally, stratifying results by potential confounders like age, gender, and H&Y could provide valuable insights into which patients may benefit most from the proposed intervention.

A further limitation of the present study is that we did not assess quality of life or community participation. While functional improvements are important, their ultimate relevance lies in how they translate into daily living, social engagement, and overall well-being in people with PD. Previous studies have shown that exercise interventions can positively affect quality of life and participation38. Future research should therefore include patient-reported outcomes and measures of participation to better capture the broader impact of McTP. Moreover, considering the non-statistical improvement in TUG, future studies might benefit from employing alternative or complementary assessment tools that are more challenging and sensitive in early-stage PD, such as instrumented gait analysis, dual-task walking assessments, or more complex balance tasks, to better capture subtle motor changes.

A thorough stratification would also allow for the exploration of the short (3-month) and long-term (6-month or more) effects on RF and MF parameters of McTP and would help to identify the optimal characteristics of the various components of such programs, including the specific types of exercises, intensity, frequency, and duration of each intervention domain. Understanding how to customise and combine these components to individual patient profiles optimally could maximise functional improvements gained by McTP.

Conclusions

This study, which employed a small sample and a non-randomised, single-group design, preliminarily supports the potential of McTP to produce meaningful improvements in MFs in PD patients; however, no statistically significant changes were observed in RFs. Future studies should assess whether adjustments in AE frequency and/or duration are required to enhance the effectiveness of McTP in improving RF parameters in this population.

Conflicts of interest. The authors declare that there is no conflicts of interest.

Authors’ contribution. Conceptualization, GD and OC; Methodology, MF, CP, SS, PD, VQ, MS, GMS, GD and OC; Data collection, MF, CP, PD, VQ, GD and OC; statistical analysis: SS; writing, original draft preparation, MF, CP, SS, PD, VQ, MS, GMS, GD and OC; writing, review and editing, MF, CP, SS, PD, VQ, MS, GMS, GD and OC. All authors contributed equally to the manuscript and read and approved the final version of the manuscript.

Ethical statement. The study procedures were approved by the Ethics Committee of the Faculty of Sport and Physical Education, University of Novi Sad, Serbia, (protocol number 49-03-02/2023-1, approved on March 16, 2023) and conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all subjects involved in the study

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