In this episode of The ABMP Podcast, Kristin and Darren are joined by Cal Cates and Kerry Jordan from Healwell to discuss their research study, Massage Therapy for Hospitalized Patients Receiving Palliative Care: A Randomized Clinical Trial, what the objective of the study was, the methods used, and the surprising results that were found.
Physicians Weekly Article: https://www.physiciansweekly.com/massage-therapy-for-palliative-care-patients-in-hospital/
CBS News Article: https://www.cbsnews.com/news/hospice-massage-therapists/
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0:00:49.3 Darren Buford: I am Darren Buford.
0:00:52.5 Kristen Coverly: And I'm Kristen Coverly.
0:00:53.5 DB: And welcome to the ABMP podcast. A podcast where we speak with a massage and body work profession. Our guests today are Cal Cates and Kerry Jordan, executive director and operations director for Healwell. Healwell offers live and online courses for massage therapists and other allied health professionals to support meaningful integration of massage therapy as well as interprofessional collaboration in the role of self-awareness in effective and sustainable caregiving. Healwell partners with hospitals and other healthcare facilities and their team of specialty trained MTs support patients at hospitals throughout the Washington DC area. For more information, visit healwell.org. Hello Cal, Kerry, and Kristen.
0:01:31.4 Cal Cates: Hi you guys.
0:01:33.6 Kerry Jordan: Hello.
0:01:35.1 KC: Hi. Cal and Kerry, so excited to have you back on the ABMP podcast. Our topic today is your recently published research study, Massage Therapy for Hospitalized Patients Receiving Palliative Care, a randomized clinical trial published in the January 30th, 2023 edition of the Journal of Pain and Symptom Management. That was a mouthful, but before we dive into the study itself, let's talk about how the project started. So what was the impetus to do the research and to apply for the Palmer Foundation grant? How did you get involved? Tell us everything.
0:02:06.1 CC: Well, 7000 Years ago...
0:02:11.4 CC: I mean, it truly, it's definitely a four score and seven years ago situation. As anyone who's spent a minute involved in research knows, we, this project began in terms of thinking about it and what we might do in 2017. So just like, I just wanted everybody to think about in 2023, the paper about this study was published.
0:02:33.9 CC: Yeah, we actually had a contact with the Palmer Foundation and that, unfortunately I think is kind of how a lot of funding happens, at least from private foundations is that you have to be invited to apply. And so that got us thinking and you know, we've been at this, trying to integrate palliative trained massage therapists into hospital settings since 2009 and with success certainly compared, to how it's happening in lots of other places, but still sort of feeling at a loss. And we really wanted to answer this question when we talked to hospital administrators and we talked to them about standing up a massage program. Most people, hospital administrators included, are thinking about an hour long experience on a massage table where the person getting the massage has to be naked, et cetera, et cetera, et cetera.
0:03:25.3 CC: Right. Everything that you sort of like get when you go get a massage and try as we might getting them to understand that when you pay a palliative trained massage therapist to come into your hospital for an hour, that person is able to touch more than one patient in that hour and that, but we didn't know how many patients and in our time working in various hospitals throughout the DC area and some other places in the country, we had kind of settled as a practice team on about 20 minutes. Generally, I mean there are lots of factors that would affect the length of time we might spend with a patient, but mostly it was somewhere between 10 and 20 minutes. So we thought, well what if we, let's look at it, is 20 minutes better than 10 minutes? Can we have the same impact?
0:04:10.7 CC: And you know, really that thing of research like, I don't know, but it would be fun to know, right? We see that 20 minutes is pretty good, but the idea that less is more is antithetical.
0:04:24.6 CC: And so, thinking that 10 minutes could possibly be as good as 20 minutes, we... I think we kind of thought we wouldn't find that but at least we would find something that we could say to administrators and people who count the beans, when you pay x number of dollars for an hour of the presence of this provider, they will have this many what they call patient contacts. And so when we break it down, this is actually much more affordable and much more cost effective than you might initially be thinking. So that was really the drive for the basic research question.
0:04:56.5 KJ: I think in addition, one of the things that we see in the existing research literature is often it's a single massage. And particularly when we're looking at things like pain, the pharmaceutical interventions, nobody gets one dose of morphine during their hospital stay. Like that doesn't, [chuckle] that's not how it works. And so...
0:05:18.0 CC: It would be unethical.
0:05:19.4 KJ: Right. So the other thing that we wanted to do in the study was show, we suspected that if you got several massages several days in a row, we would see a different outcome than from a single massage.
0:05:33.0 DB: Okay. So my question is, do you pitch the Palmer Foundation or they know what you are doing and you're up to, and they come to you?
0:05:42.2 CC: In this case they knew what we were up to and came to us. Yeah. We still had to pitch them because there was one person in their team of, letter of interest reviewers that was like, I think what you're doing would fit within our mission areas. So here's what you have to do when you submit a letter with a full project proposal and budget and then you know, the person who knows you theoretically goes to bat for you when the 25 other applicants come in and they say, this is why I think we should give some of our money to these people.
0:06:13.0 DB: Okay, perfect. That helps. I think me and our audience understand that just a little bit more. So if you haven't mentioned it already, what was kind of the official objective of the study?
0:06:24.1 CC: It really was a dosing study. We really wanted to see, what's the dose response rate, in this population, which for this study it was palliative eligible patients, which we were talking about hospitalized patients, which there's a lot of debate about what is palliative care and who qualifies for it. And the folks that we work with on the palliative care team, we are in agreement that if you're in the hospital, you could benefit from palliative care.
0:06:51.3 CC: It's really, its goal is to improve quality of life, theoretically, to get you home sooner, to hopefully help you have less of an experience of what they call polypharmacy, where you're taking a lot of different pharmaceutical interventions to manage your disease or your symptoms. So that gave us a wide array of diagnoses and disease states that we were able to work with throughout this. So, with our, we had a sample size of 407 patients, which was also, I mean, that's just kind of unheard of for what they call a prospective study, which is that we're not going back and looking at charts later. We're actually enrolling and engaging patients in real time. And so it took almost two years to collect all of that data and work with all those patients.
0:07:33.1 KC: Okay. Let's talk about the methods you used. How was the research study structured?
0:07:39.7 KJ: Well, we had a study coordinator who was a medical student actually. And so she was in charge of randomizing and getting people to agree to be in the study. And we had a baseline, a survey that was about, it took people almost a half an hour. It was a pretty lengthy survey about quality of life and pain and all different kinds of things. And then people were randomized to one of three arms. And when I say arm, I mean group. So in a research study arm one, is the group of people who got this intervention. Arm two is the group that got this other intervention. So, you got one 20 minute massage, you got three 20 minute massages, you got one three days in a row, so 20 minutes, three days in a row or you received a 10 minute massage three days in a row.
0:08:29.0 KJ: So before and after each intervention session, the massage therapist had a tablet that had three questions on it. And the patient would answer, what is your pain on a one to 10 scale? What is your level of peacefulness? And it was sort of very peaceful, not peaceful at all. And then what is your level of distress? So each patient answered both before and after just those three questions. And so when we were able to look at the data, we had really a lot of data.
0:09:03.3 KJ: Because then after the intervention was complete, the study coordinator came back and did another pretty lengthy, 30 minute or so closeout interview with patients. And so we really had both the baseline and the finished data, but then even within the arms at each session, we could see were there changes particularly in the people who were in the arms where they had three different sessions. Did you see a difference in pain from session one to session three or peacefulness or stress?
0:09:39.8 KC: And talk to us about the practitioners who were conducting the work and do, you know, part of the research group. What was their background? Did they have special skillset? Tell us about that.
0:09:49.6 CC: Yeah, I think this is the thing that, as we continue to design research studies, we were really working to highlight because we actually on our own podcast last week had the wonderful opportunity to talk with two leaders in the physical therapy realm. And they, we were sort of comparing notes about shared challenges, in terms of professionalization and forward movement in our two professions.
0:10:09.4 CC: And one of the folks we talked with said this really resonant thing about physical therapy suffers from what he called commodification. And you will see, you'll hear people say, I tried physical therapy and it didn't work. And you don't hear people say, I tried dentist and it didn't work, right? I tried doctor and it failed. Like, and, but we have the same story with massage therapy. People say, oh, I tried massage, it didn't work.
0:10:34.1 CC: Well, okay, that's like a really broad statement. And so we really want to look at what is the impact of massage therapists of these providers to what, what's the possibility of these providers to impact care and the experience of illness? So in the case of this study and and Healwell's massage therapist, we've got 17 folks who are employees of Healwell, who have gone through our hospital-based training programs and oncology, massage and hospital-based and palliative care.
0:11:03.9 CC: And we really, I would say 85% to 90% of that training is about collaboration with medical and nursing teams. It's about how to provide patient-centered care and what does that actually mean? It's kind of like unpacking these buzzwords that people say, well, of course it's patient-centered. Like I wouldn't be here if it wasn't for the patient. You'd be amazed how un-patient centered it can be [chuckle] even though it's just you and a patient. They're able to adapt their work so that there's really, it's very rare that these therapists encounter a patient who can't safely receive some kind of touch from them regardless of their disease progression or whatever complications they may be experiencing.
0:11:45.0 CC: And we also designed this study without a protocol, without a script because we really wanted to highlight what happens when these providers work within the broad confines of their discipline as opposed to, I will rub this part of the body for this long and in this way. We come in and we are, these therapists are able to say to the patients, so like, I talked with your nurse and they shared with me these pieces of information about you and I'm wondering how are you feeling today? Like sort of what feels most salient to you as a thing that I might be able to help with?
0:12:21.4 CC: And the nurse might be saying, oh, you know, they've been saying that this hurts, or they're here for, they had surgery on their insert body part and you think, oh, well, I'm gonna work in that area. And the patient says, yeah, yeah, like I had open heart surgery, right, or I had a shoulder replacement, but if you could massage my feet or if you could work with my other shoulder, that would be great. And just being able to walk in without an agenda but with the scaffolding of, I can support this person in their experience and that I'm not bound by, these are the steps that I have to follow.
0:12:56.1 DB: So let me ask, I'm kind of curious 'cause some people familiar with research might ask, well, was there a no massage group or a faux massage group or these aren't real massage therapists giving touch group?
0:13:07.5 CC: We had a group of ferrets, actually.
0:13:10.7 DB: Genius.
0:13:10.8 KC: They're were posing as massage therapists.
0:13:12.6 CC: No one knew. Nobody knew. They're real handsy ferrets. We had what's called a usual care control group, because it could safely be assumed, and we certainly knew at the facility where this study happened that usual care did not involve massage therapy.
0:13:28.3 DB: Alright, I'm sure our listeners are waiting for the big reveal here. So what were the results?
0:13:36.0 KJ: The results were surprising and not surprising, I think. As we had expected, three was better than one and in both arms where the patients got repeated sessions, there was significantly more positive improvement than there was. All three arms showed improvement. And there was something like almost 90% of the participants said they would like to have massage therapy as part of their care. But what was surprising to me anyway, was that 10 minutes actually was slightly better in the outcomes than 20 minutes.
0:14:04.9 KJ: And we have lots of hypotheses about why this was true. I think personally having provided some of these sessions, 20 uninterrupted minutes in a hospital is not a thing that happens. And so almost every time I was providing a 20 minute session, another provider came in, the phone rang, family was present, something else happens. And so it was much easier to complete your 10 minute session uninterrupted. And so I personally think that has an effect. I also think these were very, very sick people. And so it's possible that even 20 minutes is a lot to ask of the nervous system and so I think that to me was the most interesting and surprising outcome. What about you Cal? What do you think?
0:15:00.1 CC: Yeah, I mean for me definitely that when you think about, okay, so now I can say to administrators, in an hour I can... Four, four and a half patient contacts can happen, if you count charting time and moving through the unit, et cetera. But also that when we looked at, you know, Kerry was talking about, the basic pre and post measures were pain, distress and peacefulness. And I think one of the most interesting things that really points to, and again, is kind of shaping some of the research projects we're designing now are that there were many times where pain barely moved or didn't even move at all, but peacefulness improved. And I think this is the piece that is really missing from existing research is that what we're trying to do is change the experience of illness.
0:15:53.8 CC: If you have just had open heart surgery, if you have just had a left ventricular assist device implanted in your body, the most skillfully administered massage is unlikely to limit your pain, right, in those first few days after surgery. But if what I can do and the time I spend with you is help you feel like you can handle it, that changes your nurse's experience, it changes your family's experience, it changes your ability to engage with your care. And pretty much I would say a majority of the data that exists about massage therapy, A, there's not a lot of data about massage therapy with seriously ill populations, period. But a majority of it is very much looking at the intervention and does it limit pain? Does it limit anxiety?
0:16:39.0 CC: And these very discrete ways that don't look at symptom clusters, that don't look at the way that factors affect each other. And this is a deeply psychosocial intervention. When you have a properly trained therapist who can emotionally regulate themselves and truly provide patient-centered care in a collaborative way with other team members. It's not about the hands, the hands are part of it, but it really is this interaction between two people that can create a space for peace and coping that pharmaceutical interventions don't do or don't do in the same way. And that's the kind of stuff we need to start looking at with our research.
0:17:19.7 KJ: My favorite quote that came out of this, was a patient who was very sick and had incredibly high pain levels and at the end of a session he said, so my pain is still an eight, but pain is no longer my only experience.
0:17:35.3 KC: Let's take a short break to hear a word from our sponsors.
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0:18:05.3 KC: Let's get back to our conversation. Okay, so that is all incredibly exciting and impactful. So I'm curious, and I'm sure the listeners are curious, how can we or can we as practitioners in a more traditional massage therapy setting in our own offices or clinics apply some of this research to our own work?
0:18:25.8 KJ: I think as Cal said earlier, it feels really liberating to me and exciting that we can know that less can be more. I think that especially in private practice, there's... Feels like such stress to like get, 60 minutes of table time and if your client is talking or if you're running late or if things are happening, there's this sort of sense of rush and of, I paid for every second of this session. And I think to be able to kind of open ourselves up to the idea that, I mean first of all, the whole thing is the session, the second they walk into your space, the session starts, but also that really 10 minutes can have a really profound impact, I think is a very freeing idea, particularly when you feel strained about, only 50 minutes or only 60 minutes.
0:19:11.0 CC: Well, and I feel like the... People say, well, right, but you're talking about really sick people. And I feel like I've been saying for a long time and now I feel like in our current world, people are sick, they may not have a diagnosis, but find me a person who's feeling super hopeful about the future in this moment, or who's feeling like there's not a lot of stress as they worry about whether it's politics or the planet or whatever it might be that like... A lot of us, our nervous systems are kind of fraying at the edges. And if we think about what we're doing in terms of supporting the nervous system, whether we're in private practice, where we're seeing ostensibly healthy people, or whether we're in a hospital ICU, there's a basic benefit to addressing the nervous system in this, I am just here for you kind of way. And that I think facilitates whatever other work you do. So I don't see us shifting to a place where we're booking 10 minute appointments for people, that doesn't make sense in a private practice setting, but a person comes in and says, I'm having this challenge with my hip and your brain goes, okay, we're going to spend a half hour with your hip, right? And then we're going to work with the rest of you.
0:20:19.7 CC: And it's like, maybe all that hip needs is 10 minutes or 15 minutes or, just like, I'm going to say hi to this. I'm going to acknowledge that it's doing some things that its owner would prefer it wasn't doing and then maybe we come back to it the next time they come in. But that, I'm not going to solve cancer. I'm not going to solve heart failure in this 10 minute massage. But if I can help this person be in their body in a more expansive way, whatever they came to see me for, that's always a thing that I feel like is achievable.
0:20:48.3 DB: And I mean, this may be a bit of a leap, but this seems, if you could make the correlation kind of a huge boost for chair massage.
0:20:58.1 KJ: Well, and I think really opening our minds to what massage therapy can be. I think that patients certainly and clients certainly think it's 30 up 30 down with your clothes off on a massage table. But it can look like so many things. And I do think that you're right Darren. I think chair massage is a great example. That I can have all my clothes on. I can be sitting up. I can be sitting at my desk chair in fact [chuckle] and receive something that's really, really important.
0:21:31.0 CC: And I think this points as well to the work that we have been able to do with health care providers in exactly that way, Darren, that, you know, just a five or 10 minute massage, either on a massage chair at their desk at the unit, right there where the computers are in the middle of the unit and it's led us to do some, we just finished collecting some semi structured interview data with nurses on units where these therapists have been working regularly. And what we're finding is that the nurses are saying, even if the nurses themselves aren't receiving massage, it changes the culture on the unit. When they can send a massage therapist, when a person complains of pain, anxiety, loneliness, that there's a concept, there's a thing called moral distress that is very common in health care providers, and it's knowing what you can... What you should do, but being prevented from doing it because of any number of barriers, whether they be bureaucratic, financial, etcetera, and that nurses revealed to us quite organically in these interviews that when a patient says, I'm in pain and either they can give them more medicine.
0:22:37.3 CC: Okay, great. Or maybe they just gave them medicine and the patient is saying, you know, it's not helping. They feel like the thing they have to give is a pill, is an infusion. And if there's a massage therapist available and they can send a person to be with that person, the nurse feels better about the care that they're providing and that actually, possibly can connect back to addressing the nursing burnout situation and the nursing shortage situation and that turnover. So I think with proper integration, there are a lot of ways we can show that massage therapy at the very least saves money. It definitely improves outcomes, not only for patients, but also possibly for nurses. Nurses saying that patients are hitting their call bell less often, which helps the nurses feel more efficient and less harried. That's important, but nobody's measured that yet. So we're going to measure that.
0:23:30.4 KJ: And that the massage therapist is the key. It's not like, it's all well and good to have a volunteer rub. But we often hear administrators say, well, I'll just have CNAs or nurses, add massage therapy to the workload they already have. Guess what's not going to do anything good for anybody. [laughter] And so...
0:23:51.6 CC: Guess what some of the nurses actually said again, unbidden in our interviews with them was like, you know, administrators have asked me, like, why don't I massage patients? And I'm like, how could... When would I find time to do that? And so it's very, nurses are saying... It's coming out of nurses own mouths. We can't do this. And some nurses who have been nursing for a long time miss that and the ability to do that because that was a standard of care. But what we need to remember is, that having been a standard of care means that it's always been believed to be important. It doesn't mean we should make nurses do it again.
0:24:23.5 DB: All right, as we bring this podcast to a close, can you let our listeners know what you're doing with the research now or any new research that you're pursuing?
0:24:35.1 CC: Absolutely. So, in fact just this week, we are submitting a proposal for what's called an implementation study. We were asked by one of the journals to write what's called a narrative review of massage therapy with palliative populations. And what that included was, we looked at a survey of existing research and what could be deemed palliative populations, because actually if you search for massage research and palliative care, you get, like, nothing. So we had to look for massage and serious illness, massage and ALS, massage and... And so we boiled it down I think at the end of the day to maybe 10 papers. And we described what's missing in this body of research. It was over the last 10 years that we looked at. And the main thing that is missing is that, the body of data that exists right now, honestly, in massage broadly, not even with palliative populations alone, is, it's clear that what we've done is respond to this really nonspecific demand for, "more data." There's a pile of data out there that say, Massage is great. Mostly it doesn't hurt people. Nobody hates it.
0:25:43.5 CC: There is zero data about how to implement it. Real world settings, a majority of the massage research that exists, there was not a massage therapist in sight. Sometimes not even providing the intervention. Many of the studies that we found in our narrative review, it was provided by social workers, nurses, CNAs, the researcher whose credentials were unknown in terms of their knowledge of massage therapy. So we really need to, massage therapist should be at the table when we're talking about research about massage therapy. They should definitely be the providers, but we've had the incredible opportunity to be. We have written the protocols and the studies we've participated in. We've trained the therapist. We've said, like, this is what we want to learn about massage therapists in these settings. So that narrative review really pointed us in the direction of, okay, implementation is missing. The way a lot of the studies have been designed is not amazing and really is hard to replicate and again, doesn't happen in real world settings in ways that we could say, if we had a massage therapist integrated in this place, this is what it would look like. I mean, even our dosing study, like, I think we learned a lot from this large sample size about what can be effective, but three days in a row for people whose length of stay in the hospital is 60, 80, 170 days.
0:27:07.4 CC: Three massages is not going to change your experience, right? You need massage probably every day. So we've just submitted a proposal, or we will be at the end of this week an implementation study where we would, we will be looking at having a massage therapist seven days a week on the unit for eight hours a day, at hours that have been decided in collaboration with the nursing team talking about like, when do we really need you? And when will you be able to do what you need to do? Because patients are off the unit having all kinds of stuff like in the morning until like lunchtime. So come in after lunch, hang out till just before dinner, have like a two hour break and then come back around 8:00 and stay until midnight and help us with those people who are restless and can't sleep in the evening. Seven days a week and looking at call bells. And are they being used and how often. Talking with nurses doing some semi structured interviews about what is your experience of having a massage therapist available so regularly, and it will be a two month study. So, for two full months, seven days a week, eight hours a day on what's called a gen med unit.
0:28:11.8 CC: So all kinds of different conditions, post surgical recovery, typically people with a length of stay around 7 to 10 days and looking at implementation models. So we're looking at how does this look when you have a massage therapist available this often, but also on the one unit, the patient will have to wait for a provider to write an order. So, that's called the opt-in unit. So, you can only have massage if your provider knows it's available and thinks that it works for you. So, it becomes incumbent upon us to teach the providers when and for whom this is valuable and then when that order for three massages runs out, then the patient has to advocate or the provider has to remember to write another order, which is how a lot of therapies work.
0:28:58.2 CC: And you can, I mean, I can see it from your faces, you're like, well, that's not going to work. We're like, yeah, I think that's what we'll find.
0:29:02.1 KJ: We think so.
0:29:03.6 CC: Right. But then the other unit will be an opt out unit and that unit, you, by virtue of being on that unit, massage therapy will be one of the things that you are offered and the massage therapist will come in, will talk to the charge nurse, find out who's on the unit that day, get the rundown by joining the team in rounds and huddle, and then be able to work with patients and look at a dose on each of these units will be three days. So on that unit, people will be able to get lots of doses theoretically, if they're available and there's a therapist available, they will be able to get massage. The folks on the opt in unit, there'll be some interruptions of care because we have to chase down their provider and get that order in the chart. So we're looking at a variety of aspects of how to make this look, but palliative trained therapists, massage therapist, providing massage and really measuring not only our impact on patient experience, but also our impact on the unit broadly and the other providers on that unit.
0:30:05.2 KJ: And while you're collecting the data, we always collect patient anecdotes and things like that. So we can do these case studies, or we can do sort of smaller bits, or use anecdotal evidence to kind of strengthen our case while we're waiting for the hardcore research to be published in the fancy journals, but I think it's really, really important to do and to just be, know that it's going to be a bit of a slog.
0:30:31.8 CC: Well, and I would say we would be incredibly remiss, if we left you with even the vaguest impression...
0:30:36.2 KJ: Oh, no.
0:30:37.4 CC: That Kerry Jordan and Carl Cates did this study.
0:30:40.7 KJ: Oh yeah, no.
0:30:40.8 CC: We had an incredible team of physicians and, we did all the data and we had it all sitting there and then the statistician who was supposed to analyze it left the facility where we were partnering. So we're sitting on two years of data that we thought was going to be real valuable and like eight months went by before we connected with Nikki Monk and her team Dr. Monk and her students came in and collated and analyzed the data and made it so that we could see what we could see. [chuckle] And without that this would be nothing. We wouldn't understand what to do with this information. And we just actually attended via Zoom, the PhD Defense of the student who did the bulk of the work on this. And she was so excited that we were there and we were so excited for her. And so just like the friendships and like camaraderie in the, there are probably easily 20 people who made this finally published paper a reality. And that's super fun because you don't have to know all the things. We know the massage things and people that we work with are like, let me teach you about this part of this so the next time we do a study, we can do it like this.
0:31:51.8 CC: So it can feel daunting. And if you're into immediate gratification, research maybe is not for you. But the people are so great and the experience of doing it and then being able to say, like, look at this thing we did and now people are writing to us and saying, thank you for this paper. Now we can do X, Y, Z, and that's why you do it. So I feel like the benefits are rich. And it is a slow walk. [laughter]
0:32:17.9 DB: I want to thank our guests today, Cal Cates and Kerry Jordan. For more information about the research study and the good work that they're doing in Healwell, visit Healwell.org. Thanks Cal, Kerry and Kristen.
0:32:30.1 CC: Thanks for having us. Always a pleasure.
0:32:31.8 KC: Thanks so much for being with us and for what you're doing for the profession. And listeners I wanna make sure you know that Cory Rivera on the HealWell Team put together an incredible infographic that takes all of the bits and pieces of this research study and puts them into a beautiful visual format for you. So visit the research page at healwell.org to see that and learn more about the study.
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