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Int. J. Environ. Res. Public Health 2015, 12, 5046-5060; doi:10.3390/ijerph120505046
International Journal of
Environmental Research and
Public Health
ISSN 1660-4601
www.mdpi.com/journal/ijerph
Article
Dog-Assisted Therapies and Activities in Rehabilitation
of Children with Cerebral Palsy and Physical and
Mental Disabilities
Dilek Tunçay Elmacı 1,† and Sibel Cevizci 2,†,*
1 Private Gercek ILGI Training and Rehabilitation Center, Perge Branch, Antalya 07200, Turkey;
E-Mail: dlktncylmc@gmail.com
2 School of Medicine, Public Health Department, Canakkale Onsekiz Mart University,
Canakkale 17100, Turkey
† These authors contributed equally to this work.
* Author to whom correspondence should be addressed; E-Mail: cevizci.sibel@gmail.com;
Tel.: +90-286-218-0018.
Received: 14 March 2015 / Accepted: 4 May 2015 / Published: 12 May 2015
Abstract: The aim of the present study was to evaluate dog-assisted therapies and
activities in the rehabilitation of children with cerebral palsy and physical and mental
disabilities who have difficulties in benefiting from well-being and health-improving
services. This descriptive-explanatory study was conducted in disabled children of various
ages between 2008 and 2011 by an experienced team in a private training and
rehabilitation center in Antalya (Turkey). In this study, five study groups were formed
among the children with physical and mental disabilities. During the therapy studies, three
dogs were used. For each therapy group, the goals for the children and therapist were
defined, and the activities were determined according to these goals. The entire study
process was followed using audio-records and photographs of patients. The expected
targets were reached in all study groups. The children who experienced fear, anxiety and
difficulties due to their disabilities in daily life learned to cope with their anxieties and
fears, set goals and make plans to achieve their aims. During this study, the children
improved their abilities to use their bodies according to their capabilities. Accordingly,
they improved their ability to develop empathy between themselves and a therapy dog, to
receive and present help, and to communicate. The results of the present study revealed
that dog-assisted therapies and activities can be a supportive method for routine
OPEN ACCESS
Int. J. Environ. Res. Public Health 2015, 12 5047
treatment procedures in the rehabilitation of children with cerebral palsy and physical and
mental disabilities.
Keywords: cerebral palsy; children; dog-assisted therapy; mental disability; physical disability
1. Introduction
Dog-assisted therapy is a model that is widely used in animal-assisted therapy (AAT). AAT is a
supportive, goal-oriented intervention that primarily results in human and animal interaction [1–6].
The positive-helpful bond that results from this interaction is the basis for the effect mechanism of
AAT. This curative effect comprises four basic mechanisms: psychological, emotional, playing, and
physical stimulation, according to Ballarini [4]. All of the mechanisms together demonstrate the
psychosomatic effects of the human-animal bond and the interaction during AAT and animal-assisted
activities [5,6]. Lafrance et al. reported that patients’ social and verbal behaviors may improve in the
presence of a therapy dog [7]. Additionally, AAT can be beneficial for the rehabilitation of life quality and
psycho-social behaviors [8]. Various researchers have reported that AAT should be considered when
planning the treatment of individuals with physical and mental disabilities such as dementia [1,9–12].
The interaction between an animal and human results in an increase in neurochemicals, which
initiates a decrease in blood pressure and induces relaxation. This relationship may be beneficial for
ameliorating agitated behavior and psychological symptoms of chronic diseases that involve physical
and mental disabilities. Richeson revealed that AAT can increase social interactions by decreasing the
agitated behaviors of patients with dementia [12]. Kongable et al. observed that a therapy dog increased
patients’ social behaviors, including smiling, laughing, looking, touching, and verbalizing [13].
Animals can act as transitional objects, which allows people to first establish a bond with them and
then extend this bond to people. Most studies have revealed that AAT, particularly dog therapy, has a
“calming effect” on patients with dementia and Alzheimer’s disease [14–17]. This bond can be helpful
as a communication link during therapy sessions and can decrease agitation behaviors.
Cerebral palsy (CP) is a non-progressive neurological condition that results in limitations in motor
function. Children with CP often require multiple health, rehabilitation, and community health care
services [18]. Almasri et al. examined the child, family and service characteristics of families that
include children with CP. They found that limited child gross motor function was a risk factor but that
the perception of family-centered services was a protective factor. Health care providers need to
understand this evidence and thereby provide better quality services for their patients [18].
It is well known that the incidence of aggression, agitation, social withdrawal, depression, and
psychotic disorders is growing in children with cerebral palsy and physical and mental disabilities.
These disorders are observed in rehabilitation centers and special care units and by staff and family
members of patients. Furthermore, environmental factors in rehabilitation centers and other health care
units have become barriers for therapy. Under these conditions, AAT and other animal activities may be
helpful in coping with these difficulties by presenting a different method and a more humanistic
therapy environment.
Int. J. Environ. Res. Public Health 2015, 12 5048
AAT aims to benefit from animal companionship during a targeted therapy, to achieve optimal
results in patients, and to support the therapy. It provides positive effects, such as adapting to stressful
situations and hospital environments; decreasing anxiety, stress, pain and blood pressure; and
increasing mobility and muscle activity. Guiding animals increase physical activity, help prevent
mental states such as loneliness and depression, improve daily life activities and provide social support
by increasing quality of life [19–24].
Why Do We Need a New Therapy Model for the Rehabilitation of Children with CP and
Other Disabilities?
Physical therapy (PT) plays a central role in managing CP; it focuses on function, movement, and
the optimal use of a child's potential. Physical therapists use physical approaches to promote, maintain
and restore the physical, psychological and social well-being of disabled people. PT interventions are
preferred increasingly by therapists, doctors and parents [25]. However, we need to understand the
effects of PT interventions for evidence-based decision-making. AAT is a widely used PT intervention
that is currently supported by limited evidence. Substantial research has investigated the physical and
social effects of equine-assisted therapies to improve the well-being (social, cognitive, psychosocial,
and physical) of individuals with CP [26,27]. Equine-assisted therapy studies have indicated that
parents of children with CP were satisfied in categories such as connection, developmental gains,
socioemotional gains, and personal gains [26,27]. However, there is a gap in showing the synergistic
effect of AAT and occupational therapy goals in children with cerebral palsy and physical and mental
disabilities. The current study aimed to evaluate the effects of dog-assisted therapy on occupational
therapy needs in the rehabilitation of children with cerebral palsy and physical and mental disabilities.
2. Methods
This qualitative study was conducted in a private training and rehabilitation center in Antalya under
the supervision of an experienced team between 2008 and 2011. A total of 10 patients with various
disabilities were enrolled in the study. We used the mechanism of action of AAT, as identified by
Ballarini [4] and The Lifestyle Performance Model developed by Velde and Fidler [28], to evaluate the
effects of occupational therapy in our patients. In the current study, therapy sessions with five study
groups were recorded by a therapist using videotaping and photography. We used qualitative
techniques, including interviews and observation, for study evaluation.
2.1. Materials
2.1.1. AAT Mechanism of Action
The mechanism of action of AAT is based on positive-healing bonding, which occurs in human-animal
interactions, and psychological, emotional, playing and physical mechanisms cause physical and
biochemical reactions by activating this bond [4,29]. The primary structures that activate these
mechanisms in patients should be structured according to four theories: touching, biophilia, learning
and cognitive theories [30]. In animal-assisted therapy, all types of applications, which are performed
according to these four theories, can provide various benefits (Figure 1).
Int. J. Environ. Res. Public Health 2015, 12 5049
Figure 1. Mechanism of action of AAT and theories for the therapies.
2.1.2. Occupational Therapy and the Lifestyle Performance Model
Occupational therapists believe that AAT can transfer the internal responses of the patient to the
external environment. During the AAT process, purposeful activities can be useful for gaining skills or
actions that satisfy personal needs [31]. For example, if a patient enjoys doing something such as
gardening, the occupational therapist could include gardening in therapy to help the patient recover
their impaired body functions or skills. Including a purposeful activity in the occupational therapy
maximizes the patient’s benefits from therapy [31,32]. We used a purposeful activity for each patient
in addition to a therapy dog during occupational and physical therapy in the current study.
Velde et al. revealed that AAT is a suitable method for occupational therapy and stated that The
Lifestyle Performance Model can be used for the analysis and interpretation of positive outcomes of
animal-assisted therapy in an occupational therapy context [31]. The Lifestyle Performance Model
consists of five domains that are compatible with AAT. These domains are intrinsic gratification,
societal contribution, reciprocal interpersonal relationships, self-care and self-maintenance and
responsive environment. The first four domains are related to human performance. A responsive
environment facilitates pet-related activities [28].
2.2. Study Design
We established five study groups with therapy dogs according to the therapists’ goals and patient
needs to evaluate the effect of AAT on the rehabilitation and wellbeing of children with various
physical and mental disabilities (Table 1). Three different dogs were used in the therapy process.
Int. J. Environ. Res. Public Health 2015, 12 5050
Table 1. Characteristics of study participants.
No of Study Group Age of Patients Number of Patients Gender Disability Type
I 9, 14, 23 3 2 male and one female Mental and
physical disabilities
II 4 1 Male
Cerebral palsy
and hemiparesis
III 5 1 Male Bilateral cerebral palsy
IV 22, 11, 8, 18 4 2 male and 2 female Mental and
physical disabilities
V 5 1 Male
Spastic type
of cerebral palsy
We identified the occupational needs of each patient through an interview with their parents and
observed their physical and social disabilities. We developed each study group to improve the
occupational needs of patients based on The Lifestyle Performance Model and the mechanism of
action of AAT. We included each patient’s occupational needs, the therapists’ goals, and a dog-assisted
therapy, consistent with The Lifestyle Performance Model (Table 2).
Table 2. Descriptions of study groups.
No of Study
Group
Patients’
Occupational Needs
Activity with
Dog-Assisted Therapy
The Lifestyle
Performance Model Expected Therapy Results
I
Reduction in fear
from medical
interventions, anxiety
and stress in the
hospital environment
Health control activities
with therapy dog. These
activities were planned
to trigger the touching,
learning and cognitive
mechanisms of AAT
Internal emotional
gratification, Social
contribution, Reciprocal
relationship
Improving skills of children,
Increasing self-confidence,
Decreasing fear and anxiety
II
Use the right side of
his body, Increase
active motility on the
same side
Giving cold yogurt to
therapy dog using the
child’s foot to create a
vibration from
sequentially warm
tongue of the dog,
Feeding the dog and
playing football with the
dog to do active
movements.
Intrinsic gratification,
Self-care and
self-maintenance,
Reciprocal relationship,
Responsive environment
Increasing motor learning
with high motivation,
Relaxation of general body,
Decreasing body tonus and
gaining a general feeling
of comfort
III
Increasing muscle
activities (hand skills,
standing up in balance)
Writing, painting,
Feeding therapy dog
Internal emotional
gratification, Social
contribution, Reciprocal
relationship, Responsive
environment
Increasing the motivation of
the child, Improving body
balance and skills requiring
small muscle movements
Int. J. Environ. Res. Public Health 2015, 12 5051
Table 2. Cont.
No of Study
Group
Patients’
Occupational Needs
Activity with
Dog-Assisted Therapy
The Lifestyle
Performance Model Expected Therapy Results
IV
Increasing
communication,
planning and
empathy skills
Birthday celebration
activities (baking a cake
and organizing a party)
with the therapy dog
Societal contribution,
Reciprocal interpersonal
relationships, Responsive
environment, Self-care and
self-maintenance
The goal of the therapist was
to improve the empathy skills
of children with people and
living creatures around them,
communication skills; help
gain team spirit and the skill
of being a team member
and provide a feeling
of belonging
V
Decreasing the risk of
contracture
development,
Increasing mobility to
prevent constipation
Relaxation studies for
muscle tonus in lower
and upper extremities
with the therapy dog
Responsive environment,
Self-care and
self-maintenance,
Societal contribution
Regulating muscle tonus and
preventing contracture,
Increasing active movements
2.3. Ethics
The study was planned and performed after the children’s physicians confirmed that these activities
were safe; the patients were then directed to the rehabilitation center. The entire study process was
explained to the parents and children. Written signed consent was obtained from the parents who
confirmed that their child could participate in this study. The present study followed the principles of
the Declaration of Helsinki. The therapy dogs’ health states and therapy compliance were confirmed,
and they were approved by veterinary surgeons and AAT experts.
3. Results
3.1. Group I
Two male subjects and one female subject, who had different disabilities and were aged 9, 14,
or 23 years, underwent dog-assisted therapy in March 2011. Special children are exposed to many
different medical interventions beginning in infancy and continuing throughout their lives.
Therefore, simple medical controls such as vaccinations and going to the doctor’s office may frighten
them, and they become anxious. Being in the stressful hospital environment can negatively affect the
children themselves, their family members, and healthcare personnel.
The goal of the children in this group was to prepare Komur (therapy dog) for the health check that
it would attend shortly. The goal of the therapist was to improve the children’s ability to cope with
their own anxieties and fears; to define a goal; to plan; and to improve their skills to implement the
plan. During these practices, children could improve their skills to use their own bodies according to
their capabilities; to develop empathy with themselves and with a different living being; to improve
their skills of receiving and presenting help; and to develop their communication skills (Figure 2).
Int. J. Environ. Res. Public Health 2015, 12 5052
Figure 2. Dog-assisted therapies and activities in children of various ages and mental and
physical disabilities who were frightened by health checks.
The children knew that Komur was frightened by the veterinary surgeon. They thought that if they
played this game with their friend (Komur), they would encourage Komur and the dog would be less
frightened when it had to go to the health check. They applied many simple examinations on Komur.
They used toys and real materials that were present in Komur’s health bag. They measured the dog’s
temperature, listened to its abdomen, listened to its lungs using a stethoscope, performed vaccination
by using an injector, and bandaged its feet by using surgical dressings. At the end of the study, the
children thought that they had achieved their goals. Additionally, the therapist achieved the primary
goals of the group according to the various needs of each child.
3.2. Group II
The second study group included a 4-year-old boy who had cerebral palsy and hemiparesis, and the
therapy was performed in July 2004. Applications to use the right side of his body were performed
with the therapy dog. He had difficulty in using the right side of his body. Muscle tonus was also
increased on the same side. He was faced with muscle shortening and deformity formation risks in the
lower and upper extremities, where the muscle tonus was high. Moreover, he preferred to not use the
right side of his body. His awareness of the right side of his body was quite low. He was performing
actions by using only the left side of his body while moving and defining movement plans.
In the present study, the goal of the therapist was to help increase the muscle tonus regulation by
providing various sensorial stimulations on the right side of his body and to increase the active motility
of that side. Preventing contracture and providing coordination between the hemispheres of the brain
were additional goals. The goal of the child was to give his dog yogurt and enjoy the experience.
Cold yogurt followed by the warm tongue of the dog, as well as the vibration triggered by the dog’s
licking, aided the decreased muscle tonus and increased the awareness of that extremity (Figure 3).
Increasing the circulation to that part of the body provided warming for the extremity. By causing
the extremity to relax, the general body tonus started to decrease, and a general feeling of comfort was
gained. However, the decreased body tonus and the feeling of comfort were temporary. Therefore,
performing active movements immediately after this gain was quite important, and these movements
eased motor learning. A child who would like to feed or play football with a dog should start to
perform the active movements repeatedly. Therefore, the repetition requirement for motor learning is
developed spontaneously, without forcing and with high motivation.
Int. J. Environ. Res. Public Health 2015, 12 5053
Figure 3. Dog-assisted therapies and activities in a child with cerebral palsy and hemiparesis.
3.3. Group III
In the third group, a 5-year-old boy participated in therapy in February 2008. The boy had bilateral
cerebral palsy, and his right side was affected more than his left. Muscle activities such as hand
movements and balanced standing were performed with the therapy dog. He received a good training
report because he came to the center for the entire year and performed his homework. He received his
training report and a testimonial that could be painted from his beloved friend Komur, who helped him
while he was studying, as shown in Figure 4.
Figure 4. Dog-assisted therapies and activities in a child with bilateral cerebral palsy.
The boy was delighted with his report and showed the dog how well he could paint. The boy also
intermittently gave some of the pretzels that he was eating to Komur. In this group, the goal of the
therapist was to increase the motivation of the child, who was trying to perform activities that
challenged him both physically and mentally due to his small age and to provide continuity of therapy
by facilitating the acceptance of future studies. During the activities, the goal was to stand with
balance, and the boy improved the skills that required small muscle movements while he was standing.
3.4. Group IV
The fourth group included a 22-year-old girl, an 11-year-old blind girl, and 8- and 18-year-old boys
with various mental and physical characteristics (one of them had both severe physical disability and
blindness); the therapy was conducted in September 2012. The therapy dog (Joey) and its friends were
included in this group. Various activities were performed to improve communication, planning and
Int. J. Environ. Res. Public Health 2015, 12 5054
empathy skills with the therapy dog. Birthday celebration activities were performed. The goal of the
children was to bake a cake and organize a party for Joey. For this purpose, they planned to invite
people whom Joey loved and its dog friends to the party.
Joey was a 9-year-old male golden Labrador half-breed who was born in the USA and had been to
Israel, Istanbul, and Antalya. The dog initially guarded the therapy center, but it was later trained to
become a therapy dog after its veterinarian watched it perform rehabilitation activities. According to
the physical therapist, Joey was a clever therapy dog. After the dog had finished training, it started to
work with physical therapist, accompanied by his vet. The physical therapist said that the dog had
changed their lives at the center as well as the lives of children and their parents who came to therapy.
The goal of the therapist was to improve the children’s empathy skills with people and living
creatures around them and communication skills and to help them gain team spirit, the skill of being a
team member, and a feeling of belonging. As the dog helped the children experience various smells,
textures, and consistencies in a sensorial fashion, the children could improve their skills to use their
bodies according to their physical capabilities and to improve their physical and mental coordination,
motor planning skills, goal definition and goal-oriented planning skills. Therefore, their effort would
result in a product and a successful process.
The children baked a birthday cake for Joey, Komur and its friend visitor dog, Gaia. They brought
all of the ingredients for the cake themselves. While using the ingredients, they smelled, touched,
kneaded, and talked about them. They planned how to prepare the cake, and they blew out the candles
on this cake for Joey and its friends and cut the cake. Then, they sang a happy birthday song for them;
they danced while listening to music, and as a result, they achieved their goals (Figure 5).
Figure 5. Dog-assisted therapies and activities in children with mental and physical disabilities.
The dogs also achieved their goals, and they ate a cake with fish and rice. The therapist achieved
her goals, which she had pre-specified for each child separately according to their needs. Other people
were invited and participated in the birthday party. During the therapy sessions, the dog is required to
not make contact with or play with the child all of the time. By relying only on its presence, many
activities with pre-specified goals and achievements can be planned. The children continued to feel
Joey’s presence after its death, and they wrote letters, drew pictures for Joey, and tried to continue to live
with it.
Int. J. Environ. Res. Public Health 2015, 12 5055
3.5. Group V
The fifth group included a 5-year-old boy with the spastic type of cerebral palsy, which affected
him bilaterally. He was a child with intense muscle tonus in his upper and lower extremities, he had
limited active movements, and he was at high risk for contracture development. Because he was
inactive, he had frequent constipation issues. Relaxation studies were performed for muscle tonus in
his lower and upper extremities with the therapy dog. In this group, the goal of the child was to give
lunch to his friend Komur by using his hands and feet and to put Komur to sleep by lying down with it,
as shown in Figure 6.
Figure 6. Relaxation practices in a child with spastic type of cerebral palsy accompanied
by the therapy dog.
The boy thought that Komur had not yet had its lunch nap. The goal of the therapist was to help the
boy regulate his muscle tonus and thereby prevent contracture development. Active movements of his
body were increased, and his bowel motility regulation was supported by using the body temperature
and body oscillations of the dog.
4. Discussion
In the present study, the groups underwent therapy activities, and the observed changes in children
were recorded during therapy. These therapy groups were the first to scientifically apply dog-assisted
therapy under the supervision of an experienced team. We found consistent results with the literature.
The changes observed at baseline, during and after therapies were similar to those observed in previous
studies [33,34]. Barol observed and recorded processes in an autistic male child after applying
dog-assisted therapy [34]. Before the application, the therapists and the investigator held a meeting and
discussed which dog therapy activities would provide motivation, which included improving
hand-skills, awareness, self-esteem, and behaviors such as playing with a ball, cutting with scissors,
feeding (serving), tracking, following, bringing water to the dog, and brushing the dog. At the end of
therapy, improvements or disappearances of temper tantrums; improvements in focusing on something
by playing games, in selection ability, in independent behaviors, in decision making, in attention;
increases in awareness, communication desire, being sensitive of surroundings, being happy, and
Int. J. Environ. Res. Public Health 2015, 12 5056
improvements in behaviors and moods were observed [34]. In our study, similar improvements were
also found in children with cerebral palsy during the treatment processes.
Dog-assisted therapies and the activities conducted on patient groups have substantially facilitated
treatment compliance, particularly in children [35,36]. Previous studies investigating various health
problems have shown that animal-assisted therapies and activities may be helpful during routine
therapy by achieving optimal results and supporting patient therapy [37–42]. Although many studies
have examined physiological and motor outcomes in children with cerebral palsy during equine-assisted
therapy [43–47], few studies have investigated the performance of dog-assisted therapies and activities
in children with cerebral palsy or mental or other physical disabilities [34–36]. In the present study,
dog-assisted therapies and activities were performed in Turkey, under the supervision of an
experienced team, for children with cerebral palsy and physical and mental disabilities. The outcomes
were similar to those found in the literature. Our results suggest that dog-assisted activities and
therapies can be a supportive method for routine treatment in the rehabilitation of children with
cerebral palsy and physical or mental disabilities.
Forbes and Marxen found that occupational therapy with a therapy dog increased the enjoyment of
and participation in the therapy process of a child with CP. They observed that a therapist utilized both
her own skills and the skills of a dog when the child is motivated by the therapy dog [48]. In our study,
visual analysis revealed that occupational and physical therapy with a therapy dog increased children's
social adjustment and adaptation to therapy process. Overall, the therapy dog created a more enjoyable,
safe and stress-free therapy environment for all individuals, particularly for the patients and therapists
who participated in the current study.
Comparative studies of various diseases would provide more detailed information. Studies in this
field, which specifically evaluate the effect of animal-assisted therapies on improvements of life quality
and the physical, mental and social health of children with physical and mental disabilities or chronic
diseases, will provide supportive information and are important to improve rehabilitation [5,6,49].
Additionally, the concept of public health requires individuals to participate in rehabilitation and
long-term health care throughout their lifespan to improve their quality of life.
Limitations
This study has some limitations. First, the study is limited to 10 cases in Antalya. We could not
compare our results with those a control group that included patients working without a therapy dog.
Further studies should assess whether physical and occupational therapy with a therapy dog in children
with disabilities has a superior effect compared with other therapy models. Second, data collection was
limited to interviews and observations. Third, the authors of this article had experience using physical
therapy and chose to only apply dog-assisted therapy. Fourth, the lack of research literature
investigating dog-assisted therapy in children with physical and mental disabilities from a physical and
occupational therapy perspective did not allow us to compare our findings with other research.
Finally, this study was limited by the pre-selection of many participants by the physical therapy center,
Private Gercek ILGI Training and Rehabilitation, Antalya. However, if we followed our participants
during their daily activities after dog-assisted therapy, our findings could have reflected daily life.
Int. J. Environ. Res. Public Health 2015, 12 5057
5. Conclusions
Despite these limitations, our study findings indicated that children who experienced fear, anxiety
and difficulties due to their disabilities in daily life learned to cope with their anxieties and fears and to
set goals and create plans to achieve their aims during therapy. Children improved their abilities to use
their bodies according to their capabilities. Accordingly, they improved their skills in developing
empathy between themselves and a therapy dog, receiving and presenting help, and improving
communication skills. The results of the present study revealed that dog-assisted therapies and
activities can be a supportive method for routine treatment in the rehabilitation of children with
cerebral palsy and physical and mental disabilities.
In conclusion, the individual and social benefits gained by dog-assisted therapy may aid in the
prevention, improvement and development of children with various disabilities. Dog-assisted therapy
can be developed and used as a supportive tool in veterinary public health to help the rehabilitation of
children with disabilities.
Acknowledgments
The authors thank all of the patients and their parents for their participation in the present study as
well as the professional staff at the rehabilitation center.
Author Contributions
Dilek Tuncay Elmaci and Sibel Cevizci conceived the study. Dilek Tuncay Elmaci and
Sibel Cevizci contributed to the design of the study methods. Dilek Tuncay Elmaci was involved in
field work and data collection. Sibel Cevizci contributed to the data interpretation. Dilek Tuncay Elmaci
and Sibel Cevizci contributed to the initial manuscript draft. All authors made editorial contributions to
the final paper.
Conflicts of Interest
The authors declare no conflict of interest.
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