Managing Shoulder Pain - Allied Health Ed
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Treatment and Rehabilitation of Orthopedic Shoulder Conditions
Holt Physical Therapy & Performance Trainingjaimeholtpt@gmail.com
Twitter: @HOLTPT1
Provider Disclaimer
• Allied Health Education and the presenter of this webinar do not have any financial or other associations
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displayed in this presentation. • There was no commercial support for this presentation.
• The views expressed in this presentation are the views and opinions of the presenter.
• Participants must use discretion when using the information contained in this presentation.
Biography
• East Carolina University
• BS Exercise Phys 1995
• MS Ad. Phys Ed. 1997
• MPT Physical Therapy 1999
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Biography
APTA Sports Certified
Specialist
NSCA Certified Strength and
Conditioning Specialist
Owner and Sports
Orthopaedic PT at Holt Physical Therapy &
Performance Training
PT Consultant NHL Carolina
Hurricanes 2007-2014
Mentors• Pete Friesen
• Doug Geiger
• Gary Gray
• Walt Jenkins
• Kevin Wilk
• Co-workers
• Patients
Outline• Etiology and Incidence of Shoulder Injuries
• Shoulder Anatomy
• Common Shoulder Injuries
• Shoulder Impingement
• Adhesive Capsulitis
• Bicipital Tendonosis
• Rotator Cuff Tendonitis
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Outline
• Rotator Cuff Repair Rehab
• Multidirectional Instability
• GIRDs
• Labral Repairs
• Non-operative Treatment
• Controlling Pain and Inflamation
Outline• Restoring Normal Motion
• Restoring Functional Strength
• Strengthening for the Overhead Athlete
• FUN: Ther Ex Videos
• Physical/Surgical Interventions
• Conclusion
Etiology and Incidence of Shoulder Injuries
• Traumatic injuries
• Chronic injuries
• Bony deformities
• Poor posture
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Etiology and Incidence of Shoulder Injuries
• Neer: 40% never performed
strenuous physical work
• 50% no recollection of
shoulder trauma
• 70% of defects occur in
sedetary people doing light work
• 2/3 of cases occur in males
The Cause of
Shoulder Pain?
• MRI of asymptomatic shoulders
• 4% incidence in 19-39 yo
• 26% in subjects > 60 yo
• So is the cuff tear causing the patient’s pain?
Shoulder Anatomy
Bony
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Shoulder Bony
Anatomy
Shoulder Anatomy
Shoulder Anatomy
Muscles
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Shoulder Anatomy
Rotator Cuff
Recent ResearchArthroscopic Capsulolabral Reconstruction for Posterior Shoulder Instability in Patients 18 years Old or Younger
• 22 athletes unidirectional instability treated with posterior capsulolabral reconstruction 63 mo follow up
• 92% of shoulders were still stable
• 67% return to sport at the same level
Recent ResearchFactors Affecting Satisfaction and Shoulder Function in
Patients With a Recurrent Rotator Cuff Tear: JBJS 1/2014
• It is widely accepted that most patients treated with rotator cuff repair do well regardless of the integrity of the repair
• 26% had a re-tear
• Three age groups: < 55 years, 55-65, > 65
• ASES and SST scores in re-tear group were significantly lower
• In patients with a re-tear, younger age, lower education
level and a workers comp claim were associated with poorer outcomes
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Recent ResearchEfficacy of a static progressive stretch device as an adjunct to
physical therapy in treating adhesive capsulitis of the shoulder: a
prospective, randomized study: Physiotherapy 9/2014
• Compared static progressive stretch device plus traditional
therapy with traditional therapy alone for treatment of adhesive capsulitis
• Each group had 3 sessions per week for 4 weeks
• Measured AROM/PROM abduction and PROM ER, DASH and pain scale
• Results continued to improve 12 months later in experimental group
Recent ResearchRehabilitation following rotator cuff repair: a systematic
review: Shoulder and Elbow January 2015
• Researched 12 studies
• Strong evidence that early initiation of rehabilitation does not
adversely affect clinical outcome
• Strong evidence that initiation of functional
loading early in the rehab program does not adversely affect clinical outcome
Role of the Rotator
Cuff• provide stability through force
couples and aid in motion of the GH joint
• humeral head depressing effect that counteracts the
superior pull of the deltoid
• maintain proper position of
the GH head within the glenoid
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Role of the Scapula
• Position glenoid fossa to
align with humeral head
• Fossa is at a 30 deg angle
• Advantageous length tension relationship of
muscles
• Stable base of support:
crucial to prevent injuries, improve performance
GEM
• Look for pec minor
tightness
• can cause protraction and
forward tipping of the scapula
• CFM to pec minor is very effective
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Attachments on ScapulaSubscapularisSupraspinatus
InfraspinatusTeres Minor
Teres MajorSerratus Anterior
Latissimus DorsiDeltoid
TrapeziusLevator Scapula
RhomboidsTriceps
Pec MinorCoracobrachialis
Biceps brachiiOmohyoid
Acromion Types
Born to Fail?
• Of patients with RTC tears:
• 70% have Type 3
• 27% have Type 2
• 3% have Type 1
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Common Shoulder
Injuries• Shoulder Impingement
• Adhesive Capsulitis
• Bicipital Tendonosis
• Rotator Cuff Tendonitis
• Rotator Cuff Tear
• Multi-directional Instability
• GIRDs
• Labral Repairs
Shoulder Impingement
• Subacromial Impingement
• Internal (posterior) Impingement
Subacromial
Impingement• Subacromial bursa and
supraspinatus tendon gets pinched between humeral
head and coracoacromial arch
• long biceps tendon may also be impinged
• increased pressures with increased shoulder elevation
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Painful Arc
• usually preceded and
followed by normal, painfree ROM
• arc usually between 70-120 degrees
• lessens as symptoms improve and ER strength
improves
Subacromial
Impingement (video)
• Treatment:
• Postural re-training
• Scapular re-positioning
• Posterior Cuff strengthening
• Sleeper Stretch
Prone Row
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Prone Row w/ ER
Prone T
Prone Extension
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Prone Y
Bentover Row
Bentover T
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Bentover Extension
Bentover Y
RTC Endurance (video)
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Subacromial
Impingement
• Surgical Options:
• Distal clavicle excision and subacromial decompression
• Very effective, easy rehab
• Usually performed on Type 2
and 3 acromions
Posterior Impingement
• also known as internal
impingement
• infraspinatus and teres minor
pinch between humeral head and posterior glenoid rim
during abduction and ER
• associated with posterior
capsular contracture (GIRDS)
Posterior Impingement
• Mainly seen in overhead
athletes but occurs in weight lifters as well due to poor
lifting technique
• MOI is shoulder extension,
abduction and ER
• ie. throwing a ball overhand
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S/S of Posterior
Impingement• Pain with excessive ER at
90deg abd
• excessive ER and limited IR
• Posterior shoulder tenderness
• ER and empty can weakness
• Scapular dyskinesia
• Hx of recurrent symptoms
Adhesive Capsulitis
• Effects more females than
males
• 2nd most common shoulder
condition in 40-60yo females
• Incidence among DM 10-
20%
• 15% will develop symptoms
in other shoulder within 1 year
Adhesive Capsulitis
• Abnormal Capsular
Thickening
• Produces stiffness and limits
motion
• Inflammation produces pain
with movement
• Usually insidious onset
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Stages of Adhesive
Capsulitis
• Early Painful Stage: (Freezing)
last 2 to 9 months
• Stiffening Stage: (Freezing) last 4
to 12 months
• Recovery Stage: (Thawing) lasts
5 to 24 months
The Cumulative Injury Cycle
Adhesive Capsulitis
Stretches• Cane Flexion
• Cane External Rotation
• Horizontal Adduction
• Towel IR Stretch
• 5-10 minutes 3x/day for 6-12
weeks
• symptoms improve in 90%
• Griggs et al JBJS 2000
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Cane Flexion
Cane ER
Horizontal Adduction
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Towel IR Stretch
Snow Angels
Non-op Results
• Levine et al JSES, 2007
• 105 shoulders
• only 10 required surgery
• All given NSAIDs
• 48% had steroid injection
• Flexion 118 to 164: External Rotation 26 to 59
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Manipulation Under
Anesthesia• Indication: Primary Frozen Shoulder
• Contraindications
• Post fracture
• Post Surgical
• Severe Osteopenia
• RSD
• Diabetes??
MUA Results
• Farrell et al, JSES, 2005
• 26 shoulders
• Min 15 year f/u
• Mean SST 9.5, ASES 80
• durable results at long term
follow up
Arthroscopic Capsular
Release
• Combined with manipulation
• manipulate before arthroscopic release
• may decrease risk of intra articular injury (Loew,
JSES, 2005)
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Capsular Release
Results• Not many new studies
indicating decreased usage
• due to medical costs??
• Ogilvie-Harris 1997 n=38
• 15/20 with capsular release
had excellent result compared with 7/18 with
manipulation alone
Treating the Stiff Shoulder
• Determine if capsular or muscular splinting
• Treat dominating problem first if both are present
• Control pain using cryotherapy
• Be patient, and encourage patient
• Can be frustrating for both patient and therapist
• Chronic pain is depressing
GEM
• Try PROM with EMPI 300PV
stim unit on TENS
• Turn it up to sensory
threshold (adjust as needed)
• Be careful and hand and pad
placement
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Bicipital Tendonosis(video)
• unless a traumatic event, it is
due to poor balance and mechanics of the rotator cuff
• Special Tests:
• MOI and palpation may be
best one!
Bicipital Tendonosis
• Pain in the “groove”
• Rarely a bicep tendon issue, usually secondary to another
condition
• Loss of dynamic stability
Biceps Tendonosis
• treatment: emphasize source
of the pain, not just the pain
• NSAIDs
• cuff strengthening
• modalities
• cross friction massage
• activity modification
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Rotator Cuff
Tendonitis
• usually develops over time
with poor RTC function
• possible spurring
• subacromial impingement and OH activities
• left untreated will result in a tear
Subacromial Spur
Types of RTC tears
• partial thickness
• full thickness
• undersurface
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Rotator Cuff Tears• 70% of RTC tears occur in sedentary individuals due to
degeneration
• Partial thickness tears can progress to full thickness tears withut
activity modification
• RTC is a tensile tissue
• Full thickness tears will retract with time and be more problematic in surgery and function
• Undersurface tears are on the surface of the cuff that attach to the tuberosity
Clinical Presentation
• PAIN
• night pain or pain w activity
• partial thickness more painful than full thickness
• STIFFNESS
• posterior capsule tightness
• WEAKNESS
• uncommon because adjacent cuff fibers pick up the load
Clinical Tests for RTC
Tear
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Clinical Tests for RTC
Tears
• According to Murrell and
Walton, 98% chance of RTC if:
• All 3 tests are positive
• or 2 out of 3 if 60+ yo
Classification of Cuff
Tears• Small: <1cm
• Medium: 1 to 3 cm
• Large: 3 to 5 cm
• Massive: >5cm\
• American Academy of
Orthopedic Surgeons
Rotator Cuff Repair
Rehab Factors
• COMMUNICATION WITH
MD IS CRITICAL!!
• This determines how
aggressive you can be
• All cuff repairs are not the
same
• surgical history
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Wolff’s Law
• a law according to which
biologic systems such as hard and soft tissues become
distorted in direct correlation to the amount of stress
imposed upon them.
• Jonas: Mosby's Dictionary of
Complementary and Alternative Medicine. (c)
2005, Elsevier.
Rotator Cuff Repair
Rehab Factors
• Type of Repair: scope vs mini open
• Tissue Quality: soft tissue, bony quality, fixation strength
• Size of Tear
• Location of Tear
• Surrounding Tissue Quality:
GEM
•The incision is a mirror image of what
type of healing is going on inside the
shoulder.
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Rotator Cuff Repair
Rehab Factors
• Mechanism of Failure: traumatic vs. gradual progression
• Patient Variables: activity level, motivation, worker’s comp
• Rehab Potiential: clinic vs. HEP
• MD Philosophy: conservative vs aggressive
• Type of Tear: horizontal vs. vertical vs. avulsion
Rotator Cuff Repair
Rehab
• Maintain Integrity of Repair
• Re-establish GH jt passive mobility
• Re-establish muscular balances
• Decrease pain and compensatory patterns
• Improve dynamic stability
Take Home Message
• Rehab must be based on type of surgery, tissue quality
and size of tear
• Communication between surgeon and PT is critical
• Gradual restoration of motion
• Resume dynamic stability via ER/IR ratios and scapula
• Do not exercise through shoulder shrug sign
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Take Home Message
• Muscular balance between ER/IR
• Be careful with “empty can” exercise
• Do not overstress healing tissues
• Marathon not a sprint!
GEM
• Increase 1 pound per week provided painless and no compensatory substitution patterns
Multidirectional
Instability
• What helps stabilize GH
joint?
• GHL complex is taught at
different shoulder positions
• depth of the fossa enhanced
by labrum, as much as 50%
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Multidirectional
Instability
• Common in swimmers,
dancers and gymnasts
• Size of RTC interval plays a
role as well
Shoulder Instability
• TUBS
• Traumatic
• Unidirectional
• Bankart Lesion
• Surgery
Shoulder Instability
• AMBRI
• Atraumatic Onset
• Multi-directional in nature
• Bilateral
• Rehabilitation
• Inferior Capsular Shift
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Shoulder Instability
• respond well to rehab
• technique is critical!
• strengthen scapular
stabilizers and RTC muscles to provide dynamic stability
• proprioception exercises
GEM
• Most people strengthen what they see in the mirror
• Must keep rotator cuff strength gains at the same
progression as power muscles
Rehab Principles
• Early CONTROLLED motion
• Regain static and dynamic stability
• Restore GH joint proprioception
• Stable and supportive scapula
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Rehab Principles
• Dynamic Functional Control
• Perturbation (Kevin Wilk)
• Increase Muscular Endurance
• Sport Specific Activities
Video
Surgical Options
• Bankart Repair
• Capsular Shift
• Putti-Platt
• Thermal capsulorrhaphy
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Gross Internal
Rotation Deficit
• Stabilize the scapula and
measure IR bilaterally
• Compare involved side wtih
uninvolved
Gross Internal
Rotation Deficit (GIRD)
• IR deficit compared to opposite
• greater than 20 degrees indicated shoulder at risk
• Burkhardt, Morgan, Kibler 1998
Gross Internal
Rotation Deficit• GIRD ROM data correlated to
shoulder and/or elbow injuries
• 3 year study on Tampa Bay
organization pitchers
• If greater than 20 deg diff, 5x
more likely to develop RTC injury
• Red flagged and put in daily PT
with IR stretching
• Wilk, Porterfield, Harker, Macrina,
2007
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Total Motion Concept
• Acceptable: 170-185
• Caution: 185-200
• Monitor Carefully: >200
Sleeper Stretch• Mike Reinhold: Controversial!
• similar to Hawkins Impingement Test
Sleeper Stretch (video)
• Bottom line is that it is a very
effective way to decrease posterior capsular tightness
• Must be done carefully to pain free end range and in
correct position
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SLAP Lesions
• superior labrum anterior and
posterior
• MOI: sudden downward force
on a supinated outstretched UE or repetitive microtrauma
(OH athlete)
• average time from onset of
sx to dx is 2.5 years
Special Tests• Speed’s Test
• Grind Test
• Clunk Test
• Crank Test
• Active Compression Test
• Biceps Load
• Pain Provocation
Classification of SLAP
• Type 1: Superior labrum frayed
• Type 2: Superior labrum frayed/detatched
• Type 3: Bucket handle tear, displaced
• Type 4: Bucket handle tear, biceps involvement
• Type 5: Ant/inf Bankart lesion w/ separation of biceps tendon
• Type 6: Unstable flap tear of labrum and biceps tendon separation
• Type 7: Superior labrum-biceps tnedon separation extends beneath MGH
ligament
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Treatment for SLAP
• NSAIDs, cortisone injection
• RTC and periscapular rehab
• limit strengthening to 90 deg
• Surgery
Type 1/3 Rehab
• Immediate ROM exercises
• Full PROM by 2 weeks
• Active ROM week 2
• Isotonics at 2 weeks
• Focus on dynamic stability
• Advance strength at weeks 4-6
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Type 2/4 Rehab
• Immobilizer for 3-4 weeks
• No motion above 90 deg 4 weeks
• Full ROM at Week 8
• No isolated biceps for 6-8 weeks
• Isotonics at Weeks 4-6
• Advance strength week 10-12
GEM
• Only thing worse than the patient not doing their HEP is them doing it incorrectly
Non-operative
Treatment
• Physical Therapy
• Controlling pain and inflammation
• Restoring normal range of motion
• Restoring functional strength
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Controlling Pain and
Inflammation
• Rest
• Ice
• Anti-inflammatories
• Therapeutic Ultrasound
• Ice and electrical stimulation
Restoring Normal
Motion• Joint mobilizations
• Soft tissue mobilizations
• Passive ROM
• Active assistive ROM
• Active ROM
• Resistive ROM
Joint Mobilizations (video)
Shoulder PROM (video)
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AAROM/AROM
Resisted ROM (video)
GEM
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Gem
• Can increase shoulder
flexion ROM by releasing the lats but also by releasing the
ispilateral psoas.
• body builder/cross fit type
athletes
Restoring Functional
Strength• Functional Training:
• ROM
• Strength
• Proprioception
• Endurance
• Stabilization
Restoring Functional
Strength
• Primary goal is to enhance
dynamic functional joint stability
• Periscapular strengthening
• Rotator cuff strengthening
• Best 3 RTC strengthening exercises
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Supraspinatus:
Standing Full Can
Sidelying External
Rotation
Subscapularis:Tband IR or belly press
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Normal Strength
Ratios
• Internal to External Rotation: 3 to 2
•Adduction to Abduction: 2 to 1
•Extension to Flexion: 5 to 4
Physician
Interventions
• Prescription anti-
inflammatories
• Cortisone injection
• Diagnostic tests
• Surgical interventions
Strengthening of the
Overhead Athlete• extraordinary demands on
the shoulder joint
• excessively high stresses are
applied
• tremendous angular
velocities
• GH joint must be lax enough
to allow for excessive ER
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Strengthening of the
Overhead Athlete
• Kevin Wilk Thrower’s Paradox: “Loose enough to throw but stable enough to prevent symptoms”
• ala Gary Gray’s “mostability” concept
• Mobility <---------------------------------> Stability
Core Strengthening
• Center of Kinetic Chain
• A strong core allows extremities to function unopposed
• Centripetal acceleration begins with trunk strength
• Maintaining appropriate spine angle allows for efficient use of extremities and injury prevention
Strengthening for the
Overhead Athlete
• Below shoulder level
• Above shoulder level
• Closed chain exercises
• Plyometrics
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Below Shoulder Level
• Need to make sure this is a
good solid base before we advance.
• Zero impingement or overhead symptoms before
progressing.
Prone Row
Prone Row w/ ER
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Prone T
Prone Y
Videos
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Bentover Row
Bentover T
Bentover Extension
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Bentover Y
Body Blade ER/IR
Body Blade Flexion
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Body Blade Add/Abd
Body Blade Abduction
CC Row
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CC Row
CC Pulldowns
CC Pulldowns
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Above Shoulder Level
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Video
Closed Chain
Exercises
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Video
Video
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Video
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Video
Plyometrics (video)
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Advanced UE Strength Exercises (video)
Videos
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Conclusion
• Most shoulder injuries can be rehabilitated
• MD communication critical!
• Strengthen posterior cuff
• Protect healing tissues
• Keep it interesting for you and your patient
Thank You!
• Jaime Holt, PT, MPT, SCS, CSCS
•jaimeholtpt@gmail.com
•Twitter: @HOLTPT1
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