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Allison Shipton

Mark Shirley
Mark Silvester
Margot Skinner
Gisela Sole
Diane Sorrell
Jane Stone
Nikki Tse
Steve Tumulty
Colin Tutchen, Focus Health Physiotherapy
Leonie van den Bergh
Kathryn Vickers
Waikato DHB Physiotherapy
Wairarapa DHB Clinical Board
Stella Ward, Counties Manukau DHB Physiotherapy
Rochelle Wardle
John Wellingham
Wellington School of Medicine Physiotherapy
Chris Whatman
Graeme White
Carlene Wilkie
Janice Wilson ( Deputy Director General) Ministry of Health- (Population Health)
Winifred Wing Ho
Nancy Wright, Occupational Therapists
Fiona Young
Nola Younger, Bay of Plenty DHB Physiotherapists

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Acknowledgements

The lead authors of this document are:

Janice Mueller MBA (Distinction), ADP (Paediatrics), MNZCP


Director of Allied Health, ADHB

Lynne Taylor MBA, MSc, MNZCP


Senior Lecturer, AUT University

Janet Copeland BA, MHealSc (Rehabilitation), MNZCP


Research and Professional Development, NZSP

Jonathan Warren Dip MT, PGD Sports Med, MHSc, MNZCP


Private Practitioner, President NZSP

G. David Baxter TD, BSc (Hons), DPhil, MBA, MCSP


Dean, School of Physiotherapy, University of Otago

Steve White MHSc (Hons), Dip Public Health; MNZCP


Senior Lecturer, AUT University

The working party gratefully acknowledges financial support for this work from the
New Zealand Society of Physiotherapists and the New Zealand College of
Physiotherapy

Contact details

Janice Mueller & Lynne Taylor


New Zealand College of Physiotherapy
PO Box 27 386
Wellington
E-mail:college@physiotherapy.org.nz

Published in 2008
by the New Zealand Society of Physiotherapists & New Zealand College of Physiotherapy
Advanced Practitioner Working Party.
This document is available on the NZSP website
http://www.physiotherapy.org.nz

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Introduction

The Advanced Practitioner Working Party is a joint project between the New Zealand
College of Physiotherapy Inc. (NZCP) and the New Zealand Society of
Physiotherapists Inc. (NZSP), which arose from a request from the profession to
consider how it could enhance future physiotherapy services in light of current and
future healthcare requirements.

The Working Party was asked to:


Examine both the scope and recognition of the role of ‘Advanced
Practitioner’ within the physiotherapy profession in New Zealand and
develop a set of recommendations for consultation with the profession and
key stakeholders.

To answer this question, the Working Party developed a Consultation Document


which was sent to health provider groups in November 2007 for comment. The
overwhelming majority of submissions supported the proposal for recognition of
physiotherapy specialisation, though there were a range of suggestions regarding
the title, qualifications and experience required for such a role. These suggestions
and comments have been incorporated into the recommendations detailed in this
report.

In considering a role for physiotherapy specialisation, it is important that any title and
definition of physiotherapy specialisation is relevant and meaningful to New Zealand
consumers, employers and purchasers of physiotherapy services.

It is also important that any recommendations are placed in the context of the current
New Zealand health environment and the role physiotherapists already play.
Physiotherapists act as independent practitioners, as well as members of health service
provider teams. The majority of physiotherapists (51%) work in either private
practice as primary healthcare providers or as members of health provider teams,
within the provider arm services of District Health Boards (30%) New Zealand Health

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Information Service, 2007). New Zealand physiotherapists are recognised as first
contact practitioners, meaning patients may seek their services directly without
referral from another health professional.

There is currently no statutory or formal recognition of physiotherapists with


additional qualifications and experience, although the potential for physiotherapists to
expand and enhance the role they play within the health and disability sectors is
evident in the literature. In particular a recent independent review of physiotherapy
services in New Zealand led by David Goddard QC endorsed the concept of
specialisation, and stated it had the potential to provide significant advantages to
claimants, to reduce administrative costs for ACC, and to encourage the retention and
motivation of senior highly qualified members of the profession (Review of the Way
in Which Physiotherapy Services are Funded by ACC, 2007). It is anticipated that this
new role will provide substantial benefits to the health and well being of the New
Zealand public who will be able to identify Physiotherapy Specialists within defined
fields of healthcare.

Given the positive response to the consultation, and the potential benefits to
healthcare in New Zealand, the Working Party is committed to seeing action on this
critical issue for the profession.

Process

The initial business of the Working Party was primarily completed over a period of
eight months through four one-day meetings hosted at the Society’s offices,
supplemented with regular communication between members of the Working Party.
As part of its deliberations, the group considered and reviewed a range of documents
including:
a. The New Zealand College of Physiotherapy’s current advanced practitioner
framework;
b. Preliminary results from the Society’s Membership Survey;
c. Relevant published Strategies relating to New Zealand healthcare;

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d. Reports and strategy documents available nationally and internationally, including
the most recent consensus statement from the World Confederation for Physical
Therapy; and,
e. Published literature relating to physiotherapy advanced practice.

Following this a Consultation Document outlining the Working Party’s main


proposals was sent to all members of the NZSP, and other interested stakeholders
including other professional organisations and regulatory bodies, the Accident
Compensation Corporation, the Ministry of Health, and Government Ministers with
health-related portfolios.

The Consultation Document briefly reviewed the recent history of physiotherapy


specialisation and the evidence to support this within a national and international
context, and then detailed the individual elements of the Working Party’s proposal to
the profession.

These included:
1. The proposed title for this role;
2. Defining the scope of a Physiotherapy Specialist;
3. Requirements for physiotherapy specialisation;
4. Considering who would have the responsibility for recognition and monitoring
of the Physiotherapy Specialist process;
5. Defining specialty areas of physiotherapy practice; and
6. Defining extended scopes of practice for physiotherapists.

The rationale for each recommendation was outlined and questions were asked to
prompt feedback from interested parties. There were one hundred and nineteen
responses to the consultation document; the following report is based on the analysis
of these results.

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Results

1. Title
The initial proposal was:

The Working Party proposes that the title for this new role be Specialist
Physiotherapist.

The majority of respondents agreed with this title with the proviso that the area of
specialisation was also included, although there was a strong argument put forward by
some respondents for the title to be ‘Physiotherapy Specialist’. The rationale behind
this suggestion was that it was more in line with titles given to other health
professionals who held additional qualifications (e.g. cardiac surgeon) and was
therefore more likely to be relevant to the public. The need to promote the profession
– first and foremost as physiotherapy – was discussed; in particular it was recognised
that consumers were more likely to look for our services and identify with a title
beginning with Physiotherapy rather than Specialist.

The Working Party is cognisant of the proposed Career Framework developed jointly
by the Ministry of Health (MoH) and District Health Boards New Zealand (DHBNZ).
Although this framework has the scope for advanced practitioner the Working Party
note that this is a position created within an organisation. In contrast, the proposed
role of Physiotherapy Specialist is directly related to the individual not a career
framework, and is therefore transferable across different employment environments. It
was also noted that 51% of physiotherapists are in private practice and the proposed
Physiotherapy Specialisation could form a component of a quality assurance
mechanism for this group of practitioners. From information currently available it is
thought that up to 10% of the profession would currently be eligible to apply to
become a Physiotherapy Specialist.

Recommendation: The Working Party recommends the title for the new role be
Physiotherapy Specialist (nominated area of expertise).

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2. Scope of Practice

In the Consultation Document the Working Party proposed the following description
for the physiotherapy specialist scope of practice.

A Specialist Physiotherapist is a physiotherapist who has formally demonstrated an


ability to apply advanced clinical competence in a defined clinical area, within the
scope of practice recognised as physiotherapy. A Specialist Physiotherapist will work
primarily in a specific area of clinical and /or teaching practice, but would be
expected to also be involved in research and evaluation and practice/service
development relevant to their practice setting.

The main concern with this proposed scope of practice related to the need for
involvement in research. Respondents highlighted the difficulties of participating in
research for the sole practitioner, especially in rural settings, and that the requirement
for involvement in research shifted the emphasis to academic activities rather than
clinical expertise. The Working Party reconsidered the rationale for inclusion of
research involvement within the scope of practice. We regard it as a method of
demonstrating an active contribution to the profession, but also acknowledge that
evaluation of practice, for example through clinical audits and practice/ service
development are also methods of professional contribution. However, the Working
Party remains of the view that Physiotherapy Specialists need to be ‘critical
consumers of research’, to enhance their clinical practice.

The focus of the proposed role was on clinical practice with the explicit aim of adding
value to the consumer. To better reflect this intent, the wording on scope of practice
has been altered accordingly.

Recommendation: The Physiotherapy Specialist is a physiotherapist who has


formally demonstrated an ability to apply advanced clinical competence in a
defined clinical area, within the scope of practice recognised as physiotherapy.
The Physiotherapy Specialist will work primarily in a specific area of clinical
practice, but would also be expected to contribute to the profession through
leadership, research and/or evaluation and/or practice/service development
relevant to their practice setting.

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3. Requirements for attaining Specialisation

In the Consultation Document, the proposed requirements for physiotherapy


specialisation were:

The appropriate body (to be confirmed) will recognise New Zealand registered
physiotherapists as Physiotherapy Specialists who meet the following requirements:
Qualifications
− A current annual practising certificate
− A relevant postgraduate Master’s degree (from an approved tertiary institution)
or an approved equivalent
Experience
− The equivalent of four years’ full time clinical experience in the nominated
speciality area
Continuing professional development
− Evidence of a minimum of 120 hours of continuing professional development in
the relevant or nominated speciality area over the last 3 years, including peer
review
In addition, each applicant must:
− Submit their professional portfolio of evidence
− Complete an application form / statutory declaration
− Pay the prescribed fee

Although the majority of respondents agreed with these criteria there were some
concerns expressed in respect of the requirement for a Master’s qualification, the term
‘approved equivalent’ and the amount of clinical experience required. In general,
respondents who had concerns considered a Master’s degree too much and the clinical
experience of 4 years too little. Respondents also requested further detail on the
expectations of the peer review and the purpose of the prescribed fee.

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Qualifications: There are currently a wide range of undergraduate and postgraduate
physiotherapy programmes available world-wide. The Working Party emphasise the
need for the required qualification for the Physiotherapy Specialist be a postgraduate
Master’s, and not an entry level programme. For the Master’s programme to be
acceptable it also requires a demonstrable component of research skills training. This
offers assurance that proposed Physiotherapy Specialists have expertise in critical
analysis of current research.

The NZ College of Physiotherapy recognises that they currently have members with
Advanced Practitioner status who would meet all the requirements for Physiotherapy
Specialist, while there are others who hold postgraduate qualifications but not a
Master’s degree. The inclusion of the words ‘Master’s degree or approved equivalent’
accommodates the possibility of a ‘grand parenting’ clause for clinicians who would
otherwise meet the criteria of a Specialist Physiotherapist and can demonstrate
postgraduate learning equivalent in content to current Master’s degrees. It is
anticipated this approved equivalent will be for a limited time frame.

There was also concern regarding the time and cost of supervision and training of the
Physiotherapy Specialist. The Working Party acknowledges there is a cost attached to
any postgraduate education, whether that cost is borne by the individual or subsidised
by an employer. This has been the case for all physiotherapists who have chosen to
undertake postgraduate education in the past, and we do not believe physiotherapy
specialisation will increase this cost.

Recommendation: Qualifications
Physiotherapists applying for the Physiotherapy Specialist role should hold a
current Annual Practicing Certificate with a general scope of practice and a
postgraduate Master’s qualification that demonstrates relevance to the area in
which the individual is seeking specialisation.

Experience: Despite some respondents suggesting the need for an increased amount
of clinical practice in the designated area the Working Party feels that four years full-

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time equivalent within the designated specialty area of practice is appropriate. This is
based on other models that have been developed and keeps our framework broadly in
line with the Australian College of Physiotherapy which recommends three years of
clinical practice with the addition of a practical exam.

Recommendation: Experience
The equivalent of four years’ full time clinical experience in the nominated
speciality area

Continuing professional development: The original conditions for ongoing


professional development were accepted:

Recommendation: Continuing professional development


Evidence of a minimum of 120 hours of continuing professional development in
the relevant or nominated speciality area over the last 3 years, including peer
review

Additional requirements: Following feedback, information regarding the content of


the professional portfolio was expanded. There were concerns regarding the reason
for a prescribed fee. The purpose of this fee is to cover the costs related to the initial
assessment(s) of portfolios and annual costs involved in auditing the maintenance
requirements.

Recommendation: In addition, each applicant must


ƒ Submit their professional portfolio of evidence which shows evidence of
meeting the scope of practice within their nominated speciality area.
ƒ Complete an application form/statutory declaration
ƒ Pay the prescribed fee

5. The proposed maintenance requirements

In the Consultation Document, the proposed maintenance requirements were:

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− Annual practising certificate with the Physiotherapy Board of New
Zealand
− Evidence of continued clinical practice within their nominated specialty
area
− Bi-annual peer review
− Continued professional development as required by the Physiotherapy
Board of New Zealand recertification criteria, with the majority of
activity (>50%) in their nominated specialty area and
− Membership of a relevant professional association

The majority of respondents agreed with these requirements. There was discussion
regarding the requirements for “evidence of continued clinical practice” and whether
this should be replaced with the term “professional practice”. The Working Party
agreed the proposed specialist role is to support and develop a career pathway for
clinicians who have attained further postgraduate qualifications and clinical skills
within a specialised area, and have therefore retained the phrase: “evidence of
continued clinical practice.”

Bi-annual peer review was considered excessive and is replaced with biennial peer
review. It is anticipated that the format for peer review would follow the format
already developed by the NZ College of Physiotherapy for use by its members.

The Working Party considers that a minimum of 50% of a person’s continuing


professional development in a designated area is sufficient to demonstrate continued
competence in that area. While an individual may choose to do more than 50% of
their continuing professional development in their nominated area, the Working Party
also recognises an increasingly holistic approach to healthcare and the need for
clinicians to access knowledge and learning activities across a range of clinical
practice areas. Therefore, the proposed continuing professional development
requirements provide clinicians with the flexibility to choose to devote a substantial
proportion of their professional development in professional activities outside of their
specialty area.

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Recommendations
- Annual practising certificate with the Physiotherapy Board of New Zealand
- Evidence of continued clinical practice within their nominated specialty area
- Biennial peer review
- Continued professional development as required by the Physiotherapy Board
of New Zealand recertification criteria, with the majority of activity (>50%) in
their nominated specialty area and
- Membership of a relevant professional association

6. Recognition, implementation and monitoring of


Physiotherapy Specialist scope of practice

Three options that could be used to progress the model for the profession were put
forward for discussion:

− The New Zealand College of Physiotherapy implements and monitors the


process, taking full responsibility as an independent body;
− The Physiotherapy Board of New Zealand recognises Specialist
Physiotherapist as a specific scope of practice and monitors the process,
taking full responsibility as per the HPCAA; or
− The Physiotherapy Board of New Zealand recognises Specialist
Physiotherapist as a specific scope of practice and works collaboratively
with New Zealand College of Physiotherapy to assess applicants for the
new scope of practice.

There was widespread support for the Physiotherapy Board taking a leadership role in
this process and this is supported by the Board who acknowledged:

“that the principle of recognition of specialist physiotherapists be endorsed as


desirable and in the public interest.”

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Equally there was support for the NZ College of Physiotherapy continuing and
expanding the role they currently hold, utilising the structures and processes they
already established for recognition of specialisation. It was acknowledged that:

“a working relationship be established with the College (and the Board) to determine
how this recognition can best be given.”

Recommendation: The Working Party establish a working relationship with the


Physiotherapy Board to determine how this recognition can best be conferred
and monitored.

7. Nominated speciality areas of practice

The following models were put forward for discussion:

The New Zealand College of Physiotherapy currently endorses ten speciality


areas for their advanced practitioners, limiting it to those areas supported by a
clinical ‘special interest group’ of the NZSP. These are: older adults, paediatrics,
women’s health, occupational health, neurology, cardiothoracic, manipulative
physiotherapy, acupuncture, hand therapy and sports & orthopaedics.
These can be grouped into the following categories:
− a population service group (i.e. older adults, paediatrics, women’s health,
occupational health) or
− a recognised area of medical practice (i.e. neurology, cardiothoracic, hand
therapy) or
− a specific rehabilitation intervention (i.e. manipulative physiotherapy,
acupuncture) or
− a combination of both population and area of medical practice (i.e. sports
& orthopaedics)

While the majority of respondents agreed with the current categories, there were
suggestions for both consolidation and expansion of specialisation categories. Some

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suggested consolidating the interventions such as manipulative physiotherapy and
acupuncture into an area of practice, for example musculoskeletal physiotherapy or
hand therapy. On the other hand, numerous suggestions were put forward for
expanding speciality areas, including pain, palliative care and health promotion.

In summary, the Working Party considers it is very important that any nominated
specialisation areas put forward are relevant and meaningful to the New Zealand
public.

Recommendation: Before proceeding further it was agreed to discuss the


suggested specialisation categories with consumer groups.

8. Extended Scope of Practice

The proposal in the Consultation Document was:

The Working Party’s recommendation on extended scopes of practice is that:


Extended scopes of practice, within a recognised specialty area of practice will be
recognised when underpinned by:
Relevant postgraduate education from a recognised tertiary institute
− This shall include relevant theoretical background and the assessment of
risk and indications for use of the relevant practice
Relevant clinical practice
− Supervised where considered appropriate

There was some confusion regarding the difference between physiotherapy


specialisation which was the focus of the Working Party’s Consultation Document,
and Extended Scope of Practice. This led to concerns that the Working Party was
advocating for physiotherapists to undertake roles outside of their general scope of
practice, such as injection therapy or limited prescribing rights, for which they do not
have the requisite knowledge or skill levels.

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To clarify, the Working Party sees the role of the Physiotherapy Specialist sitting
within the current New Zealand scope of practice for physiotherapy. Extended scopes
of practice e.g. limited prescribing rights or injection therapy, are seen as sitting
outside of the current New Zealand scope of physiotherapy practice, and therefore
require specific additional education, and relevant supervised clinical practice.
Therefore, the Working Party takes the prudent approach that physiotherapists should
achieve the status of Physiotherapy Specialists prior to applying for any proposed
extended scopes of practice. These expanded roles would be congruent with their area
of specialisation and increased level of skills.

The Working Party is aware of the work that has already been done by the NZSP
Limited Prescribing Rights Working Party on an extended scope of practice and the
need for the two groups to continue to work closely together on this issue.

Recommendation: The Working Party recommends that a physiotherapist needs


to reach specialist status as defined in this document prior to applying for any
extended scope of practice. An application for extended scope of practice would
need to be supported by the relevant postgraduate education.

Summary

The feedback received on the Consultation Document was overwhelmingly in support


of the concept of physiotherapy specialisation; the Working Party therefore
recommends the establishment of the role of Physiotherapy Specialist. Further
consultation will now take place with the Physiotherapy Board and other key
stakeholders such as ACC and DHBNZ to determine how this position can best be
established and monitored.

It is also important that any new role, such as a Physiotherapy Specialist is evaluated
to ensure the original objectives of the position have been met. Consequently the
Working Party anticipates development of an independent pilot study to evaluate the
role in terms of its benefits to the consumers, employers and purchasers of these
physiotherapy services.

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The Working Party would like to thank all the physiotherapists and interested parties
who have taken the time to respond to the Consultation Document. The support given
for the proposed physiotherapy specialisation role has endorsed the Working Party’s
findings and allowed a way forward to establish recognition of this role.

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Appendix 1- List of Individuals and Organisations who
submitted responses to the Consultation Document,
December 2007- March 2008
One hundred and nineteen responses to the Consultation Document were received
from the following individuals and organisations.

Haxby Abbott
Don Allomes
Margo Angland
Rebecca Armstrong
Jane Ashby
Hamish Ashton
Jo Ayers
Barbara Barbara
Lyndsey Bargy
Jennifer Baty Myles
Ruth Baxter
Storm Baynes
Karen Blakey, ACC (Rehabilitation Service Development)
Julie Bradley
Tanya Browne, Sports Physio
Miranda Buhler
Jackie Chiplin , NZ Association of Hand Therapists
NZ College of General Practitioners
College of Optometry
Jenny Collett
Jenny Conroy
Caroline Cross
Jill Cutfield
Margaret Davidson , ADHB Child Development Team
Jan Davies
Bridget Dickson

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Barry Donaldson
Hilary Exon
Emma Ferris
John Forest
Lesley Frederikson, NZ Association of Optometrists
Christine Gillespie, Kowhai Health Trust
Jeanie Glasgow
Heather Gordon
Carol Green
Catherine Grey
Philippa Grimes
Stephen Gunn, Te Korowai Hauora O Hauraki
Leigh Hale
Daniel Harvey
Hawkes Bay DHB Physiotherapy
Marilyn Head, NZ Nurses Organisation
Cheryl Hefford
Anne Hewetson, Gisborne Occupational Health & Physiotherapy Services
Graham Hill
Richard Hoskin
Jill Howard
Maree Hutchinson , Waitemata DHB Physiotherapists
Julianne Jackman
Julianne Jackson, Podiatrists Board
Gill Johnson, University of Otago, School of Physiotherapy
Andrew Jones
Jacqui Kerins
Deborah Kerry
Susan Kohut
Peter Larmer
Mark Laslett
Craig Leong
William Levack

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Robert Lindsay
Jenny Lucy
Anne Luty
Greg Lynch
Claire Matheson
Jill McDowell
Cameron McIvor (CEO), the NZ Medical Association
Anna McRae
Marion Meates
Jennine Mitchell
Margaret Moom
Sarah Mooney
Sarah Mooney
Suzie Mudge
Hilda Mulligan
Kara Mulvein
Fiona Murdoch
Ann Newsom
Kristine Nicol, ADHB Physiotherapy Clinical Supervisors
Nicky Nunn
NZ College of Midwives
Anne O'Donnell
Julianne O'Donnell, Mid Central DHB Physiotherapists
John Olsen
Sharon Peck
Physiotherapy Board of New Zealand
Liz Pollitt
Duncan Reid, NZ Academy of Sport (North Island)
Ineke Riley-Stol
Carole Rogers
Gabrielle Scott
Andrew Scott
Karen Setz

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Allison Shipton
Mark Shirley
Mark Silvester
Margot Skinner
Gisela Sole
Diane Sorrell
Jane Stone
Nikki Tse
Steve Tumulty
Colin Tutchen, Focus Health Physiotherapy
Leonie van den Bergh
Kathryn Vickers
Waikato DHB Physiotherapy
Wairarapa DHB Clinical Board
Stella Ward, Counties Manukau DHB Physiotherapy
Rochelle Wardle
John Wellingham
Wellington School of Medicine Physiotherapy
Chris Whatman
Graeme White
Carlene Wilkie
Janice Wilson ( Deputy Director General) Ministry of Health- (Population Health)
Winifred Wing Ho
Nancy Wright, Occupational Therapists
Fiona Young
Nola Younger, Bay of Plenty DHB Physiotherapists

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