Bethesda, MD 20894, Web Policies From a clinical perspective, the results of this Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. %PDF-1.5 Hop testing was the most commonly reported functional test following ACL reconstruction and differences between graft types were examined, providing information that may assist providers in determining timing of return to unrestricted sporting activity. 2017;5(8):1-5. The ACL rehabilitation plan has 9 Phases: Time frames vary among different sports. You can implement a running program when the athlete archives 90% quadriceps index to make sure the running mechanics will be as close to normal[17]. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. $[A`M A&Zb @2`@&F!# * endstream endobj 309 0 obj <> endobj 310 0 obj <>/ExtGState<>/Font<>/XObject<>>>/Rotate 0/Tabs/S/Type/Page>> endobj 311 0 obj <>stream 1 0 obj Progress each week by increasing a minute of running and decrease a minute of walking, till the athlete is able to run for a progressive 20 minutes. The test batteries in the current literature show high variability and a lack of essential components necessary for RTS, suggesting a disconnect between recommended guidelines and clinical practice. uuid:0145AEDA-8081-4B56-969A-0706CADDFBEE <> About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features Press Copyright Contact us Creators . 1 0 obj Methods: A prospective cohort study design. This criteria-based protocol incorporates a dynamic assessment of baseline limb strength, patient-reported outcomes, functional knee stability, bilateral limb symmetry with functional tasks, postural control, power, endurance, agility, and technique with sport-specific tasks and serves as a foundation to expand future evidence-based evaluation. Researchers consider ROM symmetry to be the most important factors in successful rehabilitation and long-term patient satisfaction: Achieving symmetry depends on many factors such as surgical approach; graft type, donor site, proper graft placement, knee hyperextension after graft placement, pre-operative rehab, post-operative, rehab periodic evaluations and follow-ups up to 10 years after surgery[9]. The Vail Sport Test has great potential to be an optimal test for safely returning athletes to sports. Construct validity was assessed using the reference standards of the camera system and the IKDC short form. Would you like email updates of new search results? Bousquet BA, O'Brien L, Singleton S, Beggs M. Y Balance Test Explained. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> The findings indicate that patients are not fully rehabilitated 11months after ACL reconstruction, and it is suggested that functional testing should be performed both under non-fatigued and fatigued test conditions. in the graduate school of the . Functional outcomes suggest that a subgroup of noncopers require additional supervised rehabilitation to pass stringent criteria to return to sports. Published in International Journal of Sports Physical Therapy 2012, J. C. Garrison, E. Shanley, C. Thigpen, R. Geary, M. Osler, Jackie Delgiorno. Garrison JC, Bothwell JM, Wolf G, Aryal S, Thigpen CA. 2017 Oct;475(10):2472-2480. doi: 10.1007/s11999-017-5418-2. 2 0 obj 2017-12-06T10:45:58-06:00 Careers. <> ;R~*:x5Tj8GY~*6vUFDe}>:}CDY~*6v*}}( % Lower extremity muscle strength after anterior cruciate ligament injury and reconstruction. Waldron K, Brown M, Calderon A, Feldman M. Andrade R, Pereira R, van Cingel R, Staal JB, Espregueira-Mendes J. Adams D, Logerstedt D, Hunter-Giordano A, Axe MJ, Snyder-Mackler L. Sinacore JA, Evans AM, Lynch BN, Joreitz RE, Irrgang JJ, Lynch AD. Vail Sport Test Scoring One point is given for each criterion completed with proper technique during the time intervals (yes = 1, no = 0) . 160 0 obj <>stream Ability to walk on treadmill or cycle with resistance for 20 minutes. The Reliability of the Vail Sport Test As a Measure of Physical Performance Following Anterior Cruciate Ligament Reconstruction. Anterior Cruciate Ligament Rehabilitation and Return to Sport: How Fast Is Too Fast? The Vail Sport Test is a return to sports assessment that incorporates a series of dynamic multiplanar functional activities against the resistance of a sportcord . It is important to set specific goals and milestones for your athlete and build time frames accordingly. ?~t2\muN>7'Y[AG*gCq5!VB7}m%Qn1/O` e.U0^.AA4v_aUU3we3nlcpZEC5Z&NcjcY^,Bj%*^-[eK8pQBaRS(se" 2wH\(/IPXcmwr(PTr,UL(#QKm\9V!AyK7(P.Q%T*&>S)VY9:wY`? 4 0 obj Hetsroni I, Wiener Y, Ben-Sira D, Iacono AD, Marom N, van Stee M et al. x]k6nA_tHd/bg"HFg=_[$ q?X"UInw7WovO>aZoxy:h_b~_={KV0VVuGLU+$)Zsfqm(,t6=I*B:q_^?/3!6wlvDq/[^G]zlrYvzyWX\.yq^RGRZ%#|vZYlg-^v^lK+t^m7d.8w+(jy{''AGs c[y[r IJy"MW6gDF/e4)LD=)9{e ]+y"M__NLB }WZ#Ni);3tr. x][s~0/9/jW-$r Compared with matched healthy controls, the participants who underwent ACLR demonstrated an inferior objective profile at RTS, consisting of deficits in surgical limb loading, self-reported outcomes, and strength. hb```c``*``a`f`@ fV8GC-{Ym6{d| Three major. Available from: Demonstration of Anti-Gravity Treadmill at Michigan Medicine. A recent study of this test on patients post . Orthop J Sports Med. Disclaimer. Br J Sports Med. endobj measure the time it takes to patient to complete the test. Objectives: To determine the validity and inter-session reliability of the Vail Sport TestTM. Return to Sport after ACL Reconstruction and Other Knee Operations, This chapter summarizes return to sport (RTS) and reinjury data after anterior cruciate ligament (ACL) reconstruction in 42,275 patients from 95 studies published from 2004 to 2018. % The reliability of the vail sport test as a measure of physical performance following anterior cruciate ligament reconstruction. >rXCSEPT>TWYC{*Tg+s A2 _ /_% QE#&\&"\#p=@14'5h"hQ{o6qfsWa8h Semantic Scholar is a free, AI-powered research tool for scientific literature, based at the Allen Institute for AI. Symmetries in Muscle Torque and Landing Kinematics Are Associated With Maintenance of Sports Participation at 5 to 10 Years After ACL Reconstruction in Young Men. Microsoft Word 2016 1d, Fig. Return to Sport after ACL Reconstruction and Other Knee Operations, This chapter summarizes return to sport (RTS) and reinjury data after anterior cruciate ligament (ACL) reconstruction in 42,275 patients from 95 studies published from 2004 to 2018. There is no specific program that is superior to the others, however, there are similar goals within in all rehabilitation programs. Due to the inadequacy of current return-to-sport tests, the Vail Sport Test (Fig. A comprehensive RTS decision-based model for sports medicine practitioners is discussed that assesses risk of reinjury from multiple factors and determines the clinicians threshold for acceptable risk. endobj Dietvorst M, Brzoskowski MH, van der Steen M, Delvaux E, Janssen RPA, Van Melick N. J Exp Orthop. endstream endobj startxref The purposes of this study are 1) to describe a functional test (Vail Sport Test) that includes the evaluation of muscle strength, endurance, power, and movement quality in those patients. stream The relatively low rate of return to competitive sport despite the high rates of successful outcome in terms of knee impairment-based function suggests that other factors such as psychological factors may be contributing to return-to-sport outcomes. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> The decision to return an athlete to sports following anterior cruciate ligament reconstruction can be controversial. and transmitted securely. ~. The test batteries in the current literature show high variability and a lack of essential components necessary for RTS, suggesting a disconnect between recommended guidelines and clinical practice. These goals should be prioritized depending on athletic needs. @]aYb%0R1YjbE:>{\qwWM8e)RT|B [WdOn1P4{hq|Rdf? As a physiotherapist, you have a role in guiding your patient through a long-term rehabilitation plan. Age, gender, quadriceps strength and hop test performance are the most important factors affecting the achievement of a patient-acceptable symptom state after ACL reconstruction. Complete 10 rep squat / 10 rep leg press with >90% of the predicted 1RM. 0 b+-~G6I4l#/o*>zw,wq(iY}{o=.(I_Pq/|^WmU=T.>Wy*#nK}u1{M)^$P?J ?H[]?|BlCgaAgM7W;Hcp3TOwkvi1xQ8*BN8kvt5 lwGl9-!BVCu 1"g3(-`E2HjCHTh^_B^Mv#)v n5-ZbRq [C:2z9;~d7sGU[{[H*m4A1R'sC'R~Bp1y>-X5j56wQ. International journal of sports physical therapy, PURPOSE/BACKGROUND Comparing the injured knee to the other side and trying to reach as much as possible symmetry is essential for recovery and return to function. Knee Surgery, Sports Traumatology, Arthroscopy. Starting power training should begin when the athlete shows the following criteria: A different characteristic of muscular strength is power which is a combination of force and velocity. Return to sport test Weeks 20-24 (Prior to 6-month follow-up appointment) Test Dynamic Valgus * (Y/N) R L % Y-Balance Leg length (ASIS to medial . 1 0 obj Predicting outcomes and time-frames, using your clinical experience and clinical reasoning skills, for each goal is also part of your role. The Vail Sport Test, originally described by Hagerman and Atkins, 34 is a functional assessment to return to alpine skiing and has been used as a criterion to return to sport, as previously described in the literature. 9 0 obj reconstruction . There was a significant difference for the uninvolved limb (p = 0.015). The purpose of this clinical commentary is to provide the rehabilitation specialist such a program directed toward safely returning the athlete to alpine skiing. Three major. 308 0 obj <> endobj endobj for the degree of doctor of philosophy . When refering to evidence in academic writing, you should always try to reference the primary (original) source. Y BALANCE TEST ANTERIOR REACH SYMMETRY AT THREE MONTHS IS RELATED TO SINGLE LEG FUNCTIONAL PERFORMANCE AT TIME OF RETURN TO SPORTS FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION. Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes. Preliminary Functional Test Week 12 (Prior to 12-week follow-up appointment) Test Dynamic Valgus * (Y/N) R L % . }, author={James Craig Garrison and Ellen Shanley and Charles A. Thigpen and Ryan Geary and Mike Osler and Jackie Delgiorno}, journal={International journal of sports . C. Wilke et al. endobj 3 0 obj By the end of this phase your patient must be able to[14]: Anterior cruciate ligament (BTB) rehabilitation guideline [12], Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. 2020 Oct 15;7(1):83. doi: 10.1186/s40634-020-00298-8. 1 0 obj %PDF-1.5 % Cristiani R, Mikkelsen C, Edman G, Forssblad M, Engstrm B, Stlman A. Biggs A, Jenkins WL, Urch SE, Shelbourne KD. Test; VHST: Vail Hip Sport Test; *predictive validity regarding injuries of lower extremity. Developing velocity requires lower resistance, about 30% 1 RM for 6 reps, 1-3 sets with 3 minutes rest. Cohort study-exploratory methodological research design. Available from: Monday Academic Session - Luke O'Brien - Rehabilitation. Participants: Forty-eight participants who underwent ACL-R. Main outcome measure: Participants performance on the Vail Sport TestTM was graded by an experienced rater in real-time, and . 5 0 obj Journal of orthopaedic research : official publication of the Orthopaedic Research Society. The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 22 triple hop indices.16 In addition, the quadriceps strength of these patients was correlated with . endobj There were no significant difference between the scores collected in real-time and from the kinematic data on the involved limb (p = 0.222). A total of, Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine. Archives of orthopaedic and trauma surgery. The relatively low rate of return to competitive sport despite the high rates of successful outcome in terms of knee impairment-based function suggests that other factors such as psychological factors may be contributing to return-to-sport outcomes. In most cases Physiopedia articles are a secondary source and so should not be used as references. 2018 Jan;52(2):128-138. doi: 10.1136/bjsports-2016-096836. 1c, Fig. Request PDF | The Validity And Reliability Of The Vail Sport Test As A Measure Of Performance Following Anterior Cruciate Ligament Reconstruction | Objectives: To determine the validity and . ,(s*@ ;@p'D2g g.wxaCOi!o\/~iwY_\R>9 ~:KmPDP\ S@YVPc^4?~)=TJ`sK+lvS|o%SMm 9 A/naYMM@&(gq[`-RKsUBH$m,'MCkOo0_^x0?W~6}Xlz*i:EsTJbcW#xsH/,x.29YgeULX!N$MS"7a4F.AaonTl@^O.l1wnxg(wYap_@s{T'\i*\eTG4@4c,lra;.$-mhJ]sKMDhK[)Ktq^u-1]~ vo!,bA In young patients with high functional demands, return to sports is allowed no earlier than 912 months after they have undergone a thorough rehabilitation programme, but it is known to be associated with secondary stiffness. Setting up milestones and goals depends on your patient's needs and aspired function. Training for high load activities requires 85-100% of 1 RM, 1-3 sets with 3 minutes rest. Thomas AC, Villwock M, Wojtys EM, Palmieri-Smith RM. {t#8x"[@QG7{/@=\~H5xu>}%wNu7cqG@pC Wa^*A^iW/*|Js0Br1^~rbn0\P+f; &B^~udO_nhA>wt~wAzpm 7qSTo$/tDy|`G0>;3jH/ Mwc huAF"fS\cs|P:rS 8D#I S'"T4UT. <> A criterion-based postoperative protocol was derived based on current evidence regarding rehabilitation following cruciate ligament reconstruction and evidence regarding lower extremity rehabilitation principles and injury prevention and allowed the patient to return to competitive athletics. Garrison JC, Shanley E, Thigpen C, Geary R, Osler M, Delgiorno J. Available from: Lewek M, Rudolph K, Axe M, Snyder-Mackler L. Logan Hutsko - Vail Sport Test. S.C]} 1}Q4;\j9c^[y^wt;!%Fl{Qbn}?] cQv_bLcK?q]~~n~/|-mIFr;g9]XLj2w.;_|*jh3.zL":'vYbDU-*0}s=$e OC(7qRj+S682ef\d}k"uGdQ{O0O+Vy^_%k!M]1 Rehabilitation for patients following ACL reconstruction: Arthrofibrosis following ACL reconstructionreasons and outcome. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). The effect of insufficient quadriceps strength on gait after anterior cruciate ligament reconstruction. % endobj 131 0 obj <> endobj 2 0 obj 147 0 obj <>/Filter/FlateDecode/ID[<14B400B356AB134B832E197A3AE22728>]/Index[131 30]/Info 130 0 R/Length 82/Prev 123080/Root 132 0 R/Size 161/Type/XRef/W[1 2 1]>>stream The results show that the described series of hop tests provide a reliable and valid performance-based outcome measure for patients undergoing rehabilitation following ACL reconstruction, and these findings support the use and facilitate the interpretation ofHop tests for research and clinical practice. For each of the test components, a clinician assesses the athlete's . The Journal of orthopaedic and sports physical therapy. The following is a suggested weekly plan for an athlete requires strong lower body as the top priority, cardiovascular fitness, core stability and upper body strength: Accordingly, the plan includes 4 lower body strengthening sessions, 2 cardio sessions, 2 pool sessions, 2 core sessions, 2 upper body strengthening sessions. PMC In the acute management phase, there are some considerations to protect the surgical repair and allow healing without compromising ROM. Compared with matched healthy controls, the participants who underwent ACLR demonstrated an inferior objective profile at RTS, consisting of deficits in surgical limb loading, self-reported outcomes, and strength. :6P~n$U=P .5z wpTW4>ws:y66#wE+7 3X9>}Qpez73.^:b/bc [Z0FYe~iweZ9+mUE_v-=kS],lbV[4u)Z'9ermUy7>M,Lh5ShDUJ2UPNmmVy':SaQT %zi@PlJ[4; KM\ Methods: Rev. Please enable it to take advantage of the complete set of features! Younger Patients and Men Achieve Higher Outcome Scores Than Older Patients and Women After Anterior Cruciate Ligament Reconstruction. Supplies: Sport Cord (Topp er Sports Medicine, black cord) GoniometerStopwatch Description: The Athlete will perform single knee bends with cord resistance to 60 at a cadence of 1 second up and 1 second down for a goal of 3 minutes. <>>> Loss of as little as 2 of extension and 5 flexion, compared to the other knee, were associated with lower subjective scores[6]. 1ea-e) was developed to assess an athlete's ability to perform four major sport-specific functional activities: (1) single leg squat, (2) lateral bounding, (3) forward running, and (4) backward running). X7+FR "m~^ w8&@f` XK10.22 l}t 8600 Rockville Pike stream stream 2017-12-06T10:45:58-06:00 Following the first 6 weeks of acute management after ACL reconstruction, creating a long-term rehabilitation plan can be challenging for physiotherapists. 1 . Int J Sports Phys Ther. DOI: 10.1016/j.ptsp.2019.05.001 Corpus ID: 174805383; The validity and reliability of the Vail Sport Test as a measure of performance following anterior cruciate ligament reconstruction. HHS Vulnerability Disclosure, Help The purposes of this study are 1) to describe a functional, Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine. For the donor site, rehabilitation should be directed towards strengthening the muscles, while ROM is the main concern in the initial phases of rehabilitation for the ACL-reconstructed knee[9]. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. a dissertation . This . Depending on the previous level of strength, 1-12 reps for 1-3 sets with 2 minutes rest between sets. cOOPvqzjCp. 17 3l5U( G$|{viar3#r6}kguwy< International journal of sports physical therapy, PURPOSE/BACKGROUND MpTp954A6eT! endstream endobj startxref 2 0 obj Journal of orthopaedic research : official publication of the Orthopaedic Research Society. 1b, Fig. The purposes of this study are 1) to describe a functional test (Vail Sport Test) that includes the evaluation of muscle strength, endurance, power, and movement quality in those patients attempting to return to sports following ACL reconstruction and 2) to assess the reliability of the Vail Sport Test. Build a specific drills program depending on your patient's sport-specific needs. %PDF-1.7 % Candace Walker Epub 2016 May 31. school of physical therapy A comprehensive RTS decision-based model for sports medicine practitioners is discussed that assesses risk of reinjury from multiple factors and determines the clinicians threshold for acceptable risk. Limited evidence for return to sport testing after ACL reconstruction in children and adolescents under 16years: a scoping review. (Males 4.5-5.5 seconds; Females 5.5-6.5 seconds) See diagram. I2^L*./Oe'Yrx` 8^, x[[s9~OU/*,SnR3>$+/INHZ?IGo'^|N y}|1$D+F`v|O'fg*!zN ~9308f900dNOraG_JpKA %%EOF A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II). You . <> Before In young patients with high functional demands, return to sports is allowed no earlier than 912 months after they have undergone a thorough rehabilitation programme, but it is known to be associated with secondary stiffness. 1 Since the inception of this test, it has remained unchanged in design but has undergone scoring changes to increase reliability. 2016 May;51(5):425-7. doi: 10.4085/1062-6050.51.5.11. performance following anterior cruciate ligament . Post-operative criterion based rehabilitaiton of ACL repairs: A clinical commentary. Principles of postoperative anterior cruciate ligament rehabilitation. METHODS A prospective cohort study design. <>/Metadata 536 0 R/ViewerPreferences 537 0 R>> The Vail sports test will give you an idea how your patient loads his/her injured knee which will reflect on running. Annals of the Academy of Medicine, Singapore. ,I)rK7KlM///mKzQd(MN6dh,t&gqh17_aiGWE+y&D]/-un..1]*9n>}}YSkt[|I L|Y>O/)Vwd4UaPq4fE]mtgEDL_W7&r0xpufoO z(^aCsl [_B8RE=;/ #u BI1h4IW'A6td~_--bw*_v8 6k-w3HOC.msl5B.[qo].d|DP# x R!R"s3cHNuq,n|;5m:#hrWs#q;v6%SV%eumNGpG Hu.Z&ERkG.#1AY+@V&>iQDC@- \S~P_K2iV_V("Zy=eEVs(Jw(. Accessibility Int J Sports Phys Ther. submitted in partial fulfillment of the requirements . struction can be controversial. Symmetry means equal ROM and equal strength. A criterion-based postoperative protocol was derived based on current evidence regarding rehabilitation following cruciate ligament reconstruction and evidence regarding lower extremity rehabilitation principles and injury prevention and allowed the patient to return to competitive athletics. FOIA Annals of the Academy of Medicine, Singapore. DOI: 10.4236/health.2017.910104 1420 Health recommendations concerning the use of the tests and to verify the quality crite-ria. Clinical Research Laboratory. Regaining full ROM for both knees should be aimed during rehabilitation. This test will be completed in reverse order (A to C to B to A) to make sure the patient is planting with both the involved and uninvolved foot. If any signs of overload was present, return to the previous stage of running progression. Quadriceps strength can be easily quantified using a handheld dynamometer to identify strength deficits and differences between the two sides[5]. 11/2017 . <> endobj Rushing rehabilitation may lead to adverse complications such as increased inflammation and loss of ROM[9]. The reliability of the vail sport test as a measure of physical performance following anterior cruciate ligament reconstruction. This study aims at reviewing the available literature on reliability and validity of existing subjective test protocols, and first recommendations for the use of different subjective screening test methods are given. Back leg squat/Leg press for 10 rep at >70% of the predicted 10 RM. 2012 Feb;7(1):20-30. A test battery consisting of a knee-extension, knee-flexion and leg-press muscle power test had high ability to determine deficits in leg power 6months after ACL injury and reconstruction and may contribute to the decision-making process when deciding whether and when patients can safely return to strenuous physical activities. For example, building a 30-40 minutes lower body workout would look like. attempting to return to sports following ACL reconstruction and 2) to assess the reliability of the Vail Sport Test. The purposes of this study are 1) to describe a functional test (Vail Sport Test) that includes the evaluation of muscle strength, endurance, power, and movement quality in those patients attempting to return to sports following ACL reconstruction and 2) to assess the reliability of the Vail Sport Test. <> Exercises should be light intensity (<50% of 1-RM) high repetitions (15-20) for 3 or more sets with less than 60 seconds of rest, 2-3 times weekly with 48 hours rest between sessions to target type 1 atrophied muscle fibers, due to arthrogenic inhibition[14]. <>/Metadata 430 0 R/ViewerPreferences 431 0 R>> endstream endobj 2 0 obj <> endobj 46 0 obj <> endobj 376 0 obj <> endobj 48 0 obj <> endobj 47 0 obj <> endobj 52 0 obj [51 0 R 54 0 R 55 0 R 56 0 R 57 0 R 58 0 R 63 0 R 63 0 R 65 0 R 65 0 R 67 0 R 67 0 R 69 0 R 69 0 R 71 0 R 71 0 R 75 0 R 77 0 R 79 0 R 81 0 R 83 0 R 86 0 R 87 0 R 88 0 R 89 0 R 91 0 R 93 0 R 95 0 R 97 0 R 98 0 R 99 0 R 104 0 R 104 0 R 106 0 R 106 0 R 108 0 R 108 0 R 110 0 R 110 0 R 112 0 R 112 0 R 116 0 R 117 0 R 118 0 R 120 0 R 122 0 R 124 0 R 126 0 R 128 0 R 132 0 R 134 0 R 136 0 R 138 0 R 140 0 R 144 0 R 146 0 R 148 0 R 150 0 R 152 0 R 156 0 R 158 0 R 160 0 R 162 0 R 164 0 R 167 0 R 169 0 R 171 0 R 173 0 R 175 0 R 177 0 R 180 0 R 182 0 R 184 0 R 186 0 R 188 0 R 190 0 R 193 0 R 195 0 R 197 0 R 199 0 R 201 0 R 203 0 R 206 0 R 208 0 R 210 0 R 212 0 R 214 0 R 216 0 R 219 0 R 221 0 R 223 0 R 225 0 R 227 0 R 229 0 R 232 0 R 234 0 R 236 0 R 238 0 R 240 0 R 242 0 R 245 0 R 246 0 R 247 0 R 248 0 R 250 0 R 251 0 R 252 0 R 254 0 R 256 0 R 258 0 R 260 0 R 263 0 R 265 0 R 267 0 R 269 0 R 271 0 R 273 0 R 274 0 R 275 0 R] endobj 277 0 obj [276 0 R 278 0 R 279 0 R 280 0 R 281 0 R 282 0 R 283 0 R 284 0 R 285 0 R 286 0 R 287 0 R 288 0 R 289 0 R 293 0 R 295 0 R 296 0 R 297 0 R 298 0 R 299 0 R] endobj 301 0 obj [300 0 R 302 0 R 304 0 R 311 0 R 312 0 R 313 0 R 314 0 R 315 0 R 316 0 R 317 0 R 319 0 R 303 0 R 318 0 R 310 0 R 309 0 R 307 0 R 306 0 R] endobj 321 0 obj [320 0 R 322 0 R 323 0 R 324 0 R 328 0 R 330 0 R 332 0 R 334 0 R 336 0 R 338 0 R 340 0 R 342 0 R 344 0 R 346 0 R 348 0 R 350 0 R 352 0 R 353 0 R 354 0 R 355 0 R] endobj 320 0 obj <> endobj 322 0 obj <> endobj 323 0 obj <> endobj 324 0 obj <> endobj 328 0 obj <> endobj 330 0 obj <> endobj 332 0 obj <> endobj 334 0 obj <> endobj 336 0 obj <> endobj 338 0 obj <> endobj 340 0 obj <> endobj 342 0 obj <> endobj 344 0 obj <> endobj 346 0 obj <> endobj 348 0 obj <> endobj 350 0 obj <> endobj 352 0 obj <> endobj 353 0 obj <> endobj 354 0 obj <> endobj 355 0 obj <> endobj 50 0 obj <> endobj 41 0 obj <>/MediaBox[0 0 612 792]/Parent 2 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/StructParents 3/Tabs/S/Type/Page>> endobj 42 0 obj <>stream