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International Urogynecology Journal

, Volume 23, Issue 11, pp 1495–1516 | Cite as

Biofeedback for the treatment of female pelvic floor muscle dysfunction: a systematic review and meta-analysis

  • Fátima Faní FitzEmail author
  • Ana Paula Magalhães Resende
  • Liliana Stüpp
  • Marair Gracio Ferreira Sartori
  • Manoel João Batista Castello Girão
  • Rodrigo Aquino Castro
Review Article

Abstract

Biofeedback (BF) has been widely used in the treatment of pelvic floor dysfunctions, mainly by promoting patient learning about muscle contraction with no side effects. However, its effectiveness remains poorly understood with some studies suggesting that BF offers no advantage over the isolated pelvic floor muscle training (PFMT). The main objective of this study was to systematically review available randomized controlled trials assessing the effectiveness of BF in female pelvic floor dysfunction treatment. Trials were electronically searched and rated for quality by use of the PEDro scale (values of 0–10). Randomized controlled trials assessing the training of pelvic floor muscle (PFM) using BF in women with PFM dysfunction were selected. Outcomes were converted to a scale ranging from 0 to 100. Trials were pooled with software used to prepare and update Cochrane reviews. Results are presented as weighted mean differences with 95 % confidence intervals (CI). Twenty-two trials with 1,469 patients that analyzed BF in the treatment of urinary, anorectal, and/or sexual dysfunctions were included. PFMT alone led to a superior but not significant difference in the function of PFM when compared to PFMT with BF, by using vaginal measurement in the short and intermediate term: 9.89 (95 % CI −5.05 to 24.83) and 15.03 (95 % CI −9.71 to 39.78), respectively. We found a few and nonhomogeneous studies addressing anorectal and sexual function, which do not provide the cure rate calculations. Limitations of this review are the low quality and heterogeneity of the studies, involving the usage of distinct protocols of interventions, and various and different outcome measures. The results of this systematic review suggest that PFMT with BF is not more effective than other conservative treatments for female PFM dysfunction.

Keywords

Biofeedback Pelvic floor muscle Urinary incontinence Fecal incontinence Sexual dysfunction 

Abbreviations

BF

Biofeedback

PFMT

Pelvic floor muscle training

PFM

Pelvic floor muscle

Notes

Acknowledgments

This study was funded by the National Council for Scientific and Technological Development (CNPq) research foundation, grant nº 153287/2010-1.

Conflicts of interest

None.

References

  1. 1.
    Smith CA, Witherow RO (2000) The assessment of female pelvic floor dysfunction. BJU Int 85:579–587PubMedCrossRefGoogle Scholar
  2. 2.
    Bø K, Sherburn M (2007) Introduction. In: Bø K, Berghmans B, Mørkved S, Van Kampen M (eds) Evidence-based physical therapy for the pelvic floor, 1st edn. Elsevier, Philadelphia, pp 47–49Google Scholar
  3. 3.
    Abrams P, Cardozo L, Fall M, Griffiths D et al (2002) The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Am J Obstet Gynecol 187:116–126PubMedCrossRefGoogle Scholar
  4. 4.
    Glavind K, Nøhr S, Walter S (1992) Pelvic floor training using biofeedback for muscle awareness in the treatment of stress urinary incontinence: preliminary results. Int Urgoynecol J 3:288–291CrossRefGoogle Scholar
  5. 5.
    Burgio KL, Locher JL, Goode PS et al (1998) Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA 280:1995–2000PubMedCrossRefGoogle Scholar
  6. 6.
    Bø K (2007) Pelvic floor muscle training for stress urinary incontinence. In: Bø K, Berghmans B, Mørkved S, Van Kampen M (eds) Evidence-based physical therapy for the pelvic floor, 1st edn. Elsevier, Philadelphia, pp 171–186Google Scholar
  7. 7.
    Kegel AH (1948) Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynecol 56(2):238–248PubMedGoogle Scholar
  8. 8.
    Sherrington C, Herbert RD, Maher CG, Moseley AM (2000) PEDro. A database of randomized trials and systematic reviews in physiotherapy. Man Ther 5:223–226PubMedCrossRefGoogle Scholar
  9. 9.
    Higgins JPT, Green S (eds) (2011) Cochrane handbook for systematic reviews of interventions version 5.1.0 (updated March 2011). In: The Cochrane Collaboration. Available via www.cochrane-handbook.org
  10. 10.
    Review Manager (RevMan) (computer program). Version 5.1 (2011) The Nordic Cochrane Centre, The Cochrane Collaboration, CopenhagenGoogle Scholar
  11. 11.
    Meyer S, Hohlfeld P, Achtari C, De Grandi P (2001) Pelvic floor education after vaginal delivery. Obstet Gynecol 97(5 Pt 1):673–677PubMedCrossRefGoogle Scholar
  12. 12.
    Lee IS, Choi ES (2006) Pelvic floor muscle exercise by biofeedback and electrical stimulation to reinforce the pelvic floor muscle after normal delivery. Taehan Kanho Hakhoe Chi 36(8):1374–1380PubMedGoogle Scholar
  13. 13.
    Gallo ML G, Staskin DR (1997) Cues the action: pelvic floor muscle exercise compliance in women with stress urinary incontinence. Neurourol Urodyn 16(3):167–177PubMedCrossRefGoogle Scholar
  14. 14.
    Burgio KL, Goode PS, Locher JL et al (2002) Behavioral training with and without biofeedback in the treatment of urge incontinence in older women: a randomized controlled trial. JAMA 288:2293–2299PubMedCrossRefGoogle Scholar
  15. 15.
    Hui E, Lee PS, Woo J (2006) Management of urinary incontinence in older women using videoconferencing versus conventional management: a randomized controlled trial. J Telemed Telecare 12(7):343–347PubMedCrossRefGoogle Scholar
  16. 16.
    Wong KS, Fung KS, Fung SM, Fung CW, Tang CH (2001) Biofeedback of pelvic floor muscles in the management of genuine stress incontinence in Chinese women: randomised controlled trial. Physiotherapy 87(12):644–648CrossRefGoogle Scholar
  17. 17.
    Burgio KL, Locher JL, Goode PS (2000) Combined behavioral and drug therapy for urge incontinence in older women. J Am Geriatr Soc 48:370–374PubMedGoogle Scholar
  18. 18.
    Bocassanta P, Venturini M, Salamina G, Cesana BM, Bernasconi F, Roviaro G (2004) New trends in the surgical treatment of outlet obstruction: clinical and functional results of two novel transanal stapled techniques from a randomised controlled trial. Int J Colorectal Dis 19(4):359–369CrossRefGoogle Scholar
  19. 19.
    Goode PS (2004) Behavioral and drug therapy for urinary incontinence. Urology 63(3 Suppl 1):58–64PubMedCrossRefGoogle Scholar
  20. 20.
    Ilnyckyj A, Fachnie E, Tougas G (2005) A randomized-controlled trial comparing an educational intervention alone vs education and biofeedback in the management of faecal incontinence in women. Neurogastroenterol Motil 17:58–63PubMedCrossRefGoogle Scholar
  21. 21.
    Sherman RA, Davis GD, Wong MF (1997) Behavioral treatment of exercise-induced urinary incontinence among female soldiers. Mil Med 162:690–694PubMedGoogle Scholar
  22. 22.
    Wang AC (2000) Bladder-sphincter biofeedback as treatment of detrusor instability in women who failed to respond to oxybutynin. Chang Gung Med J 23(10):590–599PubMedGoogle Scholar
  23. 23.
    Castleden CM, Duffin HM, Mitchell EP (1984) The effect of physiotherapy on stress incontinence. Age Ageing 13:235–237PubMedCrossRefGoogle Scholar
  24. 24.
    Cammu H, Van Nylen M (1998) Pelvic floor exercises versus vaginal cones in genuine stress incontinence. Eur J Obstet Gynecol Reprod Biol 77:89–93PubMedCrossRefGoogle Scholar
  25. 25.
    Knight S, Laycock J, Naylor D (1998) Evaluation of neuromuscular electrical stimulation in the treatment of genuine stress incontinence. Physiotherapy 84(2):61–71CrossRefGoogle Scholar
  26. 26.
    Glavind K, Nøhr SB, Walter S (1996) Biofeedback and physiotherapy versus physiotherapy alone in the treatment of genuine stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 7:339–343PubMedCrossRefGoogle Scholar
  27. 27.
    Oresland T, Fasth S, Hultén L, Nordgren S, Swenson L, Akervall S (1988) Does balloon dilatation and anal sphincter training improve ileonal-pouch function? Int J Colorectal Dis 3(3):153–157PubMedCrossRefGoogle Scholar
  28. 28.
    Miner PB, Donnelly TC, Read NW (1990) Investigation of mode of action of biofeedback in treatment of fecal incontinence. Dig Dis Sci 35(10):1291–1298PubMedCrossRefGoogle Scholar
  29. 29.
    Awad R (1994) Biofeedback in the treatment of fecal incontinence. Rev Gastroenterol Mex 59(2):171–176PubMedGoogle Scholar
  30. 30.
    Enck P, Däublin G, Lübke HJ, Strohmeyer G (1994) Long-term efficacy of biofeedback training for fecal incontinence. Dis Colon Rectum 37(10):997–1001PubMedCrossRefGoogle Scholar
  31. 31.
    Bleijenberg G, Kuijpers HC (1994) Biofeedback treatment of constipation: a comparison of two methods. Am J Gastroenterol 89(7):1021–1026PubMedGoogle Scholar
  32. 32.
    Koutsomanis D, Lennard-Jones JE, Roy AJ, Kamm MA (1995) Controlled randomised trial of visual biofeedback versus muscle training without a visual display for intractable constipation. Gut 37(1):95–99PubMedCrossRefGoogle Scholar
  33. 33.
    Guillemot F, Bouche B, Gower-Rousseau C et al (1995) Biofeedback for the treatment of fecal incontinence. Long-term clinical results. Dis Colon Rectum 38(4):393–397PubMedCrossRefGoogle Scholar
  34. 34.
    Hämäläinen KJ, Raivio P, Antila S, Palmu A, Mecklin JP (1996) Biofeedback therapy in rectal prolapse patients. Dis Colon Rectum 39(3):262–265PubMedCrossRefGoogle Scholar
  35. 35.
    Engberg S, McDowel BJ, Donovan N, Brodak I, Weber E (1997) Treatment of urinary incontinence in homebound older adults: interface between research and practice. Ostomy Wound Manage 43(10):18–22PubMedGoogle Scholar
  36. 36.
    Heymen S, Wexner SD, Vickers D, Nogueras JJ, Weiss EG, Pikarsky AJ (1999) Prospective, randomized trial comparing four biofeedback techniques for patients with constipation. Dis Colon Rectum 42(11):1388–1393PubMedCrossRefGoogle Scholar
  37. 37.
    Glia A, Gylin M, Gullberg K, Lindberg G (1997) Biofeedback retraining in patients with functional constipation and paradoxical puborectalis contraction: comparison of anal manometry and sphincter electromyography for feedback. Dis Colon Rectum 40(8):889–895PubMedCrossRefGoogle Scholar
  38. 38.
    Pager CK, Solomon MJ, Rex J, Roberts RA (2002) Long-term outcomes of pelvic floor exercise and biofeedback treatment for patients with fecal incontinence. Dis Colon Rectum 45(8):997–1003PubMedCrossRefGoogle Scholar
  39. 39.
    Norton C, Chelvanayagana S, Wilson-Barnett J, Redfern S, Kamm MA (2003) Randomized controlled trial of biofeedback for fecal incontinence. Gastroenterology 125(5):1320–1329PubMedCrossRefGoogle Scholar
  40. 40.
    Solomon MJ, Pager CK, Rex J, Roberts R, Manning J (2003) Randomized, controlled trial of biofeedback with anal manometry, transanal ultrasound, or pelvic floor retraining with digital guidance alone in the treatment of mild to moderate fecal incontinence. Dis Colon Rectum 46(6):703–710PubMedCrossRefGoogle Scholar
  41. 41.
    Chang HS, Myung SJ, Yang SK et al (2003) Effect of electrical stimulation in constipated patients with impaired rectal sensation. Int J Colorectal Dis 18(5):433–438PubMedCrossRefGoogle Scholar
  42. 42.
    Chiaroni G, Whitehead WE, Pezza V, Morelli A, Bassoti G (2006) Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology 130(3):657–664CrossRefGoogle Scholar
  43. 43.
    Norton C, Gibbs A, Kamm MA (2006) Randomized, controlled trial of anal electrical stimulation for fecal incontinence. Dis Colon Rectum 49(2):190–196PubMedCrossRefGoogle Scholar
  44. 44.
    Byrne CM, Solomon MJ, Young JM, Rex J, Merlino CL (2007) Biofeedback for fecal incontinence: short-term outcomes of 513 consecutive patients and predictors of successful treatment. Dis Colon Rectum 50(4):417–427PubMedCrossRefGoogle Scholar
  45. 45.
    Heymen S, Scarlett Y, Jones K, Ringel Y, Drossman D, Whitehead WE (2007) Randomized, controlled trial shows biofeedback to be superior to alternative treatments for patients with pelvic floor dyssynergia-type constipation. Dis Colon Rectum 50(4):428–441PubMedCrossRefGoogle Scholar
  46. 46.
    Rao SS, Seaton K, Miller M et al (2007) Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol 5(3):331–338PubMedCrossRefGoogle Scholar
  47. 47.
    Remes-Troche JM, Ozturk R, Philips C, Stessman M, Rao SS (2008) Cholestyramine—a useful adjunct for the treatment of patients with fecal incontinence. Int J Colorectal Dis 23(2):189–194PubMedCrossRefGoogle Scholar
  48. 48.
    Simón MA, Bueno AM (2009) Behavioural treatment of the dyssynergic defecation in chronically constipated elderly patients: a randomized controlled trial. Appl Psychophysiol Biofeedback 34(4):273–277PubMedCrossRefGoogle Scholar
  49. 49.
    Faried M, El Monem HA, Omar M et al (2009) Comparative study between biofeedback retraining and botulinum neurotoxin in the treatment of anismus patients. Int J Colorectal Dis 24(1):115–120CrossRefGoogle Scholar
  50. 50.
    Schwandner T, König IR, Heimerl T et al (2010) Triple target treatment (3T) is more effective than biofeedback alone for anal incontinence: the 3T-AI study. Dis Colon Rectum 53(7):1007–1016PubMedCrossRefGoogle Scholar
  51. 51.
    Rao SS, Valestin J, Brown CK, Zimmerman B, Schulze K (2010) Long-term efficacy of biofeedback therapy for dyssynergic defecation: randomized controlled trial. Am J Gastroenterol 105(4):890–896PubMedCrossRefGoogle Scholar
  52. 52.
    Faried M, El Nakeeb A, Youssef M, Omar W, El Monem HA (2010) Comparative study between surgical and non-surgical treatment of anismus in patients with symptoms of obstructed defecation: a prospective randomized study. J Gastrointest Surg 14(8):1235–1243PubMedCrossRefGoogle Scholar
  53. 53.
    Engberg S, McDowell BJ, Weber E, Brodak I, Donovan N, Engberg R (1997) Assessment and management of urinary incontinence among homebound older adults: a clinical trial protocol. Adv Pract Nurs Q 3(2):48–56PubMedGoogle Scholar
  54. 54.
    Burns PA, Pranikoff K, Nochajski T, Desotelle P, Harwood MK (1990) Treatment of stress incontinence with pelvic floor exercises and biofeedback. J Am Geriatr Soc 38(3):341–344PubMedGoogle Scholar
  55. 55.
    Berghmans LCM, Frederiks CMA, de Bie RA, Weil EHJ, Smeets LWH, van Waalwijk van Doorn ESC, Janknegt RA (1996) Efficacy of biofeedback, when included with pelvic floor muscle exercise treatment, for genuine stress incontinence. Neurourol Urodyn 15:37–52PubMedCrossRefGoogle Scholar
  56. 56.
    Mørkved S, Bø K, Fjortoft T (2002) Effect of adding biofeedback to pelvic floor muscle training to treat urodynamic stress incontinence. Obstet Gynecol 100(4):730–739PubMedCrossRefGoogle Scholar
  57. 57.
    Ferguson KL, McKey PL, Bishop KR, Kloen P, Verheul JB, Dougherty MC (1990) Stress urinary incontinence: effect of pelvic muscle exercise. Obstet Gynecol 75(4):671–675PubMedGoogle Scholar
  58. 58.
    Pages IH, Jahr S, Schaufele MK, Conradi E (2001) Comparative analysis of biofeedback and physical therapy for treatment of urinary stress incontinence in women. Am J Phys Med Rehabil 80:494–502PubMedCrossRefGoogle Scholar
  59. 59.
    Demirtürk F, Akbayrak T, Karakaya IC et al (2008) Interferential current versus biofeedback results in urinary stress incontinence. Swiss Med Wkly 138(21–22):317–321PubMedGoogle Scholar
  60. 60.
    Schmidt AP, Sanches PRS, Silva DP, Ramos JGL, Nohama P (2009) A new pelvic muscle trainer for the treatment of urinary incontinence. Int J Gynaecol Obstet 105:218–222PubMedCrossRefGoogle Scholar
  61. 61.
    Wang AC, Wang YY, Chen MC (2004) Single-blind, randomized trial of pelvic floor muscle training, biofeedback-assisted pelvic floor muscle training, and electrical stimulation in the management of overactive bladder. Urology 63:61–66PubMedCrossRefGoogle Scholar
  62. 62.
    Wyman JF, Fantl JA, McClish DK, Bump RC (1998) Comparative efficacy of behavioral interventions in the management of female urinary incontinence. Continence Program for Women Research Group. Am J Obstet Gynecol 179(4):999–1007PubMedCrossRefGoogle Scholar
  63. 63.
    Laycock J, Brown J, Cusack C et al (2001) Pelvic floor reeducation for stress incontinence: comparing three methods. Br J Community Nurs 6(5):230–237PubMedGoogle Scholar
  64. 64.
    Dougherty MC, Dwyer JW, Pendergast JF et al (2002) A randomized trial of behavioral management for continence with older rural women. Res Nurs Health 25:3–13PubMedCrossRefGoogle Scholar
  65. 65.
    Aksac B, Aki S, Karan A, Yalcin O, Isikoglu M, Eskiyurt N (2003) Biofeedback and pelvic floor exercises for the rehabilitation of urinary stress incontinence. Gynecol Obstet Invest 56:23–27PubMedCrossRefGoogle Scholar
  66. 66.
    Shepherd AM, Montgomery E, Anderson RS (1983) Treatment of genuine stress incontinence with a new perineometer. Physiotherapy 69(4):113PubMedGoogle Scholar
  67. 67.
    Burns PA, Pranikoff K, Nochajski TH, Hadley EC, Levy KJ, Ory MG (1993) A comparison of effectiveness of biofeedback and pelvic muscle exercise treatment of stress incontinence in older community-dwelling women. J Gerontol 48(4):M167–M174PubMedGoogle Scholar
  68. 68.
    Aukee P, Immonem P, Penttinen J, Laippala P, Airaksinen O (2002) Increase in pelvic floor muscle activity after 12 weeks’ training: a randomized prospective pilot study. Urology 60(6):1020–1023PubMedCrossRefGoogle Scholar
  69. 69.
    Aukee P, Immonen P, Laaksonen DE, Laippala P, Penttinen J, Airaksinen O (2004) The effect of home biofeedback training on stress incontinence. Acta Obstet Gynecol Scand 83:973–977PubMedGoogle Scholar
  70. 70.
    Fynes MM, Marshall K, Cassidy M et al (1999) A prospective, randomized study comparing the effect of augmented biofeedback with sensory biofeedback alone on fecal incontinence after obstetric trauma. Dis Colon Rectum 42:753–761PubMedCrossRefGoogle Scholar
  71. 71.
    Mahony RT, Malone PA, Nalty J, Behan M, O’Connell PR, O’Herlihy C (2004) Randomized clinical trial of intra-anal electromyographic biofeedback physiotherapy with intra-anal electromyographic biofeedback augmented with electrical stimulation of the anal sphincter in the early treatment of postpartum fecal incontinence. Am J Obstet Gynecol 191:885–890PubMedCrossRefGoogle Scholar
  72. 72.
    Naimy N, Lindam AT, Bakka A et al (2007) Biofeedback vs. electrostimulation in the treatment of postdelivery anal incontinence: a randomized, clinical trial. Dis Colon Rectum 50:2040–2046PubMedCrossRefGoogle Scholar
  73. 73.
    Bergeron S, Binik YM, Khalifé S et al (2001) A randomized comparison of group cognitive-behavioral therapy, surface electromyographic biofeedback, and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis. Pain 91:297–306PubMedCrossRefGoogle Scholar
  74. 74.
    Danielsson I, Torstensson T, Brodda-Jansen G, Bohm-Starke N (2006) EMG biofeedback versus topical lidocaine gel: a randomized study for the treatment of women with vulvar vestibulitis. Acta Obstet Gynecol 85:1360–1367CrossRefGoogle Scholar
  75. 75.
    Bergeron S, Khalifé S, Glazer HI, Binik YM (2008) Surgical and behavioral treatments for vestibulodynia: two-and-one-half year follow-up and predictors of outcome. Obstet Gynecol 111(1):159–166PubMedCrossRefGoogle Scholar
  76. 76.
    Bohm-Starke N, Brodda-Jansen G, Linder J, Danielsson I (2007) The result of treatment on vestibular and general pain thresholds in women with provoked vestibulodynia. Clin J Pain 23:598–604PubMedCrossRefGoogle Scholar
  77. 77.
    Berghmans LCM, Bernards ATM, Hendriks HLM et al (1998) Guidelines for the physiotherapeutic management of genuine stress incontinence. Phys Ther Rev 3(3):133–147CrossRefGoogle Scholar
  78. 78.
    Bø K, Talseth T (1996) Long-term effect of pelvic floor muscle exercise 5 years after cessation of organized training. Obstet Gynecol 87:261–265PubMedCrossRefGoogle Scholar
  79. 79.
    Chen HY, Chang WC, Lin WC et al (1999) Efficacy of pelvic floor rehabilitation for treatment of genuine stress incontinence. J Formos Med Assoc 98:271–276PubMedGoogle Scholar
  80. 80.
    Lagro-Janssen ALM, van Weel C (1998) Long-term effect of treatment of female incontinence in general practice. Br J Gen Pract 48:1735–1738PubMedGoogle Scholar
  81. 81.
    Sluijs EM, Knibbe JJ (1991) Patient compliance with exercise: different theoretical approaches to short-term and long-term compliance. Patient Educ Couns 17:191–204CrossRefGoogle Scholar
  82. 82.
    Sluijs EM, Kok GJ, van der Zee J (1993) Correlates of exercise compliance in physical therapy. Phys Ther 73(11):771–782PubMedGoogle Scholar
  83. 83.
    Pescatori M, Anastasio G, Bottini C, Mentasti A (1992) New grading and scoring for anal incontinence. Evaluation of 335 patients. Dis Colon Rectum 35:482–487PubMedCrossRefGoogle Scholar
  84. 84.
    Dougherty MC, Bishop KR, Abrams RM, Batich CD, Gimotty PA (1989) The effect of exercise on the circumvaginal muscles in postpartum women. J Nurse Midwifery 34:8–14PubMedCrossRefGoogle Scholar
  85. 85.
    Wyman JF, Fantl JA (1991) Bladder training in ambulatory care management of urinary incontinence. Urol Nurs 11(3):11–7PubMedGoogle Scholar
  86. 86.
    Bø K, Kvarstein B, Hagen R, Larsen S (1990) Pelvic floor muscle exercise for the treatment of female stress urinary incontinence. Neurourol Urodyn 9:471–7CrossRefGoogle Scholar

Copyright information

© The International Urogynecological Association 2012

Authors and Affiliations

  • Fátima Faní Fitz
    • 1
    Email author
  • Ana Paula Magalhães Resende
    • 1
  • Liliana Stüpp
    • 1
  • Marair Gracio Ferreira Sartori
    • 1
  • Manoel João Batista Castello Girão
    • 1
  • Rodrigo Aquino Castro
    • 1
  1. 1.Department of GynecologyFederal University of São PauloSão PauloBrazil

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