human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND AND PURPOSE It has been suggested that cyclic neuromuscular electrical stimulation ( ES ) may enhance motor recovery after stroke . We have investigated the effects of ES of the wrist extensors on impairment of wrist function and on upper-limb disability in patients being rehabilitated after acute stroke . METHODS We recruited 60 hemiparetic patients ( mean age , 68 years ) 2 to 4 weeks after stroke into a r and omized , controlled , parallel-group study comparing st and ard rehabilitation treatment with st and ard treatment plus ES of wrist extensors ( 3 times 30 minutes daily for 8 weeks ) . Isometric strength of wrist extensors was measured using a device built for that purpose . Upper-limb disability was assessed with use of the  Action Research Arm Test ( ARAT ) . Observations were continued for 32 weeks ( 24 weeks after the finish of ES or the control intervention phase ) . RESULTS The change in isometric strength of wrist extensors ( at an angle of 0 degrees extension ) was significantly greater in the ES group than the control group at both 8 and 32 weeks ( P=0.004 , P=0.014 by Mann Whitney U test ) . At week 8 the grasp and grip subscores of the ARAT increased significantly in the ES group compared with that in the control group ( P=0.013 and P=0.02 , respectively ) ; a similar trend was seen for the total ARAT score ( P=0.11 ) . In the subgroup of 33 patients with some residual wrist extensor strength at study entry ( moment at 0 degrees extension > 0 ) , the ARAT total score had increased at week 8 by a mean of 21.1 ( SD , 12.7 ) in the ES group compared with 10.3 ( SD , 9.0 ) in the control group ( P=0.024 , Mann Whitney U test ) ; however , at 32 weeks the differences between these 2 subgroups were no longer statistically significant . CONCLUSIONS ES of the wrist extensors enhances the recovery of isometric wrist extensor strength in hemiparetic stroke patients .  Upper-limb disability was reduced after 8 weeks of ES therapy , with benefits most apparent in those with some residual motor function at the wrist . However , it is not clear how long the improvements in upper-limb disability are maintained after ES is discontinued Background and Purpose Motor dysfunction after unilateral deafferentation in primates can be overcome by restraining the unaffected limb . We asked whether a constraint-induced movement ( CIM ) program could be implemented within 2 weeks after stroke and whether CIM is more effective than traditional upper-extremity ( UE ) therapies during this period . Methods Twenty-three persons were enrolled in a pilot r and omized , controlled trial that compared CIM with traditional therapies . A blinded observer rated the primary end point , the Action Research Arm Test ( ARA ) .  Inclusion criteria were the following : ischemic stroke within 14 days , persistent hemiparesis , evidence of preserved cognitive function , and presence of a protective motor response . Differences between the groups were compared by using Student ’s t tests , ANCOVA , and Mann-Whitney U tests . Results Twenty subjects completed the 14-day treatment . Two adverse outcomes , a recurrent stroke and a death , occurred in the traditional group ; 1 CIM subject met rehabilitation goals and was discharged before completing 14 inpatient days . The CIM treatment group had significantly higher scores on total ARA and pinch subscale scores ( P < 0.05 ) . Differences in the mean ARA grip , grasp , and gross movement subscale scores did not reach statistical significance . UE activities of daily living performance was not significantly different between groups , and no subject withdrew because of pain or frustration . Conclusions A clinical trial of CIM therapy during acute rehabilitation is feasible . CIM was associated with less arm impairment at the end of treatment . Long-term studies are needed to determine whether CIM early after stroke is superior to traditional therapies The primary goal of this study was to assess whether repetitive practice of flexion-extension movements of the affected elbow in hemiparetic patients enhances performance and to compare the effects of this practice mode to the effects of the physical therapy variable exercise program which is routinely applied during sessions . Subjects were 27 poststroke hemiparetic patients , residents of a rehabilitation institute , divided into an experimental ( n= 15 ) and a control group ( n = 12 ) . The former were treated with 800 repeated elbow movements in a maximal predetermined amplitude of 80 ° , provided in 8 equal sessions every other day . The latter received 10 min . of conventional physical therapy for the paretic upper extremity at similar time intervals . Pre- and posttreatment assessment s included the bilateral measurements of kinematic variables and activation latencies of the biceps and triceps brachi muscles as well as motor and functional tests . For all criterion variables , the findings pointed to comparable improvement in both groups . It was concluded that repetitive elbow movements had no unique training effect on the kinematics of movement and on activation latencies of the primary muscles controlling elbow function in hemiparetic patients . Further , transfer of the effects of training to execution of movements towards and from the mouth was also comparable in both groups , pointing again to there being no particular advantage in using repetitive movements as a training mode for enhancement of elbow function in hemiparetic patients Positional feedback ( PF ) and electrical stimulation were combined in a new treatment modality for facilitating wrist extension in stroke patients . Thirty adult hemiparetic patients lacking normal voluntary wrist extension were r and omly placed in control and study groups . The control group received conventional therapy while the study group received positional feedback stimulation training ( PFST ) in addition to conventional treatment . At the end of the 4-week program , study patients showed a 280 % increase in isometric extension torque when the wrist was positioned in 30 degrees of extension and 70 % increase when positioned in 30 degrees of flexion . Control patients showed no significant changes in torque . Study patients made an average 200 % gain in selective range of motion over their starting levels while controls made only a 50 % increase . Treatment using automated PFST equipment allows controlled repetitive isotonic exercise and facilitation of wrist extension without continuous one-on-one therapist/patient supervision BACKGROUND AND PURPOSE After stroke , many individuals have chronic unilateral motor dysfunction in the upper extremity that severely limits their functional movement control . The purpose of this study was to determine the effect of electromyography-triggered neuromuscular electrical stimulation on the wrist and finger extension muscles in individuals who had a stroke > or = 1 year earlier . METHODS Eleven individuals volunteered to participate and were r and omly assigned to either the electromyography-triggered neuromuscular stimulation experimental group ( 7 subjects ) or the control group ( 4 subjects ) . After completing a pretest involving 5 motor capability tests , the poststroke subjects completed 12 treatment sessions ( 30 minutes each ) according to group assignments . Once the control subjects completed 12 sessions attempting wrist and finger extension without any external assistance and were posttested , they were then given 12 sessions of the rehabilitation treatment . RESULTS The Box and Block test and the force-generation task ( sustained muscular contraction ) revealed significant findings ( P<0 . 05 ) . The experimental group moved significantly more blocks and displayed a higher isometric force impulse after the rehabilitation treatment . CONCLUSIONS Two lines of evidence clearly support the use of the electromyography-triggered neuromuscular electrical stimulation treatment to rehabilitate wrist and finger extension movements of hemiparetic individuals > or = 1 year after stroke . The treatment program decreased motor dysfunction and improved the motor capabilities in this group of poststroke individuals BACKGROUND AND PURPOSE Subluxation is a significant problem in poststroke hemiplegia , result ing in pain and loss of function . Current treatments are not proved and not considered effective . It has been demonstrated that cyclical electrical stimulation of the shoulder muscles can reduce existing subluxation . The purpose of this study was to determine whether electrical stimulation could prevent subluxation in both the short and long terms . METHODS A prospect i ve , r and omized controlled study was used to determine the efficacy of electrical stimulation in preventing shoulder subluxation in patients after cerebrovascular accidents . Forty patients were selected and r and omly assigned to a control or treatment group . They had their first assessment within 48 hours of their stroke , and those in the treatment group were immediately put on a regimen of electrical stimulation for 4 weeks . All patients were assessed at 4 weeks after stroke and then again at 12 weeks after stroke . Assessment s were made of shoulder subluxation , pain , and motor control . RESULTS The treatment group had significantly less subluxation and pain after the treatment period , but at the end of the follow-up period there were no significant differences between the 2 groups . CONCLUSIONS Electrical stimulation can prevent shoulder subluxation , but this effect was not maintained after the withdrawal of treatment BACKGROUND AND PURPOSE Many stroke survivors have minimal to moderate neurological deficits but are physically deconditioned and have a high prevalence of cardiovascular problems ; all of these are potentially modifiable with exercise . The purpose s of this r and omized , controlled pilot study were ( 1 ) to develop a home-based balance , strength , and endurance program ; ( 2 ) to evaluate the ability to recruit and retain stroke subjects ; and ( 3 ) to assess the effects of the interventions used . METHODS Twenty minimally and moderately impaired stroke patients who had completed inpatient rehabilitation and who were 30 to 90 days after stroke onset were r and omized to a  control group or to an experimental group that received a therapist-supervised , 8-week , 3-times-per-week , home-based exercise program . The control group received usual care as prescribed by the patients ' physicians . Baseline and postintervention assessment s included the Fugl-Meyer Motor Assessment , the Barthel Index of Activities of Daily Living ( ADL ) , the Lawton Scale of Instrumental ADL , and the Medical Outcomes Study -36 Health Status Measurement . Functional assessment s of balance and gait included a 10-m walk , 6-Minute Walk , and the Berg Balance Scale . Upper extremity function was evaluated by the Jebsen Test of H and Function . RESULTS Of 22 patients who met study criteria , 20 completed the study and 2 refused to participate . The experimental group tended to improve more than the control group in motor function ( Fugl-Meyer Upper Extremity : mean change in score , 8 . 4 versus 2.2 ; Fugl-Meyer Lower Extremity : 4.7 versus -0.9 ; gait velocity : median change , 0.25 versus .09 m/s ; 6-Minute Walk : 195 versus 114 ft ; Berg Balance Score : 7.8 versus 5 ; and Medical Outcomes Study -36 Health Status Measurement of Physical Function : 15 . 5 versus 9 ) . There were no trends in differences in change scores by the Jebsen Test of H and Function , Barthel Index , and Lawton Instrumental ADL Scale . CONCLUSIONS This study demonstrated that a r and omized , controlled clinical trial of a poststroke exercise program is feasible . Measures of neurological impairments and lower extremity function showed the most benefit . Effects of the intervention on upper extremity dexterity and functional health status were equivocal . The lasting effects of the intervention were not assessed BACKGROUND AND PURPOSE Of all stroke survivors , 30 % to 66 % are unable to use their affected arm in performing activities of daily living . Although forced use therapy appears to improve arm function in chronic stroke patients , there is no conclusive evidence . This study evaluates the effectiveness of forced use therapy . METHODS In an observer-blinded r and omized clinical trial , 66 chronic stroke patients were allocated to either forced use therapy ( immobilization of the unaffected arm combined with intensive training ) or a reference therapy of equally intensive bimanual training , based on Neuro-Developmental Treatment , for a period of 2 weeks . Outcomes were evaluated on the basis of the Rehabilitation Activities Profile ( activities ) , the Action Research Arm ( ARA ) test ( dexterity ) , the upper extremity section of the Fugl-Meyer Assessment scale , the Motor Activity Log ( MAL ) , and a Problem Score . The minimal clinical ly important difference ( MCID ) was determined at the onset of the study . RESULTS One week after the last treatment session , a significant difference in effectiveness in favor of the forced use group compared with the bimanual group ( corrected for baseline differences ) was found for the ARA score ( 3.0 points ; 95 % CI , 1.3 to 4.8 ; MCID , 5.7 points ) and the MAL amount of use score ( 0.52 points ; 95 % CI , 0.11 to 0.93 ; MCID , 0.50 ) . The other parameters revealed no significant differential effects . One-year follow-up effects were observed only for the ARA . The differences in treatment effect for the ARA and the MAL amount of use scores were clinical ly relevant for patients with sensory disorders and hemineglect , respectively . CONCLUSIONS The present study showed a small but lasting effect of forced use therapy on the dexterity of the affected arm ( ARA ) and a temporary clinical ly relevant effect on the amount of use of the affected arm during activities of daily living ( MAL amount of use ) . The effect of forced use therapy was clinical ly relevant in the subgroups of patients with sensory disorders and hemineglect , respectively The purpose of this study was to evaluate the effectiveness of a functional electrical stimulation ( FES ) treatment program design ed to prevent glenohumeral joint stretching and subsequent subluxation and shoulder pain in stroke patients . Twenty-six recent hemiplegic stroke patients with shoulder muscle flaccidity were r and omly assigned to either a control group ( n = 13 ; 5 female , and 8 male ) or experimental group ( n = 13 ; 6 female , and 7 male ) . Both groups received conventional physical ther 
    Output:
    
agent
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND AND PURPOSE It has been suggested that cyclic neuromuscular electrical stimulation ( ES ) may enhance motor recovery after stroke . We have investigated the effects of ES of the wrist extensors on impairment of wrist function and on upper-limb disability in patients being rehabilitated after acute stroke . METHODS We recruited 60 hemiparetic patients ( mean age , 68 years ) 2 to 4 weeks after stroke into a r and omized , controlled , parallel-group study comparing st and ard rehabilitation treatment with st and ard treatment plus ES of wrist extensors ( 3 times 30 minutes daily for 8 weeks ) . Isometric strength of wrist extensors was measured using a device built for that purpose . Upper-limb disability was assessed with use of the  Action Research Arm Test ( ARAT ) . Observations were continued for 32 weeks ( 24 weeks after the finish of ES or the control intervention phase ) . RESULTS The change in isometric strength of wrist extensors ( at an angle of 0 degrees extension ) was significantly greater in the ES group than the control group at both 8 and 32 weeks ( P=0.004 , P=0.014 by Mann Whitney U test ) . At week 8 the grasp and grip subscores of the ARAT increased significantly in the ES group compared with that in the control group ( P=0.013 and P=0.02 , respectively ) ; a similar trend was seen for the total ARAT score ( P=0.11 ) . In the subgroup of 33 patients with some residual wrist extensor strength at study entry ( moment at 0 degrees extension > 0 ) , the ARAT total score had increased at week 8 by a mean of 21.1 ( SD , 12.7 ) in the ES group compared with 10.3 ( SD , 9.0 ) in the control group ( P=0.024 , Mann Whitney U test ) ; however , at 32 weeks the differences between these 2 subgroups were no longer statistically significant . CONCLUSIONS ES of the wrist extensors enhances the recovery of isometric wrist extensor strength in hemiparetic stroke patients .  Upper-limb disability was reduced after 8 weeks of ES therapy , with benefits most apparent in those with some residual motor function at the wrist . However , it is not clear how long the improvements in upper-limb disability are maintained after ES is discontinued Background and Purpose Motor dysfunction after unilateral deafferentation in primates can be overcome by restraining the unaffected limb . We asked whether a constraint-induced movement ( CIM ) program could be implemented within 2 weeks after stroke and whether CIM is more effective than traditional upper-extremity ( UE ) therapies during this period . Methods Twenty-three persons were enrolled in a pilot r and omized , controlled trial that compared CIM with traditional therapies . A blinded observer rated the primary end point , the Action Research Arm Test ( ARA ) .  Inclusion criteria were the following : ischemic stroke within 14 days , persistent hemiparesis , evidence of preserved cognitive function , and presence of a protective motor response . Differences between the groups were compared by using Student ’s t tests , ANCOVA , and Mann-Whitney U tests . Results Twenty subjects completed the 14-day treatment . Two adverse outcomes , a recurrent stroke and a death , occurred in the traditional group ; 1 CIM subject met rehabilitation goals and was discharged before completing 14 inpatient days . The CIM treatment group had significantly higher scores on total ARA and pinch subscale scores ( P < 0.05 ) . Differences in the mean ARA grip , grasp , and gross movement subscale scores did not reach statistical significance . UE activities of daily living performance was not significantly different between groups , and no subject withdrew because of pain or frustration . Conclusions A clinical trial of CIM therapy during acute rehabilitation is feasible . CIM was associated with less arm impairment at the end of treatment . Long-term studies are needed to determine whether CIM early after stroke is superior to traditional therapies The primary goal of this study was to assess whether repetitive practice of flexion-extension movements of the affected elbow in hemiparetic patients enhances performance and to compare the effects of this practice mode to the effects of the physical therapy variable exercise program which is routinely applied during sessions . Subjects were 27 poststroke hemiparetic patients , residents of a rehabilitation institute , divided into an experimental ( n= 15 ) and a control group ( n = 12 ) . The former were treated with 800 repeated elbow movements in a maximal predetermined amplitude of 80 ° , provided in 8 equal sessions every other day . The latter received 10 min . of conventional physical therapy for the paretic upper extremity at similar time intervals . Pre- and posttreatment assessment s included the bilateral measurements of kinematic variables and activation latencies of the biceps and triceps brachi muscles as well as motor and functional tests . For all criterion variables , the findings pointed to comparable improvement in both groups . It was concluded that repetitive elbow movements had no unique training effect on the kinematics of movement and on activation latencies of the primary muscles controlling elbow function in hemiparetic patients . Further , transfer of the effects of training to execution of movements towards and from the mouth was also comparable in both groups , pointing again to there being no particular advantage in using repetitive movements as a training mode for enhancement of elbow function in hemiparetic patients Positional feedback ( PF ) and electrical stimulation were combined in a new treatment modality for facilitating wrist extension in stroke patients . Thirty adult hemiparetic patients lacking normal voluntary wrist extension were r and omly placed in control and study groups . The control group received conventional therapy while the study group received positional feedback stimulation training ( PFST ) in addition to conventional treatment . At the end of the 4-week program , study patients showed a 280 % increase in isometric extension torque when the wrist was positioned in 30 degrees of extension and 70 % increase when positioned in 30 degrees of flexion . Control patients showed no significant changes in torque . Study patients made an average 200 % gain in selective range of motion over their starting levels while controls made only a 50 % increase . Treatment using automated PFST equipment allows controlled repetitive isotonic exercise and facilitation of wrist extension without continuous one-on-one therapist/patient supervision BACKGROUND AND PURPOSE After stroke , many individuals have chronic unilateral motor dysfunction in the upper extremity that severely limits their functional movement control . The purpose of this study was to determine the effect of electromyography-triggered neuromuscular electrical stimulation on the wrist and finger extension muscles in individuals who had a stroke > or = 1 year earlier . METHODS Eleven individuals volunteered to participate and were r and omly assigned to either the electromyography-triggered neuromuscular stimulation experimental group ( 7 subjects ) or the control group ( 4 subjects ) . After completing a pretest involving 5 motor capability tests , the poststroke subjects completed 12 treatment sessions ( 30 minutes each ) according to group assignments . Once the control subjects completed 12 sessions attempting wrist and finger extension without any external assistance and were posttested , they were then given 12 sessions of the rehabilitation treatment . RESULTS The Box and Block test and the force-generation task ( sustained muscular contraction ) revealed significant findings ( P<0 . 05 ) . The experimental group moved significantly more blocks and displayed a higher isometric force impulse after the rehabilitation treatment . CONCLUSIONS Two lines of evidence clearly support the use of the electromyography-triggered neuromuscular electrical stimulation treatment to rehabilitate wrist and finger extension movements of hemiparetic individuals > or = 1 year after stroke . The treatment program decreased motor dysfunction and improved the motor capabilities in this group of poststroke individuals BACKGROUND AND PURPOSE Subluxation is a significant problem in poststroke hemiplegia , result ing in pain and loss of function . Current treatments are not proved and not considered effective . It has been demonstrated that cyclical electrical stimulation of the shoulder muscles can reduce existing subluxation . The purpose of this study was to determine whether electrical stimulation could prevent subluxation in both the short and long terms . METHODS A prospect i ve , r and omized controlled study was used to determine the efficacy of electrical stimulation in preventing shoulder subluxation in patients after cerebrovascular accidents . Forty patients were selected and r and omly assigned to a control or treatment group . They had their first assessment within 48 hours of their stroke , and those in the treatment group were immediately put on a regimen of electrical stimulation for 4 weeks . All patients were assessed at 4 weeks after stroke and then again at 12 weeks after stroke . Assessment s were made of shoulder subluxation , pain , and motor control . RESULTS The treatment group had significantly less subluxation and pain after the treatment period , but at the end of the follow-up period there were no significant differences between the 2 groups . CONCLUSIONS Electrical stimulation can prevent shoulder subluxation , but this effect was not maintained after the withdrawal of treatment BACKGROUND AND PURPOSE Many stroke survivors have minimal to moderate neurological deficits but are physically deconditioned and have a high prevalence of cardiovascular problems ; all of these are potentially modifiable with exercise . The purpose s of this r and omized , controlled pilot study were ( 1 ) to develop a home-based balance , strength , and endurance program ; ( 2 ) to evaluate the ability to recruit and retain stroke subjects ; and ( 3 ) to assess the effects of the interventions used . METHODS Twenty minimally and moderately impaired stroke patients who had completed inpatient rehabilitation and who were 30 to 90 days after stroke onset were r and omized to a  control group or to an experimental group that received a therapist-supervised , 8-week , 3-times-per-week , home-based exercise program . The control group received usual care as prescribed by the patients ' physicians . Baseline and postintervention assessment s included the Fugl-Meyer Motor Assessment , the Barthel Index of Activities of Daily Living ( ADL ) , the Lawton Scale of Instrumental ADL , and the Medical Outcomes Study -36 Health Status Measurement . Functional assessment s of balance and gait included a 10-m walk , 6-Minute Walk , and the Berg Balance Scale . Upper extremity function was evaluated by the Jebsen Test of H and Function . RESULTS Of 22 patients who met study criteria , 20 completed the study and 2 refused to participate . The experimental group tended to improve more than the control group in motor function ( Fugl-Meyer Upper Extremity : mean change in score , 8 . 4 versus 2.2 ; Fugl-Meyer Lower Extremity : 4.7 versus -0.9 ; gait velocity : median change , 0.25 versus .09 m/s ; 6-Minute Walk : 195 versus 114 ft ; Berg Balance Score : 7.8 versus 5 ; and Medical Outcomes Study -36 Health Status Measurement of Physical Function : 15 . 5 versus 9 ) . There were no trends in differences in change scores by the Jebsen Test of H and Function , Barthel Index , and Lawton Instrumental ADL Scale . CONCLUSIONS This study demonstrated that a r and omized , controlled clinical trial of a poststroke exercise program is feasible . Measures of neurological impairments and lower extremity function showed the most benefit . Effects of the intervention on upper extremity dexterity and functional health status were equivocal . The lasting effects of the intervention were not assessed BACKGROUND AND PURPOSE Of all stroke survivors , 30 % to 66 % are unable to use their affected arm in performing activities of daily living . Although forced use therapy appears to improve arm function in chronic stroke patients , there is no conclusive evidence . This study evaluates the effectiveness of forced use therapy . METHODS In an observer-blinded r and omized clinical trial , 66 chronic stroke patients were allocated to either forced use therapy ( immobilization of the unaffected arm combined with intensive training ) or a reference therapy of equally intensive bimanual training , based on Neuro-Developmental Treatment , for a period of 2 weeks . Outcomes were evaluated on the basis of the Rehabilitation Activities Profile ( activities ) , the Action Research Arm ( ARA ) test ( dexterity ) , the upper extremity section of the Fugl-Meyer Assessment scale , the Motor Activity Log ( MAL ) , and a Problem Score . The minimal clinical ly important difference ( MCID ) was determined at the onset of the study . RESULTS One week after the last treatment session , a significant difference in effectiveness in favor of the forced use group compared with the bimanual group ( corrected for baseline differences ) was found for the ARA score ( 3.0 points ; 95 % CI , 1.3 to 4.8 ; MCID , 5.7 points ) and the MAL amount of use score ( 0.52 points ; 95 % CI , 0.11 to 0.93 ; MCID , 0.50 ) . The other parameters revealed no significant differential effects . One-year follow-up effects were observed only for the ARA . The differences in treatment effect for the ARA and the MAL amount of use scores were clinical ly relevant for patients with sensory disorders and hemineglect , respectively . CONCLUSIONS The present study showed a small but lasting effect of forced use therapy on the dexterity of the affected arm ( ARA ) and a temporary clinical ly relevant effect on the amount of use of the affected arm during activities of daily living ( MAL amount of use ) . The effect of forced use therapy was clinical ly relevant in the subgroups of patients with sensory disorders and hemineglect , respectively The purpose of this study was to evaluate the effectiveness of a functional electrical stimulation ( FES ) treatment program design ed to prevent glenohumeral joint stretching and subsequent subluxation and shoulder pain in stroke patients . Twenty-six recent hemiplegic stroke patients with shoulder muscle flaccidity were r and omly assigned to either a control group ( n = 13 ; 5 female , and 8 male ) or experimental group ( n = 13 ; 6 female , and 7 male ) . Both groups received conventional physical ther 
    Output:
    