Therapeutic massage for hip dysplasia in newborns
Hip dysplasia, or congenital hip dislocation, is a common pathology in infants, which is congenital and consists in the underdevelopment of the structural elements of the hip joint at the time of birth. This in turn leads to a mismatch between the articular surfaces and dislocation.
Despite the fact that this diagnosis is very widespread and causes parents to be horrified, congenital dislocation of the thigh is perfectly treatable, provided that the pathology is noticed on time and the parents have the time and patience to deal with the health of their baby.
In most cases, therapeutic exercises and massage will help with dysplasia of the hip joints. In more complex variants resort to the use of treatment by position( special fixing orthopedic devices for the child) and surgical correction of the dislocation.
How in time to suspect a problem?
The first thing to understand is that something is wrong with the baby, so pay attention to the signs that indicate a congenital hip dislocation in the newborn:
- the length of the legs in the child is not the same: if the lying on the back of the baby bend the lower limbs in the knees, andheel to move to the buttocks, then the knees should be on the same level, if it does not - legs have different lengths;
- asymmetric wrinkles on the legs and buttocks, but this symptom is often found in healthy children who simply have unevenly distributed subcutaneous fatty tissue;
- incomplete dilution of the legs of the child, bent in the knees: in a healthy kid, the angle of such an outreach reaches 80-90 degrees, with dysplasia it is limited, but one should not forget about the physiological hypertension of the muscles of the newborn until 3-4 months, which can create a pseudo-restriction of the dilution of the legs;
- click symptom: when breeding the legs, the mother feels a characteristic click in the hip joints.
Asymmetry of the skin folds with hip dysplasia
The signs described above are not the ones that confirm the diagnosis, so if they are found in your child, do not panic - show the baby to the pediatrician and orthopedist. Diagnosis of hip dysplasia is confirmed by ultrasound up to 3 months of age, after three months it is necessary to perform a radiography of the hip joints.
Massage for dysplasia
Massage for hip dysplasia is included in the complex treatment and is an integral part of it. Therapeutic massage along with gymnastics allows to achieve stabilization of the hip joint, correcting the dislocation, strengthening the muscles, restoring the full volume of movements in the joint, and harmonious physical development of the baby.
Massage should be prescribed only by a doctor( pediatrician or pediatric orthopedist), it can also be done only by specially trained medical personnel, for example, a massage therapist who specializes in this disorder in children.
But parents can learn not a special therapeutic massage, but a general developing and restorative, which will only benefit, as a child with dysplasia, and absolutely healthy. Perform it recommended in the evening before going to sleep.
For a more effective massage the child should have a good mood during the session
If the child is shown wearing special orthopedic structures, then massage can be performed without removing them. Children do not use all the techniques of massage and movement, but only stroking and rubbing.
General recommendations for massage:
- baby for the massage session is laid on a flat and firm surface, ideally - changing table;
- a child needs to lay a special diaper that absorbs moisture, as massage movements can provoke urination;
- massage is performed once a day, the course includes 10-15 sessions;
- perform massage only when the child is in a good mood, not hungry and does not want to sleep;
- requires 2-3 courses of massage with breaks between them 1-1,5 months.
Diagram of the general developing massage for the babyAlso you can read: Treatment of dysplasia in infants
The position of the child - lying on the back. Begin to perform light stroking movements of the abdomen, chest, arms and legs. Then we turn to the easy rubbing of all the named parts of the body. Finish also stroking.
Position of the child - lying on the tummy with the legs bent and divorced. We begin with stroking the legs, rubbing them and alternately taking them apart. Massage the back and waist. Further we fall on the buttocks. Here, in addition to stroking and rubbing, you can apply a light pat on your fingers. Further massage the hip area and the outer sides of the thighs.
Therapeutic gymnastics for the baby
Therapeutic exercises for dysplasia can and should be performed by the child's parents after they are trained by a pediatrician or orthopedist. These are not at all difficult exercises, which will quickly achieve positive results. You can do them throughout the day, when convenient for the child( take into account that the baby was in a good mood, not hungry and did not want to sleep).You can repeat the complex 3-4 times a day. As a rule, such activities are popular with children, especially when they are spent by their mother.
LFK can be performed by the parents themselves several times a day.
Complex LFK for hip dysplasia:
- The kid lies on the back. Mom or Dad bends his legs in the knee and hip joints and slowly bows to the frog pose. Try to make the exercise so that the knee joints touch the surface of the table when the legs are diluted.
- Abdominal position. Repeat the previous exercise. We bend the legs in the knees and hip joints, we bend them to the sides( as when crawling).
- Position - lying on the back. We perform the bending of the straight legs to the child's head.
- Lying on the back, straighten the legs of the child. Straight legs are bred in the sides.
- Straight legs of the child pull up to the head and from this position we breed them to the sides.
- Fold the legs of the baby in the pose of half-lotus, the left leg should be on top.
- Alternately bend the legs in the knee and hip joints.
- We turn the baby over on the stomach. Alternately, pull his legs to the level of the pelvis with the statement on the foot.
- The child lies on his back. We bend the legs in the knee joints and bend them to the sides, as we open the book.
- The child lies on his stomach. With your right hand take the heels of the baby and press them to the buttocks, perform the frog.
It is important to remember that any exercises in the sitting and squatting position can be performed only with the permission of a specialist, since such vertical loads can aggravate the dislocation.
Contraindications to massage and gymnastics
There are several contraindications when performing massage and gymnastics is prohibited:
- increase in body temperature;
- is an acute infectious disease;
- presence in the child of non-guided hernial protrusions;
- congenital heart disease.
Teaching video for parents:
Treatment of dysplasia is mandatory, because in case of complications, the child not only breaks the gait, but also there can be aseptic necrosis of the head of the femur, which leads to severe disability and the inability to move independently. Engage - and you will defeat dysplasia.
Gymnastics and exercise therapy for hip dysplasia: video in children and newborns |Are joints aching?
Dysplasia of the hip joints is their underdevelopment, depending on the severity of the process may manifest itself: prelum, subluxation and complete dislocation.
The most serious manifestation of dysplasia will be a congenital dislocation of the hip.
For all congenital malformations of the child, the pediatrician should follow the delivery in the maternity hospital, which, at the discharge, helps to arrange the patronage of the child already at the place of residence. If a pediatrician has any suspicions of pathology in the hip joints, the child is sent to the ultrasound for them, as well as a consultation of the orthopedist. Also, if necessary, the orthopedist can send the baby to a radiology examination of the joints.
Treatment ofIf the diagnosis of dysplasia is confirmed, then it is necessary to begin immediately medical measures, which can last up to 1 year. In 1 month after birth, a wide swaddling of a child is effectively used. But the most important will be the use of special gymnastics for dysplasia of the hip joints, a video of which you can see on the site. On it you can get acquainted with such exercises as hip dilution, preferably with each change of diaper and features of proper swimming on the stomach.
But if some of these exercises are not enough, then do not rush to type in the search engine gymnastics for dysplasia of the hip joints video, you may need to include in the curative program also wearing the stirrups Pavlik and orthopedic pillow( Freik).
Treatment with these devices is aimed at fixing the joints in the most physiological position. The best option for treating dysplasia in children from 1 to 6 months of age will be wearing Pavlik's stirrups.
LFK for hip dysplasia in children
In addition to the above methods of treatment, it is also necessary to perform exercises of physiotherapy exercises. Since it is LFK for hip dysplasia in children, video by the way, you can also find it on our page.
Complex exercise exercises for children, with dysplasia of the hip joints
- The child lies on his back, and you by hand, grasping the entire joint, massage the front surface of the thigh. After that, put the baby on your stomach and do the same, but massage the back surface.
- Carry out spiral movements with your hands, on the back of your hips, that is, your baby lies on his back. Do everything carefully and do not try to rub your hands into the skin.
- Then start rubbing the lumbar region of the back. Do this with your hands, but do not forget that your hands should slide on the body.
- The next exercise will be the so-called "bike" lying on the back. Hands grasp the feet of the child and start twisting them as if riding.
- After this, proceed to unbending and bending the legs together. The kid also lies on his back.
- Rotation of the child's leg with the knee and hip joint bent. With one hand, grasp the buttocks, and the other for the leg in the knee area. Start gently rotating inside and out.
Other exercises for hip dysplasia in newborns, videos with them, you can also find on the pages of the site.
After the exercises, after about a couple of weeks, you will need to consult a repeat orthopedic consultant, where further treatment tactics will be undertaken.
On our video clearly visible and understandable the performance of all exercises, both special gymnastics and exercise therapy. But before viewing it, be sure to consult your doctor.
Hip dysplasia in children( newborns).Treatment. Massage and gymnastics for hip dysplasia in newborns. Medical Center Demetra Kiev
DISSOLUTION OF TAPEDED JOINS IN CHILDREN( NEWBORN)
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Information on the site is for informational purposes and can not be used for self-treatment.
Massage for hip dysplasia in children is necessary for any degree of dysplasia. In the complex of therapeutic measures with hip dysplasia in children, usually includes: treatment by position( using tires, wide swaddling), manual therapy, therapeutic massage and gymnastics. If the dysplasia of the hip joints is not strongly pronounced, then do not resort to such severe methods of treatment as the use of tires. At the early start of treatment, many children with hip dysplasia are well assisted by massage and medical gymnastics. Several courses of professional massage( along with the constant use of some elements of massage and gymnastics by the parents of the newborn) is enough for the full recovery of the child. Unreasonable restriction of movements at an early age can adversely affect the further development of the musculoskeletal system.advertisingDownload. ..
Treatment of hip dysplasia in children( newborns)
When hip dysplasia and the induced hip dislocation massage is done only on the recommendation of an orthopedic physician. This especially applies to massage complexes, which include exercises such as reflex "walking", "dancing", squatting. When treating a child using orthopedic tires massage and exercises should be carried out in an acceptable volume. While the orthopedist does not allow you to "walk", do not perform any exercises "standing" or "squatting", you must exclude any vertical load, becausethis can lead to even greater deformations of the hip joint.
Massage with dysplasia of the hip joints in the hands of a "non-specialist" can cause irreparable harm to the health of a newborn .
Approximate complex of massage and gymnastics for children( newborns) with hip dysplasia
To relax the adductor muscles of the thighs, you can make a acupressure with the simultaneous removal of the foot: with the index or middle finger pads, gently press in the area of the hip ,bent leg of the baby outwards, combining this movement with a slight shaking. You can apply a vibrating massage of the inner surfaces of the thighs: the swinging of the pelvis of the child lying on the support, in weight.
- The starting position is lying on the back. A general stroking massage of the hands, legs, abdomen is carried out.
- The starting position is lying on the stomach. The child is laid out on the stomach with legs divorced and massage of the posterior-external surfaces of the legs is performed: stroking, rubbing, alternately removing the bent legs of the baby to the sides( as when crawling) with fixing the pelvis. Then follows the stroking of the back and lumbar region. A massage of the lumbar region ( stroking and rubbing), buttocks( stroking, triturating, stimulating techniques - tingling, finger flicking), area of the hip joint ( circular stroking, grinding) and the posterior-external surface of the legs are performed. Then follows the withdrawal of bent legs to the sides( as when crawling) and "hovering".
- The starting position is lying on the back. It should be massage anterior-external surface of the legs: stroking, rubbing combined with relaxation techniques of the leading hamstrings - bending the legs of the child in the knee and hip joints and soft thighs. Spreading your hips, you must not allow sharp movements to avoid pain when reflex reduction of the adductor muscles of the hip and negative reaction of the child to massage. Further, the hip is rotated inwards: with one hand, the hip joint should be fixed, and with the palm of the other hand gently grasp the child's knee and, gently pressing it, gradually rotate the thigh along its axis inward( this exercise achieves gentle pressure of the femoral head on the articular cavity).Then a foot massage is performed: rubbing, kneading. Then you need to perform reflex exercises for the feet. To train the support function of the feet, exercises are recommended in the position of the child lying on the stomach and back with the ball, while the support for the feet is created by hand or ball. The procedure ends with a massage of the chest.
Hip dysplasia is a congenital inferiority of the hip joint, due to its abnormal development, which can lead to( or resulted in) subluxation or dislocation of the femoral head - to the "congenital dislocation of the hip".
The laying of the musculoskeletal system takes place on the 4th-5th week of intrauterine development of the fetus, its full formation - after the child begins to walk. At any stage of the development of the musculoskeletal system, violations are possible. The most common cause of the pathology are genetic defects. If the mother or the next of kin of the child had childhood orthopedic problems, then there is a probability of inheriting such deviations.
Under dysplastic syndrome in orthopedics is understood the violation of the development of connective tissue, which can manifest as increased mobility of the joints in conjunction with the weakness of connective tissue. One of the clinical manifestations of dysplasia is a dislocation of the femoral head. The term " hip dysplasia " has, in addition to the general, also a particular meaning, being a synonym for hip prednevyha. To avoid confusion, let us cite the classification of hip dysplasia .
Classification of hip dysplasia
There are three degrees of development of the disease in question, for each of them there are certain symptoms.
1 degree - immaturity of the components of the joint tissues
Most often observed in the case of the birth of a premature baby, doctors give it a definition as a transient condition between a healthy and aching joint.
Often, 1 degree of hip dysplasia is diagnosed in fully full-term children, but those born with low weight. This happens if the mother had a feto-placental insufficiency in the period of bearing of the child.
2nd degree - prefixed hip joint
Doctors note a change in the shape of the acetabulum, but the actual femur does not leave the cavity, remains within it. There are no pathological changes in the anatomical structure of the acetabulum.
3rd degree - subluxation of the hip joint
At this stage of hip dysplasia, a change in the shape of the femoral head is already noted, it freely moves inside the joint, but it does not go beyond it.
Very important: is considered the most serious option dislocation of the hip joint, which is characterized by:
- gross violation of the anatomical structure of the joint;
- changes are observed in the ligaments, and in the muscles, and in the joint bag;
- the head of the thigh extends beyond the articular cavity and is located either from the side or behind it.
Most often, the disease is diagnosed in girls, and, in the first year of life.
Symptoms of hip dysplasia
Symptoms of hip dysplasia can be divided into two large groups:
- is a characteristic clinical picture in children of the first year of life;
- symptoms are characteristic of children over the age of 12 months.
Clinical picture in newborns
It is very difficult to diagnose 1 and 2 degrees of dysplasia of the hip joint - there are no obvious signs, attention can be paid to the manifestations of a pediatrician or orthopedist during a preventive examination. But parents themselves must closely monitor the appearance and behavior of the newborn. The following factors should be alarmed:
- is an asymmetrical arrangement of folds on the buttocks and popliteal cavities;
- to bend the legs, bent in the knees, is problematic;
- the child shows obvious discontent, loudly cries at breeding legs with bent knees.
With these signs, parents should visit a doctor and undergo a complete examination with an orthopedic surgeon. The specialist will definitely appoint an ultrasound examination of the hip joint, which will help to identify later the ossification of the head of the femur. In some cases, it is advisable to conduct an X-ray examination - the image will clearly show the sloping of the outer edge of the acetabulum and the flattening of its roof.
Much more intense manifestations of dysplasia of the hip joint in 3 degrees of flow and with a dislocation. In these cases, the following characteristics will be present:
- Symptom of "click".This sound is heard when the doctor or parent starts to bend the legs, bent at the knees, to the sides - the head of the femur at that moment begins to enter the articular cavity and does it with a characteristic click. With the reverse movement, the same sound is heard - the head of the femur again goes beyond the joint cavity.
- Skin asymmetry. This symptom is checked in the child in the supine position and lying on his back. Pay attention is not on the number of folds( it varies even in healthy children), but at their depth and height of location.
- The legs are bent to the sides with a restriction. It is this symptom that makes it possible to diagnose hip dysplasia in newborns in the first 5-7 days of life with a confidence of 100%.Adhere to the following indicator: if the limitation reaches 50%, then the disease in question is accurately present.
- Shortening of the legs is of a relative nature. Check this symptom as follows: put the baby on the back, bend the legs in the knees and set them to the table / sofa with their feet. In a healthy baby, the knees will be at the same level, if one knee is clearly higher than the other, then this means the presence of a shortening of the leg.
- The symptom of Erlacher. His doctors determine by bringing the newborn's straightened leg to the other leg, then try to get the limb to be examined for the other( fold the legs crosswise).In a healthy newborn, the legs intersect in the middle or lower part of the thigh, with dysplasia of the hip joint, this phenomenon is observed in the upper third of the thigh.
In case of a congenital dislocation of the hip, the outstretched leg will be observed( unnaturally).This is determined when the newborn is lying on the back with a straightened leg in both the hip and knee joints.
Symptoms of hip dysplasia in children older than 12 months
It is very easy to detect the disease in children over 1 year old - a characteristic sign is a gait violation: the child limps on one leg if the hip dysplasia develops on one side or has a "duck" gait incase of development of pathology from two sides.
In addition, small forms of the gluteal muscles from the affected side will be noted, and if you press on the heel bone, the mobility will be noticeable from the foot to the femur( the child must lie on his back with his legs straightened).
Methods for treating dysplasia of
As soon as a diagnosis of hip dysplasia is diagnosed, treatment should be started immediately - this will be a guarantee of recovery.
In the first month after birth, doctors appoint a wide swaddling for the child. It is done in the following way: the usual flannel diaper is folded by a rectangle 15 cm wide( approximately, + 2 cm is allowed), it is laid between the legs of the child, which are bent in the knees and spread apart 60-80 degrees. The edges of the diaper reach the knees, the bandages are fixed on the shoulders of the baby.
Note: newborn quickly adapts to this kind of swaddling, does not act up and calmly transfers the moments of "packing" the legs into the desired position. After a while the child himself starts to put the legs in the right position before changing, but you need to have patience - at first it will be hard to calm the child.
Wide swaddling is almost always combined with curative gymnastics - it is elementary: with each change of diaper or regular changing, it is necessary to slowly set the legs aside and return them to the place. Effective will be swimming on the stomach.
Any procedure for the diagnosis of hip dysplasia can only be prescribed by a specialist! The first few times the medical gymnastics is conducted by a medical worker, and parents learn how to do the procedure correctly.
An orthopedic doctor( or pediatrician) is responsible for the dynamic monitoring of the child's condition, and if no positive shifts are observed, specific orthopedic adaptations can be prescribed. These include:
- Freya's pillow is a plastic panty that constantly supports the baby's legs in the "frog" position, is most often prescribed to patients aged 1 to 9 months with a mandatory replacement as the baby grows;
- Pavlik stirrups - the most convenient device for both the child and his parents, it is advisable to wear such a device at the age of 3 weeks to 9 months;
- tire-struts - these include a tire with femoral tutors, a tire with popliteal tutors, a tire for walking.
Treatment with specific orthopedic devices is aimed at fixing the child's hip joints in the correct position of the legs.
The doctor appoints the device as the child grows and develops physically:
- from 1 month to 6 months - it is advisable to apply Pavlik's stirrups, in some cases, an effective tire with popliteal tutors;
- from 6 to 8 months the doctor appoints a tire with femoral tutors;
- at the age of 8 months and up to 12 months, if in the future the child is allowed to walk, the child should wear the outgoing tire for walking.
Specific orthopedic appliances must be worn daily, so parents are always concerned about the care of the child in this position. To facilitate your own work, you must remember the following rules:
- At the time of changing the diaper, you can not lift the baby by the legs - you have to put your hand under the buttocks and gently lift them.
- In order to change the girdle, there is no need to remove the orthopedic device - just unbind the ties on the shoulders.
- Top on the tires / stirrups you can wear suits, dresses, vests and any clothes.
- If the doctor has appointed wearing the tires, then prepare for a more infrequent bathing of the child: 3 times a day parents should inspect the baby's skin under the straps and garters to avoid the appearance of irritation on the skin, diaper rash. Instead of bathing, you can use regular wiping with rags soaked in warm water. If necessary, completely wash the child, you can unfasten one strap, but hold the foot in the desired position during the hygienic procedure, and then identically wash the second side of the trunk.
- Constantly monitor the condition of the tire itself - it should not be wet, and under its belt / strap should not get talcum powder, baby powder or cream, as this can cause irritation of the skin.
Note: , during the feeding of the baby, the mother must ensure that the legs are not hamstrung to each other, if this process is performed without specific orthopedic devices.
The duration of wearing such support devices is quite long, so parents should have patience, be ready for moods and excessive anxiety of the baby and in no case be cowed! The option "let the child rest from these terrible tires" and "nothing terrible in 30-60 minutes will not happen" can result in disability in the future.
Drawing attention to the dynamics of the disease under consideration, seeing the results of wearing specific orthopedic adaptations, the doctor can prescribe therapeutic gymnastics and massage.
In no case can you independently carry out such procedures - it can significantly worsen the health of the baby. Only a specialist who keeps a close eye on a small patient can give some recommendations.
Therapeutic gymnastics for hip dysplasia
If such procedure is prescribed, the parents of the child with a diagnosis of hip dysplasia should visit several sessions with the physiotherapist - the specialist will show how to do the exercises correctly, will give a specific timetable for classes. There is a general description of the exercises:
- The child lies on the back, the parents lift the legs of the baby one by one, while bending the knee and hip joints.
- The baby remains lying on his back, and the parent bends his legs in the knee joints and hip joints, without lifting them above the surface. Next, you need to dilute the baby's legs moderately, giving a minimal load, as well as making rotational movements of the hips.
- In the same initial position, the baby's legs, bent at the knees and hip joints, are maximally bent to the sides, trying to approach the surface of the table with knees.
Note: each of the exercises described must be performed at least 8-10 times, and at the day of such "approaches" you must make at least 3.
For more information about the diagnosis of dysplasia and exercises with dysplasia of the hip joint, you will get a child by viewingthis video review:
Massage for newborns with dysplasia of the hip joints
About the massage, we can say the following:
- , despite the fact that for infants and children under the age of 12 months it is conducted in a sparing mode,huge - this disorder is quite possible to cure;
- if you do the recommended exercises with a frequency prescribed by a specialist, then the first results can be noticed after a month of such treatment;
- massage in itself is unlikely to have any positive impact on the health of the child - it is important to carry out complex therapy.
The rules of the massage for dysplasia of the hip formulations will be told by the doctor, and the physiotherapist will show and teach the parents to perform all the procedures correctly. Recommended complex of massage exercises:
- The kid lies on the back, the parent strokes his feet, hips, kneecaps, hands and stomach. Then the child needs to be turned over on a stomach and just also soft strokes to warm up all body. Do not forget to "work" and on the inside of the legs, especially the hips - for easy access to these places you just need to push the baby's legs apart.
- The child lies on his stomach, and the parent strokes / rubs the lower back, gently moving to the buttocks, at the end we perform soft titrations of the gluteal muscles.
- We turn the child back and begin to work on the muscles of the hips - we stroke the legs, shake, neatly pinch. In no case should you make any effort in carrying out this part of the massage - the muscles of the thigh can be sharply reduced( spasmodic), which will provoke severe pain. After rubbing and loosening the muscles, it is possible to start flexing / unbending the legs in the knee and hip joints, but only within the limits indicated by the orthopedist.
- Rotation of the hip inwards - the parent should fix the hip with his hand, the second - grasp the knee and rotate the thigh to the inside with a slight pressure. Then work on the other hip joint.
After the massage it is necessary to give the child a rest - stroke it, without effort rub the body.
Please note: massage is done once a day, each exercise must be performed at least 10 times. Do breaks in the massage course is impossible - this is fraught with a stop of positive dynamics. The duration of the massage is determined by the doctor.
During the medical gymnastics and massage it is important to understand that the physiotherapeutic procedures - paraffin baths, electrophoresis with the use of medications, which include calcium and phosphorus, will also be effective.
If the diagnosis of hip dysplasia has been delayed, or if the therapeutic methods described above do not give a positive result, then doctors prescribe a long-term phased plastering. In particularly severe cases, it is advisable to conduct surgical treatment. But such decisions are made exclusively on an individual basis, after careful examination of the patient and a long-term observation of the progression of the disease.
In the case of severe forms of hip dysplasia, disruptions in the operation of this device are lifelong, even if the diagnosis and treatment were carried out in a timely manner.
Even if the treatment was successful, a child with a diagnosis of hip dysplasia remains on the dispensary record with an orthopedic doctor for a long period - in some cases until the growth ceases altogether. Experts recommend performing a control X-ray examination of the hip joints every 2 years. The child is subjected to restrictions on physical activity, it is recommended to visit special orthopedic groups in preschool and school institutions.
Dysplasia of the hip joints is quite a complicated disease, many parents literally panic when they hear such a verdict from the doctors. But there is no reason for hysteria - modern medicine perfectly copes with pathology, timely treatment started and patience of parents make the forecasts quite favorable.
Comprehensive information on the signs of dysplasia of TBS, the methods of diagnosis and treatment of dysplasia of TBS in children - in a video review of the pediatrician, Dr. Komarovsky:
Tsygankova Yana Aleksandrovna, medical reviewer, therapeutist of the highest qualification category.
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