Algorithm for phoniatric management of identification, diagnostics, treatment/rehabilitation, therapy supervision and outcome control of DDSL (modified from Neumann et al. 2016)
13.2.2.1 First Identification
Parents usually consult a phoniatrician if they or other related persons/caregivers, relatives, nursery nurses, physicians or other health professionals suspect a developmental language abnormality of a child. Often children are referred by a paediatrician or another physician to a phoniatrician. In some regions, universal screenings for speech and language are implemented and may lead to a referral of children who fail the screening to a phoniatric institution. Initially, the phoniatrician should identify whether there is a risk for an individual child to have a DDSL owing to sensory, physical, cognitive or behavioural factors such as permanent hearing loss; recurrent otitis media with effusion; DDSL history of siblings, parents or other close relatives; autism spectrum disorder and other pervasive developmental disorders; syndromes or craniofacial disorders that may impair cognitive or speech and language development; cleft palate or developmental disorders. For this, she or he will ask the parents about the medical and language developmental history of the child and will probably get a first impression by an orientating examination of the child’s spontaneous or elicited language. Parent questionnaires, informal tests and at-risk screenings may be helpful in this process (see Sects. 11.1–11.3 and 12.1).
13.2.2.2 Diagnostics
The diagnostics is performed either by the phoniatrician himself and by his co-workers according to the algorithm depicted in Sect. 11.3. At first a hearing loss and other co-morbidities of a DDSL have to be excluded by an appropriate audiological and supplementary diagnostics. If a hearing loss is present, it should be treated before a DSSL intervention starts. If other co-morbidities are present, such as intellectual disability, autism or multiple needs, they have to be considered during the set-up of an intervention plan. The phoniatrician has to manage the whole diagnostic procedure including the involvement of other expertise, e.g. from (neuro)paediatric, genetic, radiological, ophthalmological, maxillofacial-surgical, orthodontic or psychological specialties. Central to the diagnostics of DDSL are language tests, either embedded in language-covering general developmental tests or as general developmental language tests, or as specific language tests examining distinct areas of linguistic competence (see Sect. 11.3). The phoniatrician needs to know about the validity of the applied screenings and diagnostic tests, to ensure that they are up to date and provide proper performance and analysis, according to the test manuals, and to confirm the correct documentation of the results, either by her- or himself or by co-workers. The phoniatrician has to ensure the precise documentation of the test results in the medical record including the measurement conditions (such as ‘good co-operation’, ‘tired child’, or ‘no compliance’). If there remains an ambiguity, she or he has to organise repeated measurements in order to obtain a diagnosis by ‘dynamic assessment’. The phoniatrician has an important regulatory role in the analysis of the diagnostic results, not only for referring children with DDSL to an appropriate treatment but also to align the proportion of children who undergo a therapy with the prevalence expected for DDSL. For example, given that about 10% of children suffer from a DDSL (including children with language-relevant co-morbidities) and 5–8% from a specific DDSL (SDDSL; see Sect. 9.6), there is an imbalance compared with the numbers of children who undergo therapy (for example, in Germany 24% of all boys and 17% of all girls at age of 6 years received a language therapy in 2014 according to the report of the largest German health insurance (Waltersbacher and Scientific Institute of AOK 2015)). Such an inappropriateness has to be prevented by the phoniatrician, who should initiate and finish interventions according to evidence-based best practices (see Sect. 2.3).
13.2.2.3 Making a Diagnosis
The identification and diagnostic process is completed by a clear diagnosis, which needs to be documented by the phoniatrician. It is not sufficient to describe findings only. If there is an ambiguity with respect to the diagnosis, a planned follow-up needs to be documented in the medical record and the physician’s letters.
13.2.2.4 Counselling of Parents
Parents or caregivers need to be counselled by the phoniatrician in a quiet, sensitive and empathic atmosphere about the nature, treatment options and prognosis of the language disorder of their child/ward. Here, it is indispensable that the phoniatrician has a thorough and up-to-date knowledge about the state of the art of evidence-based interventions for DDSL according to scientific guidelines, systematic reviews, meta-analyses and randomised controlled trials (RCTs) (see Sect. 2.3). Even if she or he prefers one treatment method over others, it is necessary to inform the parents about the alternatives. The options for particular settings such as extensive treatments in logopaedic/SLP practices, intensive treatments courses, single or group therapies, out-patient or in-patient treatments need to be discussed with the parents/caregivers. The perspective of a child and her family with respect to the criteria of the International classification of functioning, disability, and health: children and youth version (ICF-CY; World Health Organization 2007) needs to be considered as well as the resources of a family (e.g. financial, time, driving distance, workload, knowledge of the common language, number of siblings). Furthermore, the phoniatrician needs to find out the expectations of the parents/caregivers with respect to the treatment goals. The end of this process should be an informed consent, i.e. parents/caregivers should agree to the initiation of a distinct treatment from the perspective of well-informed decision makers in terms of the best interest of the child (Engelhardt 1996).
13.2.2.5 Set-Up of the Treatment/Rehabilitation Plan and Initiation/Prescription of the Treatment
The duties of a phoniatrician include setting up a treatment plan, or at least to be involved in its elaboration. Here, precise treatment goals and a timeline have to be determined. It may, for example, be necessary to arouse enjoyment of speaking of a child before dealing with linguistic issues. If a treatment does not show an effect within a certain period (e.g. for stuttering within 3 months according to the German evidence-based guidelines on fluency disorders, Neumann et al. 2016), the treatment method should be reconsidered and changed or adapted.
13.2.2.6 Performance of Treatment/Rehabilitation by the Phoniatrician
There is a long tradition of phoniatrics in language therapy. The profession of logopaedists has been founded and further developed by an initiative and under leadership of phoniatricians such as Emil Froeschels and Hermann Gutzmann. Language therapies have been developed in particular by Hermann Gutzmann, one of the pioneers of phoniatrics, who has earned much merit in the field of language therapy (e.g. Gutzmann 1912). Hence, a phoniatrician needs to know the principles of language therapy and should be able to perform at least parts of it by her- or himself. In particular, she or he may be actively involved if instrument-based procedures are applied, such as computer-feedback or tele-training.
13.2.2.7 Treatment Supervision and Outcome Control
One of the more important duties of a phoniatrician is the supervision and outcome control of a DDSL treatment. This requires treatment reports of the therapists and repeated measures combining objective and subjective assessment methods (tests and parent reports or questionnaires, respectively) that evaluate social participation and interaction, and the quality of life of a child. Again, good medical practice requires a change of the therapy approach if a treatment is not successful within a defined period (Neumann et al. 2016). The phoniatrician has a key role in the further application, adaptation or finalisation of an intervention. In order to fulfill these tasks, regular monitoring of a child and a trustful and honest communication between phoniatrician and therapist are inevitable.
13.2.3 Integrated Approach
In order to achieve the highest benefit for a child from a treatment or rehabilitation in the case of a DDSL, a highly interdisciplinary approach is necessary. This needs a strong collaboration among all participants of the interdisciplinary network described in Sect. 13.2.1. The phoniatrician has to organise, manage and supervise this collaborative work by organising or participating in interdisciplinary case conferences for severe cases of DDSL or for children with multiple needs. She or he needs to communicate with nurseries, schools, special schools and health insurances in order to enable a child with DDSL the full integration in its familial and social environment, and participation in social activities according to the principles of the ICF-CY.
An important task of phoniatricians is their involvement in the education and training of therapists for DDSL. It is recommended that they be involved in giving lectures and providing regular practical traineeships of upcoming therapists in phoniatric institutions. Frequently, theses for bachelor, master and doctoral degrees are supervised by phoniatricians. Furthermore, phoniatricians are involved in basic and clinical research on the improvement of the quality of identification, assessment and intervention programmes, and on the implementation of evidenced-based procedures in the field of developmental language disorders.
13.3 Physiotherapy for Children with Neuromotor or Neurodevelopmental Diseases and Associated Communication Disorders
13.3.1 Introduction
Physiotherapy is a medical profession that assesses, diagnoses, treats and works to prevent diseases and disabilities through physical means for people of all ages. Physiotherapists support patients affected by injury, illness or disability through movement and exercise, manual therapy, education and advice. They are experts in movement and function. They work in partnership with their patients, assisting them to overcome movement disorders, which may have been present from birth, acquired through accident or injury or are the result of ageing or life-changing events.
In paediatric physiotherapy, it is important to consider several aspects that may influence the execution and the success of the treatment. The therapist needs to focus not only on the child but also on the parents and the familial background in general. Each long-term therapeutic intervention has an impact on the child’s life and of the family’s routine. Therefore, individual concepts with daily exercises need to be established in accordance with the family or caregivers of a child. Parents need to take on the function of a co-therapist during the treatment process. They need to be trained and guided through therapeutic measures and aids. In addition, the motivation and compliance of both parties need to be ensured and promoted without overtaxing the child or the parents. During the recent years, increasing attention has been paid to the role of the family in the child’s life, and the term ‘family-centred services’ has been introduced to improve the care for children with special needs and their families. Systematic analyses suggest two recent trends:
from child-focused to family-focused orientation and from professionally directed guidance to coaching based on equal partnership
Dirks and Hadders-Algra (2011)
of both therapists and parents
Furthermore, and differing from that in adults, physiotherapy in children has to consider that diseases or injuries in children do not only affect their somatic state but also other developmental aspects of their neurological and sensorimotor systems. This may cause a deceleration, interruption or even cessation of the sensorimotor, cognitive, perceptual, social and emotional development of the child. The general aim of paediatric physiotherapy is to promote the normal development of the postural and movement apparatus. Therefore, the therapist needs detailed knowledge about the process of growth and maturation in the early stages of child development. Paediatric physiotherapy involves assessing the needs of a child and providing neurological rehabilitation in order to improve the child’s participation and function.
Moreover, common goals should be established and consented to in an interdisciplinary approach. Paediatric physiotherapists work together with physicians, occupational therapists, nurses, speech therapists and orthopaedic technicians to support both child and parents. The primary goal should be to enable children with disabilities to achieve the highest possible level of independence throughout all stages of therapy. However, one should be aware that even with therapy not every child will achieve a healthy, normal state of life. In the following, four basic treatment methods in paediatric physiotherapy are introduced.
13.3.2 Vojta Therapy in Children
The Vojta Therapy is a concept of early assessment and treatment that focuses on the integrated treatment of disturbances of the posture and movement apparatus and of somatosensory perception disorders. It is based on reflex locomotion. The brain is stimulated in order to activate innate, stored movement patterns (International Vojta Society: http://www.vojta.com/en/organisation/international-vojta-society). The treatment generates involuntary muscular activity that patients with impairments of the central nervous system, which affect the posture and movement apparatus, are unable to perform voluntarily, regardless of their age.
An activation of movement patterns can be obtained through the precise positioning of the child (prone position, supine position, lying on the side) as well as using predefined stimuli and specific pressure points on distinct body parts (stimulation zones). The combination of positioning, stimuli and pressure elicits coordinated movement patterns involving the muscles of the trunk and extremities. Visceral muscles and muscles of the face are also involved. These movement patterns occur ‘reflex-like’ and are called ‘reflex creeping’ and ‘reflex rolling’—the two main movement complexes of the Vojta Therapy. Both movement complexes include fundamental components of locomotion such as postural regulation, standing up against gravity and phasic mobility of extremities.
Repeated activation of the reflex-like movement patterns (preferably four activation intervals per day) is assumed to induce a reorganisation of nerve and central nervous system functioning (brain and spinal cord). Dr. Václav Vojta has postulated that these pathways may be blocked in newborns. Vojta Therapy neither trains nor teaches functions such as grasping, rolling or crawling but activates innate skills (extension of the spine; muscle function differentiation of arms, legs and trunk; inducement of swallowing; increase of breathing depth; activation of visceral muscles). The treatment usually increases the quality of spontaneous posture and movement and also aims to improve somatosensory perception and the ability to initiate contact and to communicate. These effects can be observed over the entire day, in case reflex locomotion is activated regularly. The treatment focuses on replacing substitute and abnormal movement patterns used by the affected child.
Parents take on the role as co-therapist and therefore have to be instructed in the basic application of Vojta Therapy. One considerable aspect in their guidance is to explain that crying during the treatment is not caused by pain but rather expresses exhaustion and unfamiliar activation. Premature infants should be treated with Vojta Therapy as early as possible, because the central nervous system is still malleable, abnormal substitute patterns have not been established yet and growth and maturation processes may be supported by the treatment.
Although the Vojta Therapy is a popular approach, it is criticised because evidence for its effectiveness has not been clearly established on the basis of well-controlled trials as it has, for example, been shown in the literature and systematic reviews on children with cerebral palsy (Franki et al. 2012; Patel 2005). Furthermore, it is a child-oriented but not family-orientated approach, and the latter is favoured according to more recent treatment trends (Dirks and Hadders-Algra 2011).
13.3.3 Bobath Therapy in Children
The Bobath Therapy is a worldwide used neurophysiological assessment and treatment concept for patients with motor disorders caused by disturbed neurological functions, as developed by Berta and Dr. Karel Bobath (1984). It is applied in patients of all ages, but mainly in infants and children, with congenital or early-in-life acquired cerebral motor disorders, developmental delays of unknown origin, sensorimotor difficulties and other neurological and neuromuscular diseases. The neurophysiologically and neurodevelopmentally based concept focuses on both the:
inhibition or suppression of abnormal tonic reflex activity responsible for patterns of hypertonia, and the facilitation of normal reactions and highly integrated postural control and balance in their own sequence of development, progressing to specialised activities.
Hirata and Santos (2012)
It is an interdisciplinary, active hands-on therapy used to treat patients with an impairment of the central nervous system caused by lesions. Locomotor, sensorimotor, cognitive, perceptual, social and emotional development is assumed to be positively influenced by the Bobath Therapy. The treatment is performed by physiotherapists, occupational therapists, logopaedists, nursing staff and physicians such as phoniatricians and paediatricians.
For children, the paediatric physiotherapist applies a resource-orientated, problem-solving approach in order to access the individual’s activity and participation. Therefore, special therapeutic handling techniques are used and taught to the parents during each intervention. Furthermore, customised equipment (specialised seating, orthotics) supports the effects of the Bobath Therapy. In case of sensory deficits or damaged processing of sensory information, the tactile and proprioceptive input is increased in order to support the child with his or her own body exploration (The Bobath Centre: http://www.bobath.org.uk). To achieve optimal sensorimotor processing and task performance, mutual dynamic interaction between the child and the paediatric physiotherapist is essential. Parents take on the role of a co-therapist and are guided in the correct use of therapeutic aids and the thorough application of basic, play-centred physiotherapeutic techniques. During each intervention, the main objective is to enable the child to participate in daily life by influencing and regulating the abnormal postural tone to more normal coordination patterns. Improved postural alignment is assumed to increase the efficiency of the child’s movements and activities. The aim of the therapy is to lead the child towards developing and enhancing new functional skills and to involve the child further in active participation in everyday life activities with gradual reduction in assistance.
13.3.4 Castillo Morales Therapy in Children
The Castillo Morales Therapy, known as ‘orofacial regulation therapy’ (Castillo Morales Vereinigung e.V http://www.castillomoralesvereinigung.de/index_e.html), is a treatment concept developed by Dr. Castillo Morales (1999). This integrative therapeutic approach addresses children with orofacial, communicative and sensorimotor disorders. Dr. Castillo Morales discovered the interdependence of posture and movement of head, neck and jaw positions. This interdependence further influences the mimic, oral and pharyngeal muscles. Children with neurological or anatomical dysfunctions often face challenges in coordination of differentiated sensorimotor performance of the orofacial muscular system. These difficulties frequently cause problems in the ability to communicate (mimic expression and articulation) and to eat, drink and swallow. The Castillo Morales Therapy aims to support and improve the ability to communicate and strives towards enabling the children to participate in normal day activities, such as eating and drinking.
The Castillo Morales concept focuses on function and not only the movement itself, addressing each part of the oral complex and turning all of them into a dynamic system through coordinated activities (Hirata and Santos 2012; Morales 1999). It uses functional jaw orthopaedics through the palatine plate.
The paediatric physiotherapist applies manual vibration and pressing and pulling techniques to give proprioceptive experience to the orofacial system. Beyond orofacial functions, these techniques are assumed to activate also the hands, feet and trunk. The activation aims at positively re-influencing the muscular system of the whole orofacial region.
Patients with muscular hypotonia; sensorimotor impairment, e.g. in cerebral palsy; and special sensorimotor defects in the region of the face, throat and mouth may particularly benefit from Castillo Morales Therapy. It is also applied in premature infants with difficulties in ingestion, children with hypotonia (e.g. Down syndrome) and children with congenital, anatomically based malformations in the oral region. Positive short-term and long-term effects of the therapy in children with Down syndrome have been shown in several studies (e.g. Korbmacher et al. 2006).
13.3.5 Psychomotor Therapy in Children
Psychomotor therapy aims to facilitate the appropriate and age-relevant development of children with perception and movement disorders. It focuses on the improvement of perception, balance, coordination and strength. This integrated therapy approach includes play, rest and relaxation, perception, graphomotor, painting and movement exercises, as well as consulting parents. The training is organised in small groups of three to five children. Sensory integration and interpersonal relations are key elements of psychomotor therapy. A close collaboration between therapist, parents and family is essential. A supporting environment empowers the child to gain new sensory, motor, social and emotional experiences. Psychomotor therapy should enable the child to bring together, organise and assess information and stimuli in order to ensure self-controlled movement patterns.
13.4 Occupational Therapy
13.4.1 Introduction
Occupational therapists are experts in occupations. Occupations refer to everything that people do in the course of their everyday life. Occupations for children and young people may include self-care (e.g. getting ready to go out, eating a meal, using the toilet), being productive (e.g. going to nursery, school or work or volunteering) and leisure (e.g. playing with friends or doing hobbies). Occupational therapists work not only with children but with people of all ages who have complex needs or circumstances, which means that they require expert advice and guidance. The role of occupational therapists with children and young people with developmental disorders of speech and language is to enable participation in everyday life and promote independence. Through doing activities that are meaningful to the child/young person, it is believed that there will be a positive impact on his/her health and wellbeing.
Children and young people with developmental language disorders are likely to experience challenges when engaging in aspects of their day-to-day life such as playing with friends, doing their schoolwork, interacting with their family, etc. Language disorders are also a feature of other developmental disorders, and as such the impact on functioning may not be solely related to their language issues.
13.4.2 Occupational Therapy Assessment and In-Context Observations
The starting point of an occupational therapy assessment is to understand the child/young person and the family’s priorities in terms of the occupations they want to, need to, or are expected to do. On the basis of these priority areas, an occupational therapist will assess and analyse multiple elements that have an impact on a child/young person’s ability to carry out the occupations, which extend beyond the diagnosis. This would likely involve an observation of the child/young person doing the priority activity (ideally in context) and if necessary additional standardised or nonstandardised assessments to illuminate the strengths, needs, barriers and enablers of participation.
Benefits of in-context observations for a child/young person with a developmental disorder of speech and language are that the impact of the environment on the ability to participate successfully in a given task can be considered and the assessment would thus not rely on the child/young person’s understanding of assessment instructions.
13.4.3 Intervention Approaches
Intervention approaches will depend on the reasons for the challenges, as identified from the assessment. Collaboration with the child/young person, family and school (if relevant) is essential. The focus could be on the exploration of alternative ways of doing activities, making changes to the environment or developing skills or strategies to enable successful participation. Some occupational therapists may focus on the development or remediation of underlying body functions (such as motor skills, sensory skills, perceptual skills, etc.), although increasingly the evidence within the profession highlights the benefit of practicing the actual activity rather than focusing at a body function and structure level (Law and Darrah 2014).
For example, if a priority occupation for a child is to ride his or her bike, then practicing the actual task of riding (at a level that is challenging yet achievable) may be more effective than undertaking activities not associated with riding a bike but are designed to improve balance or sensory processing. Moreover, utilising the motivation of the child/young person and family through collaborative goal setting and focusing on their priorities also demonstrates effective results (Graham et al. 2013; Locke and Latham 2002). Interventions are thus likely to be contextual to the situation and specific to the child/young person. The effectiveness is measured by the change they make to the child/young person’s ability to engage and participate in their daily life tasks.
Case Study 13.1
Viktor is an 8-year-old student identified by his teachers as having challenges relating to his schoolwork tasks and associated speech, language and communication difficulties. The priority occupations identified by Viktor’s teacher, his parent and Viktor are related to completing tabletop activities such as drawing and writing. The occupational therapist observed Viktor during the classroom routine of the children’s receiving instructions whilst they were sitting on the carpet and then going to their desks and undertaking a writing and drawing activity. A School Version of the Assessment of Motor and Process Skills (School AMPS; Fisher et al. 2007) was undertaken. According to the School AMPS, Viktor was observed to have some mild clumsiness and increase in effort as he did his writing and drawing (percentile rank 50). On the School AMPS process scale, Viktor was observed to be markedly inefficient in his use of time, space and objects during the writing and drawing task (percentile rank <1). This appeared to be influenced by four main factors: (1) Viktor not remembering how to spell the words he wanted to write, (2) Viktor looking around and becoming distracted, (3) long verbal instructions being given by the teacher, and (4) a cluttered desk.
The results were clustered and documented as a baseline. A goal was developed that focused on what Viktor would like to achieve following intervention (i.e. what success would look like). For example, ‘By the end of term (4 weeks), Viktor will write his English story within the time allocated within the lesson’.
Interventions were collaboratively determined and included Viktor having a dictionary of commonly used words on his desk so that he could recall how to spell what he wanted to write. In addition, environmental modifications were made such as reducing the clutter in the class so Viktor was less distracted during the task, the teacher giving all instructions to students verbally and in writing and organising Viktor’s desk.
The interventions were trialled and evaluated, where the goal was reviewed and the School AMPS was re-administered. Viktor (and many other children in the class) was reported to have benefited from the interventions and the goal was achieved. Viktor’s school motor measure remained stable (percentile rank 50), and his school process measure was significantly improved (percentile rank 10).
13.5 Principles of Augmentative Communication Methods
13.5.1 Introduction
Augmentative and alternative communication (AAC) interventions are methods and technologies used to compensate for an individual’s reduced communicative competence (see Branson and Demchak 2009 for review). Following the broader definition of the American Speech-Language-Hearing Association (ASHA 2005):
AAC refers to an area of research, clinical, and educational practice. AAC involves attempts to study and when necessary compensate for temporary or permanent impairments, activity limitations, and participation restrictions of individuals with severe disorders of speech-language production and/or comprehension, including spoken and written modes of communication.
13.5.2 When Is AAC Indicated in Children with Developmental Disorders of Speech and Language (DDSL) and Hearing Disorders?
The expressive language group: individuals understanding others’ spoken language but having difficulty in expressing themselves
The supportive language group:
Subgroup A: children who temporarily use AAC in order to facilitate their comprehension of spoken language, as well as to express themselves
Subgroup B: children who speak but who have difficulty being understood
The alternative language group: individuals who use AAC as a permanent means of receptive and expressive communication
The children this section focuses on may belong to any of these three groups. Children at any age are reliant upon AAC if their speech is inadequate to meet their communicative goals and if they are at risk of a profound impairment of their expressive communication (Cress and Marvin 2003). Children, especially those showing or expected to show a general or mental developmental delay or impairment (e.g. children with Down syndrome or other syndromes, with cognitive impairment, with multiple disabilities, with autism) and who exhibit special or even complex needs, meet these criteria for AAC, often from birth on (Cress and Marvin 2003; Light and Drager 2007; Wilkinson and Hennig 2007; Sevcik et al. 2008).
More than 40% of children with sensorineural hearing impairment show additional impairments or will develop them during their life (Meinzen-Derr et al. 2011). These children are also at high risk of developing insufficient communicative competence via oral language, even if they have received hearing devices (hearing aids or cochlear implants) early in life (Meinzen-Derr et al. 2013; Kim et al. 2010; Boons et al. 2012).
If the continuous monitoring of communication and language development in the children named above confirms a considerable retardation, intervention should include AAC and advice to parents in using AAC in daily communication at home as early as possible (Cress and Marvin 2003; Meinzen-Derr et al. 2013; Branson and Demchak 2009).
13.5.3 Classification of AAC Modes
Unaided AAC modes are all the body’s own modes and therefore need no external devices: e.g. natural gestures, manual signs (e.g. Makaton®, see Fig. 13.3), gestural cueing systems, vocalisation and speech and eye gaze body language.
Aided AAC modes require an external device to display and store symbols or pictures, photos and objects or letters. These external aids can be:
Non-electronic, e.g. miniature objects, pictures, photos, communication boards and binders (e.g. see Fig. 13.4a, b), individual diaries/communication books
Electronic, that range from light-technology components without or with voice output (e.g. switches, see Fig. 13.5) to highly sophisticated speech-generating devices (VOCA, electronic device with voice output communication) (e.g. see Figs. 13.6, 13.7, and 13.8).
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