*

Osteopathic Medical Associates

Edward K Goering DO

Special Thank you to

Brian Tuckey PT, OCS,JSCSC
*
* Manual therapy is the therapeutic application of manually
guided forces by a practitioner to improve physiologic
function and/or support homeostasis that has been altered by
somatic dysfunction.(1)

*Osteopathic
Manipulative Treatment
Or Manual Therapy -
Definition
*Direct vs. Indirect Manipulative
Techniques
 Direct Techniques: The operator manipulates
the joint or tissue into the direction of motion
restriction. Operator generated force then
allows movement beyond the perceived
restrictive barrier. (3)

 Indirect Techniques: The operator positions the

joint or tissue away from the perceived motion
barrier toward ease or freedom. Indirect
techniques alter neural mechanisms in order to
alleviate restrictive barriers. (3)
*
 * Effects of Manipulation

Alternative Medicine and Rehabilitation: A Guide for Practitioners. Wainapel SF, Fast A, editors,
Chapter 1
* Joint mobilization or * Functional Indirect Technique
Articulatory Technique(4) (6)

* HVLA (5) * Jones Strain/CounterStrain

* Muscle Energy Technique (6) Technique (10)
* Myofascial Release Technique (7) * Cranial Sacral
* Manual Lymphatic Drainage (8)
* Visceral Manipulation (9)
*Cranial Sacral
*Examples of Direct and
Indirect Manipulation
Techniques
 Definition: A passive positional
procedure that places the body in
a position of greatest comfort,
thereby relieving pain and
dysfunction by reduction and
arrest of inappropriate
proprioceptive activity that
maintains somatic dysfunction. (11)
 CounterStrain is targeted to both
muscular and non-muscular
(fascial) tissues, e.g. - ACL, PCL,
ITB, Piriformis, Teres Major/ Minor
etc. (11)
 The technique involves positioning
for comfort, followed by a 90
second hold and finally a slow
return to neutral. (11)
*Strain and
CounterStrain
* Somatic dysfunction is defined as impaired or
altered function of related components of the
somatic (body framework) system: skeletal,
arthrodial and fascial structures and their related
vascular, lymphatic and neural elements(2)
* Somatic dysfunction is characterized in early stages
by vasodilation, edema, tenderness, pain and
tissue contraction. It is diagnosed by history and
palpatory assessment of tenderness, asymmetry or
relative position, restriction of motion and tissue
texture change. (2)

*What Are We
Treating?
* Before we can answer that question we need
to discuss 5 topics:
* Fascia and it relationships
* Proprioceptors
* Nociceptors
* Muscles
* Inflammation

*What is The Current

Theoretical Basis for
CounterStrain
 Dense, irregular connective tissue
that covers all of our muscle fibers,
organs, large vessels and nerves. It
is the largest sensory organ in the
human body (Schleip 2003)(20)
 Stecco et al. (2008) found that the
outer layers of the deep fascia
contained a rich vascular and nerve
supply, with intra-fascial nerve
fibers seen throughout. Some of
these were presumed to be stretch
receptors.(22)
 The majority of sensory receptors in
fascia are the rare type III and IV
receptors (nociceptive and
mechanoreceptor function)-respond

*Fascia
to light touch (Mitchel, Schmidt
1977)(21)
 Also, fascia is contractile!!!
(23) Yahia LH, et. al: “Viscoelastic
properties of the human
lumbodorsal fascia. J Biomed eng
15: 425-429 (1993)

(24)Straubesand J, et. al: Zum

Feinbau der Fascia cruris mit
besonderer Berucksichtigung epi-
und intrafaszialer Nerven.
Manuelle Medizin 34: 196-200
(1996)

(25) Schleip R, “Fascia is able to

contract in a smooth muscle-like
manner and thereby influence
musculoskeletal mechanics”
Proceedings of the World Congress
of Biomechanics, Munich, Germany
2006, ISBN 88-7587-270-8, pp. 51-
54.

*Examples of related research

2007 Fascia Congress
*
* Proprioceptor activity.
* Seen with meisners, merkels, pacinian, and
ruffini corpuscles and similar structures in the
superficial and deep fascial structures. Including
the golgi tendon apparatus that functions
similarly
* Feedback here is similar to the sensory
component of the spindle apparatus.
* Alteration of the homeostasis, why?

*
 *
Physiologic explanation of the function of the receptors
 *

Pain management within the spinal cord.

Nociceptive overriding of proprioceptive inhibition,
Chronic pain, acute and severe pain.
Nociceptive maintenance of the dysfunction
Medication to mimic manual treatment
 Plantaris

Inferior omohyoid

*
* Spindle count range from 2-4 times more in postural muscles
versus phasic muscles
 * Postural muscles.
* Phasic muscles.
* Expressions of dysfunction and
diagnostic pearls.
* Key muscles to treat

*
 * Humans as technologically challenged
creatures with a .5 sec monitor.
* Tension is the only language we understand.
* Aberrant balance maintained, whys and
wherefores.
* 0.75 to 1.5 seconds measured time for various
reflex responses

*
*
 *

Alteration of the homeostasis,

 Why?
*
*What Maintains Joint
Dysfunction?
* Peripheral pain arises from stimulation of free sensory nerve
endings called nociceptors(17)
* Peripheral nociceptors are found in virtually all connective
tissues including ligaments, tendons, joint capsules, the stroma
of all large blood vessels, the stroma of all internal organs, and
the meninges (epineurium.) Large numbers are found in the
peritoneum and in the muscular fascia. (17)
* Nociceptors are sensitive to mechanical, and chemical
stimuli.(17)
* Not all signals from peripheral nociceptors reach consciousness
(latent trigger – tender points.)(17)
* Because nociceptors release inflammatory chemicals like
substance P, and are stimulated by the same chemicals, a
positive feedback loop can occur.(19)
* Nociceptors enter the dorsal horn of the spinal cord where they
can branch, traveling up to 5 segments cephalad or caudad.(17)
* Nociceptors connect to motor neurons in the ventral horn and
pre-ganglionic neurons of the autonomic nervous system
(nocifensive and nociautonomic reflexes)(17) (19)

*Nociceptors
 Controlled, assessor blinded studies support
Counter Strain's ability to reduce nociception

* Changes in Masseter Muscle Trigger Points Following

,Strain-Counterstrain or Neuro-Muscular Technique
Jordi Ibáñez-García PT, DOa, Francisco Alburquerque-Sendín PT, DOa, b,
Cleofás Rodríguez-Blanco PT, DOa, c, Didac Girao PT, DOa, Albert Atienza-
Meseguer PT, DOa, Sergi Planella-Abella PT, COa and César Fernández-de-
las Peñas PT, DO, PhD (13)

* Immediate Effects of the Strain/Counterstrain

Technique in Local Pain Evoked by Tender Points in the
Upper Trapezius Muscle
Albert Atienza Meseguera, César Fernández-de-las-Peñasa, b,, Jose Luis
Navarro-Pozaa, Cleofás Rodríguez-Blancoa, c and Juan José Boscá Gandiaa
(14)

* Is There Evidence to Support

Counter strain's Ability to
Reduce Nociception?
 Counterstrain in skeletal muscle decreases the stretch reflex and
decreases nociception.
 Objective: To test the effects of SCS on nociception and the stretch reflex
 Methods: 16 tendonitis and 15 control subjects received SCS to the foot and ankle or
in the control group, sham SCS. Pre and post Stretch reflexes were measured in all
groups
 The us of SCS produced a 23.1% decrease in the amplitude of the stretch reflex of the
soleus (P<.05) in subjects with Achilles tendinitis. Similarly significant responses were
measured in the lateral and medial heads of the gastrocnemius
 Mean ratings of soreness (nociception)and stiffness were found to be significantly
reduced between pre- and post-treatment levels, as recorded at 6 hours post-
treatment and daily for 7 days post-treatment (P<.05). Swelling was significantly
reduced on post-treatment days 2 through 6 (P<.05).

(12)Stretch reflex and Hoffmann reflex responses to Osteopathic Manipulative Treatment in

subjects with Achilles tendonitis.” Howell et al. JAOA, Vol 106,Sep 06

*
Additional Evidence of A
Reduction in Nociception and
Subsequent Effects…
 A hallmark of Strain and Counterstrain Technique is the 45-90
second hold during which time, “local inflammation will
decrease as noxious chemicals are carried away” (13)
 Dr. Jones described tender points as “tense, tender , edematous
masses about a centimeter in diameter” and describes the feel
of a tender point as follows:
“He (the physician)will feel tissue tension and swelling. When
the position of comfort is found, there is a rapid relaxation felt
at the tender point. During the 90 seconds before he starts to
return the body to a neutral position, he can feel further
softening thought to be the re-absorption of edema.” (11)
 Any reduction in inflammatory chemicals will decrease
nociception since nociceptors have peripheral receptors for
chemicals like bradykinin, H+ protons and prostaglandins. (16)
 Is there any evidence of inflammation in myofascial tender /
trigger points ?

*Counterstrain And
Inflammation
Evidence of inflammation in myofascial trigger / tender points

“An in vivo microanalytical tech. for measuring the local

biomechanical milieu of human skeletal mm.” – Jay P. Shah et. al.,
J. App. Phys., 2005 (15)

 A microanalytical system was developed to measure the in-vivo

biochemical milieu of the upper trapezius muscle in symptomatic and
asymptomatic individuals
 3 different groups were tested, normal, latent and active trigger points.
 Concentrations of protons (H+), bradykinin, calcitonin gene-related
peptide, substance P, tumor necrosis factor- , Interleukin -1, serotonin,
and norepinephrine were found to be significantly higher in the Active
group than either of the other two groups (p<.01). pH was significantly
lower in the Active group than the other two groups (p<.03).

*Counterstrain and
Inflammation Cont.
 *Can SCS Actually Impact
Circulation on a Larger Scale?

Research in this area is lacking, however, some impressive case

studies do exist….
* Case Study: Humeral Fracture, Severe
Bruising and Edema (Right Lymphatic
Watershed)
*Post Counterstrain Treatment:
48 hrs
 *

Alteration of the homeostasis,

 Why?
 *Chronic Somatic Dysfunction
1)Visceral or somatic structure is traumatized
2)Nociceptors and axon branches in the spinal Explained
cord are activated
3)Peptide transmitters are released causing
vasodilation, edema and the local threshold
for nociception is lowered.
4)Spinal cord neurons are stimulated that
cause nocifensive and nociautonomic
reflexes which cause muscle / fascial
contraction.
5)Axon reflex and sympathetic vasodilation
effects engorge the affected muscles /
tissues. Tissue engorgement further
stimulates nociceptors due to the
accumulation of inflammatory chemicals like
bradykinin, substance P, and norepinephrine
6)Now, due to lower nociceptive thresholds,
any attempt to stretch the affect tissues will
trigger the nocifensive reflex.
7)Thus we have a condition of chronic somatic
dysfunction that includes pain and significant
resistance to motion counter to the current
“nocifensive” joint position
* “In Counterstrain…the already * 1) Identify tender point
shortened muscles are initially
further shortened. Maximal
* 2) Establish tenderness
shortening, removes all internal scale
stresses, totally deactivating * 3) Position to eliminate
nociceptors. By holding the tenderness
tissues in this position for at
least 90 seconds….local * 4) Maintain position 90
inflammation will decrease as seconds
the noxious chemicals are * 5) Slowly return to starting
carried away.” position
* 6) Recheck tender point
-Richard L Van Buskirk, 1990
(18)

*How Does Counterstrain

Believed to Break This
Nocifensive Loop?
Peritoneum/mesentery
Tunica/membrane
Adventitia

*Visceral Strain and CounterStrain

examples of fascial structures
targeted
 Had many “failed” patients cured by visceral manipulation.
 Studied visceral manipulation, used the technique on chronic
patients.
 Neuromuscular response to direct visceral manipulation
recognized.
 Tried indirect approach, results improved however were
inconsistent without tender points.
 Eventually discovered 3 methods of identification:
1) ”Focus of restriction”
2) Motion testing the neurologically associated segments
pre /post treatment to identify potential tender points.
3) “System phenomenon”

*Origin of
Visceral/Lymphatic
SCS
 Once a TP was identified, 3 dimensional movements of the trunk or local organ
manipulation was utilized until a position of release was identified (e.g. inspiration –
expiration, and shortening of associated visceral ligaments.)
 Experimentation continued until treatments were identified that met all of the
following criteria:
- A strong therapeutic pulse was perceived
- The dysfunction / TP did not re-occur
- The associated visceral restriction was corrected.
 Barral’s work and others were helpful in identifying the treatments for difficult organs
(e.g. Pancreas) and key locations (valves / sphincters)
 Process took over 7 years of constant work to become a viable technique, currently
more than 70 tender points related to the viscera/vascular have been indentified.

*Origin of
Visceral/Lymphatic
SCS, cont’d
 Common uncommon
* Disease (lymes disease..)
* Trauma
* Food sensitivities
* Surgery
* Postural strain
* Fibromyalgia
* Sacral “un-leveling” e.g. Leg
length discrepancy, short hemi-
pelvis

* Causes of
Visceral
Dysfunction (clinical
observation)
* Pain originating from highly innervated fascial tissues associated
with the viscera such as the parietal peritoneum.(28) Symptoms
often mimic common somatic complaints such as sacroiliac or
low back pain.(26)
* Pain, parathesias and weakness due to the release of fascial
tension which can compress associated neural tissues
(parietocecal ligaments –obturator n., sciatic n.)(26)
* Joint restrictions (e.g. bladder-sacroiliac dysfunction, liver T7-9,
C4/5 and assoc. ribs)(27)
* Significant postural changes (e.g. flexed thoracic spine with
triangular ligs., duodenum, esophagus points)(28)
* Viscerospasm (irritable bowel, urinary urgency, esophageal
etc.)(27)

*Symptoms of
Visceral/Lymphatic
Dysfunction
(Clinical Observations)
 IBD (ulcerative colitis, Crohn’s disease)
 Pregnancy- direct abdominal and pelvic techniques
 Acute infection
 Any other situation in which manipulation of the viscera
could exacerbate an existing condition (e.g. < 6 weeks s/p
abdominal surgery)

* In general, visceral manipulation is only indicated with

abdominal pain, after which, organ disease / pathologies
have been ruled out.
• Visceral tender points are NOT indicative of disease thus
should be treated whenever indentified (taking into
consideration the above precautions / contraindications.)

*Precautions /
Contraindications
 Visceral dysfunctions, in general, present as deep, multi-segmental restrictions.
 Visceral and arterial dysfunctions are resistant to manipulation, massage,
exercise, pharmacological treatments, even most modern pain management
techniques.
 Usually both the “inspiration” and “expiration” (outward and inward roll)
restrictions of each organ will be addressed, often by a combination of visceral and
arterial treatment (e.g. HEP-A and LIV-M
 Visceral dysfunction is commonly the primary area of dysfunction seen in patients
with leg length discrepancies and fibromyalgia.
 30 to 60 seconds is usually sufficient release time with Visceral SCS (45 avg.)
This differs from the classic 90 second hold.
 Most likely a variation that arises from the inherent “pacemaker” found in the
visceral tissues and vascular structures versus the longer response affecting the
primary somatic dysfunctions with the multitude of redundant inhibitory functions.

*General Rules /
Observations With
Visceral Strain and
CounterStrain
 Camelia, 58 yo PHD researcher from NIH
 PMH: Advanced DDD L4, L5 with stenosis.
 Previous Rx: NSAIDS, P.T. x 12 (ex, mod, traction)
 Sx: Thoracic pain, sacral pain 7/10, “burning” pain
into right lateral & posterior thigh.
 Bladder : Significant difficulty initiating urination,
limited flow
 Deficits: Unable to lie supine with legs ext, disturbed
sleep, unable to walk >5 minutes due to burning in LE
 Obj: Flex 25% limited, SBR 25% limited, ext 90%
limited. SLR 60/90 degrees.
 TOP: DP-V, KI-V, URT-V, OM-V, BL-V, Pyl-V

*Case History
 Treatment: Lymphatic SCS to all tender points x 1
visit.
 Results: Significant / severe generalized soreness x 1
hour following treatment – ride home.
 Thoracic pain – resolved
 Lumbar / sacral pain – resolved
 Able to sleep through the night and lie supine.
 Able to resume “old” walking program of 3-5 miles/
day
 Problems initiating urination and limited flow resolved
 All treatment benefits still present at 5 wk and 9 wk
follow-up telephone calls.

*Treatment and
Results
*
*
Is there any evidence of Counterstrain’s ability to reduce inflammation
at the cellular level?
“Modeled Repetitive Motion Strain and Indirect Osteopathic Manipulative Techniques
in Regulation of Human Fibroblast Proliferation and Interleukin Secretion” Kate R.
Meltzer, MS; Paul R. Standley, PhD, JAOA, Vol107, No 12,December 2007 (16)

 Yes! Study was performed at the Univ. of Arizona’s Basic Medical Science Dept.
 Human fibroblasts were cultured and grown in vitro on flexible collagen membranes.
 Pre-strained 10% and broken into separate groups.
 Interleukin secretion was sampled at 8 and 24 hours post intervention.
 Results : Fibroblasts that underwent RMS responded with a significant secretion of pro-
inflammatory interleukins at 24 hrs.
 Results: Fibroblasts that underwent RMS + SCS displayed a 46% reduction in pro-
inflammatory secretion at 24 hrs
 Strong scientific evidence that SCS “reverses inflammatory effects in cells that have
been strained repeatedly”

*CounterStrain and
Inflammation Cont.
*
*
 *
Anterior/posterior auricular
Nodes

Submandibular Nodes
Parotid Nodes
Jugular Digastic Nodes
Anterior Jugular Nodes

Posterior
Axillary node
Mastoid node

Lymphatic Duct
Internal jugular Thoracic/Duct node
nodes
*
*
*
*
*

Internal Jugular Lymphatic

*
*
*
*
Direction of Pressure important

*
*
*
*
Posterior Thoracic Lymphatic
Nodes Tender Points
Lateral Transverse Cervical
Nodes
Posterior Axillary Nodes

Cysterni Chyli
Transverse Process T9

Intestinal Nodes
*
Anterior Axillary Nodes B
Thoracic/Duct TP B
Internal Jugular Nodes
TP B
Medial Transverse
Cervical Node TP B
Intercostal Nodes B

Visceral Nodes rib 6 B

(anterior axillary line)
Esophagus, Gastric,
Duodenum Liver GB etc.
*
*
*
*
*
*
*
*
*
*
*
*
*
 *

Direction of palpation is from

above
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
 *

Sphincter Therapy
UES: Upper Esophageal Sphincter-Over the posterior paravertebral mass of T6.
Bilateral
GES: Gastro esophageal Sphincter-Over the inferior aspect of the left 6th rib,
Bilateral
PYL: Pylorus-1. Over the tubercle of the left 8th rib.2. Over the costochondral
margin of the left 8th rib.
ODI: Sphincter of Odi- Over the tubercle of the right 8th rib.2. Over the
costochondral margin of the right 8th rib.
DJ: Duodenojejunal Junction-Over the superior lateral aspect of the left PSIS,
push lateral to medial.
ICV: Ileocecal Valve- Over the superior lateral aspect of the right PSIS, push
lateral to medial.
LOT: Ligament of Trietz- Over the left paravertebral muscle mass of T10/11.
*
*
*
*
*
*
*
* Tender Points:
* #1 Located over the tip (costochondral
margin) of the 10th rib (FOT-V)
#2 Located over the superiolateral
aspect of the ischial tuberosity. All
points can be found bilaterally (FOTI-
V)

* Treatment: Patient supine, in hook

lying, with hips and knees flexed.
Patient’s uninvolved forearm resting on
his/her abdomen. Operator standing
on the patient’s uninvolved side.
Lower trunk rotation: Away from the
tender point side, moderately.
Compression: Of the uninvolved arm,
against the abdomen (upper abdomen
for point #1, lower abdomen #2)in
order to move the large intestine in
the direction of the posterior
abdominal wall.

* Fascia of Toldt (FOT-V

and FOTI-V)
 (1)Glossary of Osteopathic Terminology, Educational Council on Osteopathic Principles (ECOP),
American Association of Colleges of Osteopathic Medicine (AACOM), Revised April 2009, page 28
 (2)Glossary of Osteopathic Terminology, Educational Council on Osteopathic Principles (ECOP),
American Association of Colleges of Osteopathic Medicine (AACOM), Revised April 2009, page 53
 (3)An Osteopathic Approach to Diagnosis and Treatment. By Eileen L. DiGiovanna, Stanley Schiowitz,
Dennis J. Dowling, pp 78motion
 (4)Ward, Robert C. et al.; Foundations for Osteopathic Medicine (2nd ed.). Philadelphia: Lippincot
Williams and Wilkins
 (5)Maitland, G.D. Vertebral Manipulation 5th ed. Butterworths, London, 1986
 (6)DiGiovanna, Eileen L. et al.; An Osteopathic Approach to Diagnosis and Treatment; 3rd ed.;
Philadelphia: Lippincott Williams and Wilkins; 2005
 (7)DiGiovanna, Eileen; Stanley Schiowitz, Dennis J. Dowling (2005) [1991]. "Myofascial (Soft Tissue)
Techniques (Chapter 12)". An Osteopathic Approach to Diagnosis and Treatment (Third ed.).
Philadelphia, PA: Lippincott Williams & Wilkins. pp. 80–82.
 (8) Chikly BJ. Manual thechniques addressing the lymphatic system: Origins and development. J Am
Osteopath Assoc. 2005;105:457–474602-603 1)
 (9) Digiovanna Eileen, Schiowitz Stanley and Dowling, Dennis. An Osteopathic Approach to Diagnosis
and Treatment. 3rd edition, 2005 Lippincott & Wilkins, pp. 602-603
 (10)Glossary of Osteopathic Terminology, Educational Council on Osteopathic Principles (ECOP),
American Association of Colleges of Osteopathic Medicine (AACOM), Revised April 2009, page 29

*
 (11)- Jones LH. Strain and Counterstrain. Indianaplois, USA: The American Academy of
Osteopathy, 1981
 (12)Stretch reflex and Hoffmann reflex responses to Osteopathic Manipulative
Treatment in subjects with Achilles tendonitis.” Howell et al. JAOA, Vol 106,Sep 06
 (13)Jordi Ibáñez-García PT, DOa, Francisco Alburquerque-Sendín PT, DOa, b, Cleofás
Rodríguez-Blanco PT, DOa, c, Didac Girao PT, DOa, Albert Atienza-Meseguer PT, DOa,
Sergi Planella-Abella PT, COa and César Fernández-de-las Peñas PT, DO, PhD
 (14)Albert Atienza Meseguera, César Fernández-de-las-Peñasa, b,, Jose Luis Navarro-
Pozaa, Cleofás Rodríguez-Blancoa, c and Juan José Boscá Gandiaa
 (15)An in vivo microanalytical tech. for measuring the local biomechanical milieu of
human skeletal mm.” – Jay P. Shah et. al., J. App. Phys., 2005
 (16) “Modeled Repetitive Motion Strain and Indirect Osteopathic Manipulative
Techniques in Regulation of Human Fibroblast Proliferation and Interleukin
Secretion” Kate R. Meltzer, MS; Paul R. Standley, PhD, JAOA, Vol107, No
12,December 2007

 (17) Mountcaste VB (ed): Medical Physiology vol 1, St. Louis, CV Mosby Co. 1980 pp.
391-427
 (18) Van Buskirk RL. Nociceptive Reflexes and the Somatic Dysfunction: A Model,
Journal of the American Osteopathic Association (1990) Vol.90, No.9
 (19) Van Buskirk RL: Nociceptive reflexes and the somatic dysfunction: A model. J Am
Osteopath Assoc 90:792-809, 1990
 (20) Schleip R,Fascial Plasticity: A New Neurobiological Explanation Part 1, Journal of
Bodywork and Movement Therapies (Part 1 in Vol.7, No.1, January 2003, and Part 2 in
Vol.7, No.2, April 2003)
 ( 21) Mitchell JH, Schmidt RF 1977,Cardiovascular Reflex Control by afferent fibers
from skeletal muscle fibers. Shepherd JT et al. Handbook of Physiology,sec 2, Vol 3
 (22)Stecco C et al 2008 The expansions of the pectoral girdle muscles onto the
brachial fascia: morphological aspects and spatial disposition. Cells Tissues Organs.
188: 320-9.

*
 (23) Yahia LH, et. al: “Viscoelastic properties of the human lumbodorsal fascia.
J Biomed eng 15: 425-429 (1993)

 (24)Straubesand J, et. al: Zum Feinbau der Fascia cruris mit besonderer
Berucksichtigung epi-und intrafaszialer Nerven. Manuelle Medizin 34: 196-200
(1996)

 (25) Schleip R, “Fascia is able to contract in a smooth muscle-like manner and

thereby influence musculoskeletal mechanics” Proceedings of the World
Congress of Biomechanics, Munich, Germany 2006, ISBN 88-7587-270-8, pp. 51-
54.
 (26) Barral, Jean-Pierre. Visceral Manipulation. Vista, California: Eastland
Press, 2005. pp 125,133

 (27)Barral, Jean-Pierre. Visceral Manipulation. Vista, California: Eastland Press,

2005. pp 16,50, 81, 100, 145,169
 (28) Helsmoortel, Jerome. Visceral Osteopathy: The Peritoneal Organs,
Eastland Press 2010. pp 2,