Visceral Manipulation in Osteopathy

� • � Wll (jjj)

Visceral Manipulation in Osteopathy

Complementary Medicine

Eric U. Hebgen Foreword by Michael L. Kuchera

I Thieme

Written by one of the best-known European osteopaths, Visceral Manipulation in

Osteopathy explains how to successfully apply the four most common approaches for the manual treatment of abdominal disorders. The first section provides an overview of the basic principles and techniques of diagnosis and treatment from the greats of osteopathy: visceral manipulation according to Barra!; fascial treatment of the organs according to Finet and Williame; circulatory techniques according to Kuchera; and reflex point treatment according to Chapman. Organized by the individual organs, the second section contains "actien" photographs that demonstrate osteopathic tests and treatment techniques, plus in-depth information on anatomy, physiology, and pathology.

Features: •

Over 160 clear, marked-up "action" photographs illustrate the different

•

Additional graphics display the macroscopic anatomy and topography of

•

Practical tips and notes are highlighted throughout for rapid access and

techniques the organs quick review •

Organ-tooth interrelationships are demonstrated

Practitioners of osteopathy, physical therapy, or chiropractic will refer to this indispensable clinical guide on a daily basis. The book's breadth and clarity also make it ideal as a textbook for students of visceral manipulation.

Eric U. Hebgen, DO, MRO, is in Private Osteopathy Practice, Konigswinter, Germany. An award-winning international medical and scientific publisher, Thieme has demonstrated its commitment to the highest standard of quality in the state-of-the­ art content and presentation of all of its products. Thieme's trademark blue and silver covers have become synonymous with excellence in publishing.

ISBN 978-3-13-147201-4

11111111111111111 11111 1 9 783131 472014

www.thieme.com

�Thieme

For my boys, joshua and joel

Visceral Manipulation in Osteopathy Eric U. Hebgen, DO, MRO Private Practitioner Konigswinter, Germany

213 illustrations

Thieme Stuttgart New York ·

IV

Library of Congress Cataloging-in-Publication Data

Important note:

is available from the publisher.

continual development. Research and clinical experience are con­

This book is an authorized translation of the 3rd German edition

proper treatment and drug therapy. Insofar as this book mentions

published and copyrighted 2008 by Hippokrates Verlag, Stuttgart.

any dosage or application, readers may rest assured that the

Medicine is an ever-changing science undergoing

tinually expanding our knowledge, in particular our knowledge of

Title of the German edition: Viszeralosteopathie- Grundlagen

authors, editors, and publishers have made every effort to ensure

und Techniken.

that such references are in accordance with

the state of knowledge

at the time of production of the book. Nevertheless, this does not involve, imply, or express any guaran­ tee or responsibility on the part of the publishers in respect to any Translator: Sabine Wilms, PhD. Taos, NM, USA

dosage instructions and forms of applications stated in the book.

Every user is requested to examine carefully Illustrator: Christiane von Solodkoff. Neckargmtind, Germany

the manufacturers'

leaflets accompanying each drug and to check, if necessary in con­ sultation with a physician or specialist, whether the dosage sched­ ules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publi­ cation, errata will be posted at www.thieme.com on the product description page.

© 2011 Georg Thieme Verlag,

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microfilms, and electronic data processing and storage.

v

For�word to the English Edition

specifically serves up 18 additional organs in his won­

When asked to consider writing a foreword to Visceral Manipulation in Osteopathy by Eric Hebgen, DO, I was

derfully uncomplicated style. His simple clarity pro­

conflicted but intrigued. Leaving the next day to lecture

vides immense clinical practicality.

in Australia, I had hoped to empty my plateful of writing projects on the long flight, yet treatment of visceral dys­

I would like to close this foreword by observing that in

function was near dear to my heart

1990 when we wrote our first text, Osteopathic Consider­ ations in Systemic Dysfunction, we could not have imag­

(no pun intended). In

the end, the title of Chapter 3 proved impossible to resist. I offered to examine the text and happily so. The clear, uncluttered diagrams and dynamic pictures

ined its impact. In later texts and editions, we continued to build upon the acknowledged work of our respected

of osteopathic manipulative technique (OMT) immedi­

teachers and mentors (especially Korr, Denslow, Kim­

ately impressed me. Coupled with the publisher's spa­

berly, Frymann, and Zink), just as they built upon the

cious layout,

Visceral Manipulation in Osteopathy was intended for a

remarkably easy to read and "digest" (pun

work of Sutherland, Chapman, Burns and others. As future texts synthesize improved, coordinated osteo­

cooking analogy!). The author is an effective chef who

pathic approaches promoting health and visceral homeo­

has carefully balanced precise appetizers and chosen just

stasis, they will benefit from access to this text-1 know

the right ar:1ount in each entree to nourish-but not over­

our subsequent editions will.

stuff-clinicians. •

Because of its clear explanations, quality graphics and

Appetizers: In his first four chapters, the author pares

intent to convey some of the contributions of the author's

down and deconstructs several key osteopathic

colleagues and teachers, I recommend you make this text

approaches; treatments reflecting both European and

part of your library. While it benefits from a number of

American flavors. For complete recipes and their

practical OMT "recipes," in caring for patients I trust you

rationale, the reader should really return to the origi­

will find that

nal texts; but for an overview or a quick trip down

more than a mere cookbook.

Visceral Manipulation in Osteopathy will be

"memory-lane," the author handily summarizes ter­ minology and many key concepts related to visceral treatment. •

Entrees: Having introduced ingredients (concepts and

techniques) in the first four chapters, Eric Hebgen then

Prof Michael L. Kuchera, DO, FAAO (Author of Osteopathic Principles in Practice, Osteopathic Considerations in Systemic Dysfunction, and Osteopathic Considerations in HEENT Disorders)

VI

Foreword to the 3rd German Edition

During the 150 years in the history of osteopathy, numer­ ous approaches have been developed. Andrew Taylor Still, the founder of osteopathy, was far

of stimulations and overstimulations, the osteopathic view of the patient is gaining new significance. It offers an extremely interesting approach, in the context of the

ahead of his times and formulated a number of thoughts

viscera in particular. The decision to write this book was

that continue to enjoy unchanged validity for contempo­

therefore not far-fetched. To create a comprehensive sur­

rary medicine and for osteopathy. It was his desire to

vey, Eric U. Hebgen has adopted and integrated much

warn and preserve the medicine of his times against

information

overly radical specialization and mechanization. He advo­

authors. This book is also rooted in the visceral instruc­

from

previous publications by

different

cated a holistic and individualized perspective in medi­

tions by Dr med josi Potaznik, DO, who has collaborated

cine.

in the development of visceral instruction at the Institute

For this purpose, he emphasized placing the patient at

for Applied Osteopathy for a long time.

the center of the consultation. His ideal of medicine was

The present book serves not only as a general treat­

to first do everything in one's power to activate the auto­

ment of visceral manipulation, but also as a guidepost

regulatory powers of the patient. It was only when the

and textbook, describing the organs according to osteo­

limits of autoregulation were reached that allopathy

pathic criteria in their physiologic movement, defining

should get involved. His first yardstick for the healthy

movement disorders, and presenting pathologic effects.

functioning of the human body was movement, in the largest sense of the word. Eric U. Hebgen, the author of the present book, and his teacher josi Potaznik have grasped the meaning of this philosophy. Especially in our modern world with its host

Werner Langer, DO Director, Institute for Applied Osteopathy Bitburg. Germany

VII

Preface

It is my pleasure and honor to offer you this book, which

that the visceral manipulation of the internal organs

was first published in Germany in 2003 as

Viszeralosteo­

could be established as a part of osteopathy in Europe. He

pathie-Grundlagen und Techniken, now in its English translation as Visceral Manipulation in Osteopathy. The

out his own studies, and published a visceral concept that

publication of an osteopathic

book

systematized and structured existing information, carried

in the "mother

has become the most widespread model in European

tongue" of osteopathy, as it were, appears particularly sig­

osteopathy. In the present book, I have therefore devoted

nificant to me. I hope that you will find suggestions and

the largest amount of space to

inspiration for your daily work.

approach.

The osteopathic manipulation of the internal organs is as old as osteopathy itself. Andrew T. Still's books show

Furthermore,

the two

Harral's therapeutic

Belgian osteopaths Georges

Finet, DO, and Christian Williame. DO, also carried out

that he already treated the internal organs. He describes

extensive studies in the 1980s to investigate the mobility

manipulations that primarily affect the organs through

of the organs in relation to the movements of diaphrag­

the circulatory system and aim at strengthening their

matic breathing. On the basis of their research, they

self-healing powers. William A. Kuchera, DO, and Michael

developed a fascial treatment of the internal organs that

L. Kuchera, DO, compiled and refined these treatments in

surely deserves more attention. In this book, I introduce

an outstancling book that was published in 1994. This tra­

one part of this treatment concept that I consider the

ditional American treatment approach is part of this

most effective.

book, as is the reflex therapy according to F. Chapman,

For many people, manual treatments of the internal

DO, an American osteopath who at the start of the twen­

organs initially appear strange, and they may ask why we

tieth century discovered the reflex points named after

should even push around on the abdomen at all. Thus, we

him and linked them to certain organs, as a result of

should take into consideration the fact that the internal

which we know that treating the points improves the

organs are affixed mechanically to each other as well as

health of the organ.

to parts of the locomotor system and are subject to the

European practitioners also began to manually treat

same physical laws as the rest of the body. If we therefore

the abdominal organs in the late nineteenth century. The

recognize them as part of the mechanics of the body and

Swedish gymnast Marten Thure Emil Brandt (1819-

take into account the anatomical connections, we can see

1895), for example, developed a diagnostic and therapeu­

how a disturbance in the movement of an organ has an

tic method for treating the organs of the lesser pelvis.

affect on other parts of the body. Bear in mind: I am refer­

Thus, a repositioning technique for uterine prolapse is

ring here to an osteopathic dysfunction, as it occurs also

named after him, which is still used successfully today.

in the locomotor system, and not to an illness of an organ,

Henri Stapfer. one of Brandt's students, further refined

even though in such cases Andrew T. Still himself estab­

these methods. The French physician Frantz Gh�nard

lished the circulatory treatment method. Thus. I am

( 1848-1920)

and

firmly convinced that the osteopathic manipulation of

manipulations of different organs systematically during

the internal organs presents an enrichment of therapeu­

this time. In addition, he introduced a first visceral con­

tic skills. Anybody who has personally discovered them

cept.

will never want to manage without them again.

also

described

visceral

palpations

In the 1970s and 1980s, French osteopaths such as jacques Weischenk, DO, in turn took on the known treat­ ment methods and developed them further. And, finally, we have Jean-Pierre Barra!, DO, to thank for the fact

Eric U. Hebgen, DO, MRO

VIII

Introduction

Explaining the Concepts of Jean-Pierre Barral, Georges Finet and Christian Williame, William and Michael Kuchera, and Chapman

movement directions and extents, which largely concur

The following chapters offer a description of the osteo­

techniques, Finet and Williame utilize the anterior parie­

with Barral's results. In addition, they developed a treat­ ment method to influence disturbed organ movements and were also able to control their method using X-rays or ultrasound waves. In contrast to Barral, who palpates the organs and moves them directly in his mobilizing

pathic manipulation of the internal organs. I will intro­

tal peritoneum in their therapy. By moving the perito­

duce you to four treatment concepts that have one

neum, they achieve a mobilizing effect without palpating

feature in common: all of them use the anatomy of the

the organ itself. They call their method fascial because

body as the foundation for the development of each par­

the peritoneum is seen as fascia and connects all abdomi­

ticular concept. In the following paragraphs, I would like

nal organs with each other. If you pull on one part of the

to explain the differences between these concepts.

anterior peritoneum, this also has an effect on a distant

The manipulation of the internal organs according to

region, e.g., the peritoneum of the pancreas. You could

Jean-Pierre Barral, DO, is the standard method of visceral

compare the peritoneal cover to a balloon: if you push or

osteopathy in Europe. In this method, Barral views the

pull on one part of the balloon, this pull spreads through­

organs from a mechanical perspective: organs form vis­

out the entire balloon and deforms it.

ceral joints with another organ or a part of the locomotor

Ultimately, both treatment concepts succeed in restor­

system, e. g., the diaphragm. Similar to joints in the loco­

ing the physiologic mobility of an organ, with the only

motor system, the partners of a joint move against each

difference being that Finet and Williame do so a little less

other in fixed directions and ranges. To ensure that this

invasively. The indication for this method thus also

movement is executed with as little friction as possible,

extends to organs that, because of a disorder, should not

the partners of a parietal joint are characterized by a

be palpated and mobilized directly. In this book, I intro­

smooth surface and by the synovium, which produces

duce what I believe to be the most effective technique

small amounts of joint fluid. Likewise, the organs have a

from the treatment concept according to Finet and Wil­

smooth surface as their external surface is sealed off by a

liame, namely expiratory dysfunction. I consider it partic­

layer of serous skin. This layer is the peritoneum, the

ularly successful because the mobilizing effect is herein

pleura, or the endocardium. Furthermore, we find a small

achieved by the diaphragm in the context of respiration,

amount of fluid in the serous cavities between the

meaning that the patient's body is thus carrying out the

organs. The organs do not move against each other hap­

real "work" itself.

hazardly but are subject to certain laws: they are fastened

In the circulatory movements according to William A.

to each other and to the locomotor system by the mesen­

Kuchera, DO, and Michael l. Kuchera, DO, the osteopath

teries, omenta, or ligaments. This limits their range of

does not aim at contact with the affected organ, but

motion. We also find this feature in the joints of the loco­

rather analyzes which arteries, veins, vegetative nerves,

motor system. Ligaments permit and limit the extent and

and lymphatic vessels supply an organ and dispose of its

direction of movement.

waste, using special techniques to influence the circula­

Barral hence constructs his theory parallel to the pari­

tion of the organ. In this technique, the mobilization of

etal joints. His treatment techniques are also, to a large

the organ is not of primary importance. This concept is

extent, informed by them. Similar to the parts of a joint,

thus an excellent complement to the mobilizing concepts

the organs are tested for their ability to move and directly

of Barra! and Finet/Williame. These manipulations are

treated to increase mobility, until a normal range of

less invasive and far too little known in some countries.

motion is restored. It is only his concept of visceral motil­

For didactic reasons, I have recorded the appropriate

ity that follows a more energetic approach, which I will

techniques for each organ, knowing full well that an exact

treat in more detail below. Georges Finet, DO, and Christian Williame, DO, two

separation of its circulation and therefore an isolated treatment of an individual organ is not possible. The tech­

Belgian osteopaths, carried out extensive radiograph- and

niques themselves are described all together in the gen­

ultrasound-supported studies in the 1980s, to examine

eral section of the book.

the movements of the abdominal organs in relation to

The fourth treatment concept is the reflex therapy

diaphragmatic breathing. In the course of their research,

according to Frank Chapman, DO. The Chapman points

they discovered organ movements that follow certain

are a valuable diagnostic tool, can provide follow-up

rules. For the organs that they studied, they defined

results after treatment with visceral manipulation, and

Introduction

take advantage of the vegetative nervous system to influ­

IX

cia! continuum works together as a functional unit: if a

ence th · e internal organs. Reflex therapy should be found

dysfunction is present in the body that should be pro­

in every therapeutic tool kit. The Chapman points have

tected in a global chain of protection, the central tendon

become highly valued tools for me. These treatment techniques are supplemented by con­

can collaborate in this effort. The ability to carry out a fas­ cial contraction is therefore of great importance. The fas­

cise information about the physiology and clinical pathol­

cia contracts towards the location of the dysfunction,

ogy of the individual organs. This information is not

thereby contributing to the protection of this area. As the

intended to be exhaustive but rather as a quick reference

fascial organ coverings (peritoneum, pericardium, pleura)

source in one's daily work. While reading this book, you will encounter the term

are integrated into this system, compensatory increases in tension are also found in this fascia. As circulation

"central te.ndon" again and again. This is not to be con­

passes through the fascia, elevated fascial tension disturbs

fused with the "core link." That term is used in the Eng­

the circulation of the tissue behind it. In concrete terms,

lish literature to refer to the connection between the base

this means that pathologic tension in the central tendon

of the skull and the sacrum or coccyx via the dura mater.

disturbs the circulation in the organs and can be the trig­

The central tendon, by contrast, refers to a fascial string

ger point for impaired organ function or result in a

that also runs through the body from the base of the skull

reduced ability of the organ to compensate for biological,

to the pelvic floor, but is located anterior to the spinal

physical, or chemical noxa. Restoring normal tension in

column in the superficial and deeper-lying fascial layers

the central tendon is hence of vital importance for undis­

of the body and does not include the dura mater. This fas-

turbed organ function.

X

Contents

I Foundations and Techniques............................................................... 1 Visceral Manipulation according

Inhibitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

to Barral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

.................

3

Physiology of Organ Movement . . . . . . . . . . . . . . . .

3

Motricity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

Theory of Visceral Manipulation

Mobility.. . .. . . . . . . .. . . .. . . . ...... . . .. . . .

3

Motility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

Visceral joint. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

. Ligamentary System .

. . . . . . . . . . . . . . . . . . . . . .

4

. . . . . . . . . . . . . . . . . . . . . .

4

..

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4

Mesenteries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4

Double-Leaf System

Turgor and Intracavitary Pressure

Omenta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4

Pathology of Organ Movement . . . . . . . . . . . . . . . . .

4

........................ ........................

4

Disturbed Mobility Disturbed Motility

Rebound Technique

.......................

13

Treatment of Mobility . . . . . . . . . . . . . . . . . . . . . . 13 Treatment of Motility according to Barra!

......

13

2 Fascial Treatment of the Organs according

to Finet and Williame . . . . . . . . . . . . . . . . . . . .

15

Foundations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Principles of Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . 15 Principles of Fascial Organ Treatment

.............

15

Principles of the Technique for Expiratory Dysfunction 15 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Hemodynamic Test

...........................

16

Fascial Induction Test . . . . . . . . . . . . . . . . . . . . . . . . . . 16

5

Diagnosis and General Treatment Principles in Visceral Osteopathy . . . . . . . . . . . . . . . . . . . . . . . . .

5

............................

5

Medical History

1

3 Circulatory Techniques according

to Kuchera . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . 18

...................................

Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5

Objective

Palpation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

Principle of the Techniques . . . . . . . . . . . . . . . . . . . . . 19

Superficial Palpation. . . . . . . . . . . . . . . . . . . . . . .

6

Arterial Stimulation

.......................

18 19

Venous Stimulation. . . . . . . . . . . . . . . . . . . . . . . . 19

...........................

6

Inspection and Palpation Results . . . . . . . . . . . . . . .

6

Lymphatic Stimulation

Listening Tests according to Barra! . . . . . . . . . . . . . .

9

Vegetative Harmonization . . . . . . . . . . . . . . . . . . 19

Listening Test in Standing Position . . . . . . . . . . . .

9

............. .............

9

Deep Palpation

Listening Test in Seated Position Listening Test in Supine Position

9

Local Listening Test. . . . . . . . . . . . . . . . . . . . . . . . 10 Sotto-Hall Test according to Barra!

. ............

11

...... .............. .

19

Techniques . .... . . . .. . . . ....... . .. . .......... 20 Vegetative Harmonization

. . . ...............

20

Lymphatic Stimulation ... . ................. 24 Venous Stimulation ....... . . ............... 26 Diaphragm Technique... .. . .... . .. . ...... . . 27

Rebound Test according to Barra! . . . . . . . . . . . . . . . 11 Completed Tests according to Barra!

... ..... ....

12

Ventilation Test according to Barra! . . . . . . . . . . . . . 12 Hyperextension Test according to Barra!

... . .....

12

4 Reflex Point Treatment according

to Chapman . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . 28

General Treatment Principles and Possibilities

Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

in Visceral Treatment . . . . . . . . . . . . . . . . . . . . . . . . 12

Location and Shape

Possibilities in Visceral Manipulation... . .. . ... . . 13

Principle of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 28

Reflex Point Treatment according to Barra! . . . . . 13

................ . ..........

Significance of the Reflex Points

......... ... ....

.

28 28

XI

Contents

II Osteopathy of the Individual Organs 5 The liver Anatomy

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. . . . . . .. . .. . . ... . ... . . . . . . . .. . . . 33

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General Facts . . . . . .. .. . . . . . . . . . . . . . . . . . . . . 33 Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Topographic Relationships

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. ... . .. ... . . ... . . 33

Attachments/Suspensions . .. . . . . . . . . . . . . . . .. 34 Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Movement Physiology according to Barral

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Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Metabolic Functions of the Liver . . ... . . ... . . . 36 Pathologies

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Symptoms that Require Medical Clarification . . . 36 Icterus

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Acute Hepatitis

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Chronic Hepatitis Fatty Liver

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Liver Damage from Alcohol

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Cirrhosis of the Liver . . .

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Portal Hypertension

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Primary Hepatocellular Carcinoma Osteopathic Practice

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Indications for Osteopathic Treatment

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Typical Dysfunctions

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Cardinal Symptoms

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Associated Structural Dysfunctions Atypical Symptoms .

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Contraindications for Osteopathic Treatment Notes for Clinical Application

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40

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Osteopathic Tests and Treatment . . . . . . . . . . . . . . . . . 41 Direct Mobilization of the Liver . . .... . . . ... .. 41 Indirect Mobilization of the Liver Liver Pump according to Barral Oscillations on the Liver

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Test and Treatment of Liver Motility according to Barral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Fascial Treatment according to Finet and Williame . .

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Circulatory Techniques according to Kuchera

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6 The Gallbladder . . . . . . . . . . . . . . . . . . . . . . . . . .

49

Anatomy

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Reflex Point Treatment according to Chapman Recommendations for the Patient

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Gallbladder Carcinoma . . . . . . . . . . . . . . . . . . . . . 5 2 Osteopathic Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2 Cardinal Symptom

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Typical Dysfunctions

. . . . .. . . . . . . . . .. .. . . . .. 5 2 .

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Associated Structural Dysfunctions . . . . .. . . . . . 5 2 Atypical Symptoms

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Indications for Osteopathic Treatment

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Contraindications for Osteopathic Treatment .. . 5 3 Osteopathic Tests and Treatment . . . . . .. . .. .. . . . . . 5 3 Murphy Sign .

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Treatment o f the Sphincter o f Oddi (Major Duodenal Papilla) according to Barral

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Voiding the Gallbladder in Seated Position according to Barral

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Smoothing Out and Stretching the Biliary Tract according to Barral

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Stretching the Biliary Tract by Lifting the Liver

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. 55

Smoothing Out and Stretching the Common Bile Duct in Supine Position according to Barral

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Defibrosing the Gallbladder according t o Barral

55 55

De-spasming the Gallbladder according t o Barral .

56

Oscillations o n the Murphy Point . . . . . . . . . . . . . 5 6 Test and Treatment o f Motility i n the Common Bile Duct according to Barral . . .. . . . . . 5 6 Fascial Treatment according to Finet and Williame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Circulatory Techniques according to Kuchera

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Reflex Point Treatment according t o Chapman . . 57 Recommendations for the Patient

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42

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Cholecystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2

7 The Stomach Anatomy

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Anatomy of the Esophagus

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59

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Location . .. . . .. .. . . . . . ... . . . . . . . . .. . . .. . . 59 Topographic Relationships

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Attachments/Suspensions . . . . . . . . . . . .. . . . . . . 59 Circulation . . . . . .. . . . . . . .. . . . . . . . . . . . . . . . . 5 9 Anatomy o f the Stomach

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Location . . . . . . . . . . . . . . . .. . . . .. . . . . . . . . . . . 60 Topographic Relationships

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Attachments/Suspensions . . . . . . .. . . .. . .. . ... 60

49

Circulation . . . . . . . . . . . . . .. . . . .. . .. . . . . . .. . 62

General Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Movement Physiology according to Barral . . . . .. 62

Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Physiology . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . 63

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Topographic Relationships . . . . . . . . . . . . . . . . .. 50

Proximal and Distal Stomach . .. . . . . . . . . . . . . . 63

Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Main Functions of the Stomach

Movement Physiology according to Barral . . . . . . 50

Gastricjuice .

Physiology

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Composition of Bile in the Gallbladder

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Pathologies

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Symptoms that Require Medical Clarification

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Cholelithiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

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Regulating the Secretion of Gastricjuice . . . . . . . 63 Hormones . . . . . . . . . . .. . . .. .. . . . .. . . . . . . . . 64 Pathologies

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Symptoms that Require Medical Clarification . . . . . 65 Hiatus Hernia

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XII

Contents

Acute Gastritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Chronic Gastritis Gastric Ulcer

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.

Osteopathic Tests and Treatment . . . . . . . . . . . . . . . . . 83 Treatment of the Sphincter of Oddi

. . . . . . . . . . . . . . . . . . . . . . . . . 66

(Major Duodenal Papilla) according to Barra! . . . . 83

. . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Treatment of the Duodenojejunal Flexure

Stomach Cancer . . . . . . . . . . . .. . . . . . . . . . . . . . 66

according to Barra!

Osteopathic Practice . . . .. . . . . . . . . . . . . . . . . . . . . . . 67

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Cardinal Symptoms . . . . . . . . . . . . . . . . . . . . . . . . 67

Mobilization of the Superior Part in the Seated

Typical Dysfunctions

Position via the Liver according to Barra!

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84

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De-spasming the Descending and Horizontal Part

Associated Structural Dysfunctions . . . . . . . . . . . 67 Atypical Symptoms . . . . . . . . . . . . . . . . . . . . . . . . 67

in Side Position according to Barra! . . . . . . . . . . . 85

Indications for Osteopathic Treatment

Treating the Angle between the Superior Part

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. . . . . . . . 67

Contraindications for Osteopathic Treatment Notes for Clinical Application

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.

and the Descending Part in the Supine Position . . 85

. . 67

Test and Treatment of Duodenal Motility

. . . . . . . . . . . . . . . 68

Osteopathic Tests and Treatment . . . . . . . . . . . . . . . . . 69

according to Barra!

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Mobilization of the Stomach . . . . . . . . . . . . . . . .. 69

Fascial Treatment according to Finet and

Oscillations on the Stomach

Williame .... . . . . ..... . . . . . . . . . . . . . . . . . . . 86

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. . . . . . . . . . . . . . . . 72

Stretching the Lesser Omentum

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Circulatory Techniques according to Kuchera . . . 86

. . . . . . . . . . . . . 73

Pylorus Treatment according to Barra!

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Recommendations for the Patient

. . . . . . . . 73

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Mobilizing the Mediastinum to Improve Esophageal Mobility according to Barra!

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Test for Deterioration of Hiatus Hernia according to Barra! . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .. . 74

.

The Spleen

Anatomy

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Topographic Relationships

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Position according to Barra!

Attachments/Suspensions

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Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

Treatment of Hiatus Hernia in the Supine Position

.

Location . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . 88

Treatment of Hiatus Hernia in the Seated .

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General Facts . . . . . . . . . . . . . . . . . . ... . . . . .... 88

Test for Improvement of Hiatus Hernia according to Barra!

9

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Movement Physiology according to Barra! . . . . . . 89

Mobilization of the Gastroesophageal junction

Physiology

via the Liver according to Barra!

Pathologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

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Treatment of Gastroptosis according to Barra!

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Symptoms that Require Medical Clarification . . . 89 Splenomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Test and Treatment of Stomach Motility according to Barra!

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Hypersplenism

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. . . . . . . . . . . . . . . . . . . . . . . . . . 90

Osteopathic Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Fascial Treatment according to Finet and Williame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Cardinal Symptom

Circulatory Techniques according to Kuchera

. . 78

Typical Dysfunctions . . . . . . . . . . . . . . . . . . . . . . . 90

. 78

Associated Structural Dysfunctions . . . . .. . . . . . 90

.

Reflex Point Treatment according to Chapman Recommendations for the Patient

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Atypical Symptoms

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Indications for Osteopathic Treatment

8 The Duodenum Anatomy

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80 80

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Contraindications for Osteopathic Treatment Notes for Clinical Application

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Osteopathic Tests and Treatment . . . . . . . . . . . . . . . . . 91

General Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

Test and Stretch of the Phrenicocolic Ligament

Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

Stretch o f the Gastrosplenic Ligament

Topographic Relationships

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81

Spleen Pump

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Circulation . . .. . . .. . . . . . . . . . . . . . . . . . . . . . . . 82

Finet and Williame

Movement Physiology according to Barra!

Circulatory Techniques according to Kuchera

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Reflex Point Treatment according to Chapman

Pathologies

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Recommendations for the Patient

.

Osteopathic Practice . . . . . . . . . . . . . . . .. . . . . . . . . . . 83 .

Typical Dysfunctions

. . . . . . . . . . . . . . . . . . . . . . . 83 .

. . . . . . . . . . . . .. . . . . . . . . 83

Associated Structural Dysfunctions

.

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Indications for Osteopathic Treatment

.

. . . . . . . . 83

Contraindications for Osteopathic Treatment

.

.

. . 94 .

. 94

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. . 83

Duodenal Ulcer . . . . . . . . . . . . .. . . .. . . . . . . . . . 83 Cardinal Symptoms

91

. . . . . . . . . . . . . . . . . . . . . . . 93

Physiology

Symptoms that Require Medical Clarification

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Fascial Treatment according to

. . . . . 82

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Attachments/Suspensions . . . . . .. . . . . .. . .... . 82

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83

1 0 The Pancreas

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Anatomy

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95

General Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Division

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Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Topographic Relationships . . . . . . . . . . . . . . . . . . 95

Contents

Attachments/Suspensions . . . . . . . . . . . . . . . . . .

96

General Relief Technique according to Barra!



38.5 oc

Nephrotic Syndrome Definition. Complex of symptoms, consisting of:

Nephrolithiasis

•

proteinuria

•

hypoproteinemia

Definition. Urinary stones in the kidney and excretory

•

dysproteinemia

urinary tracts.

•

hyperlipoproteinemia

•

edemas

142

14 The Kidneys

Causes. We find primary or secondary preexisting glo­

Ptosis of the Right Kidney

merular disorders, e.g.: •

poststreptococcal glomerulonephritis

"Digestive kidney." This name stems from the fact that the

•

rapidly progressive glomerulonephritis

digestive tract has such a strong influence on the right

•

systemic disorders, e.g., lupus erythematosus

kidney. See also "Notes for Clinical Application," page 143. The liver and ascending colon are the main factors

Clinical •

microhematuria

•

edemas

•

hypertonicity

Renal Cell Carcinoma

affecting the kidney. Ptosis of the right kidney is more common than ptosis of the left kidney because: •

the large liver presses down more strongly

•

the Toldt fascia is weaker on the right side

•

the left colic flexure fixates more strongly

•

the scoliosis in the lumbar spinal column (LSC) brings the right kidney to anterior. which increases the pres­

Definition. Most common form of malignant tumor in the

sure from the liver

kidney, in most cases originating in the tubular cells.

Ptosis of the left Kidney

Causes. Degeneration of proximal tubular cells. Clinical •

hematuria

•

elevated ESR

•

palpable abdominal mass

•

hypertonicity

•

weight loss

•

anemia

•

intermittent fever

•

asymptomatic in the early stages

Genital kidney. This name stems from the fact that the ovarian/testicular vein has such a strong influence on the left kidney. See also "Notes for Clinical Application," page

143. Symptoms include: •

varicocele

•

left-sided dysmenorrhea

•

loss of libido

•

impotence

The left ovarian/testicular vein runs into the left renal vein, on the right side directly into the inferior vena cava.

Osteopathic Practice Cardinal Symptoms

•

Pain elicited by percussion in the kidney area

•

Hematuria

Degree of Ptosis

First degree •

ptosis runs caudally

•

subcostal nerve is irritated

Symptoms include: •

diffuse pain in the area of the lower ribs

•

sharp pain in the area of the lower ribs, radiating in

Typical Dysfunctions

the direction of the navel and disturbed breathing

•

ptosis

Second degree

•

adhesions/fixations

•

The kidney shifts in a caudal-lateral direction, the out­ ward rotation is intensified, and the lower pole moves to anterior (psoas as the slide rail).

Theory of Kidney Ptosis according to Barra/ •

Causes •

·

The genitofemoral, lateral femoral cutaneous, ilioin­ guinal, and iliohypogastric nerves are irritated.

ptosis up to the lesser pelvis is congenital

•

asthenic body

Symptoms include: corresponding to the area innervated

•

trauma (fall on the coccyx, vibrations)

by the irritated nerves, patients can experience pain in

•

rapid and extensive weight loss

the area of the groin, the lateral hip region and the lateral

•

depression

thigh, medial thigh, or in the area of the genitals.

•

turgor effect decreases with increasing age

•

ptosis after childbirth

Third degree

•

suction from below and pressure from above during

•

•

The lower pole droops in a caudal-medial direction

delivery

with an inward rotation (caused by the pull of the ves­

loose ligaments

sels and the ureter).

Osteopathic Practice

•

The inward rotation is tolerated better than the out­

143

Notes for Clinical Application

ward rotation.The psoas no longer serves as a slide

•

rail.

As an organ, the kidney functions as the body's filter. To

The femoral nerve is irritated.

perform this task, the kidney has an enormous compen­ satory capability: 75% of its filtration capacity can fail,

Symptom: knee pain (increased by flexion).

without any effect on the body. We know that a person can live well with only one kidney, but even the remain­ ing single kidney must fail at more than 50% before we

Associated Structural Dysfunctions

speak of kidney insufficiency. This immense compensa­ tory capability means that the kidney can compensate

•

T11-T12 and costovertebral joints ofT10-81

well for a diversity of disturbing factors. This fact also

•

L1-L2 (due to neurovegetative reflexes)

holds true for osteopathic dysfunctions. In the author's

•

coccyx

opinion, it is rare to find the kidney as the primary cause

•

dysfunctions of the ileum

of symptoms; it is much more likely that it is reacting to another organ, which can certainly also trigger parietal symptoms, but the kidney itself will not be impaired in

Atypical Symptoms

its function.

In contrast to other authors, Barra! additionally lists the

tal symptoms that are likely to arise with an osteopathic

Let us look at an example to illustrate this point: parie­ following organ-specific symptoms (for an explanation of

dysfunction of the kidney can be explained by the three

osteopathic chains, see "Atypical Symptoms" in Chapter 5,

nerves of the lumbar plexus, which are found posterior to

page

39):

the kidney on the psoas major. These are the subcostal, iliohypogastric, and ilioinguinal nerves.The pain that is

•

polyuria with great thirst in the early morning or during the night

characteristic of a renal colic can be interpreted as irri­

•

abdominal discomfort with dyspnea

tations of these nerves due to a congested kidney. The

•

pain below the diaphragm or in the lesser pelvis

same holds true for osteopathic dysfunctions. Whether it

•

LSC pain disappears shortly after getting up

is a disturbance in the slide bearing or a circulatory impair­

•

LSC pain during the day due to "stresses" such as

ment in the osteopathic sense that is disturbing the kid­

coughing, sneezing, prolonged sitting or standing,

ney, the three lumbar plexus nerves are irritated, resulting

tight belts

in pain e.g., in the groin or in the lateral trochanter area. It

•

gingivitis, aphthosis, stomatitis

is easy to confuse this with a coxarthrosis or a trochanteric

•

dry skin

bursitis. In the osteopathic context, we also like to speak

•

patient is flexed, holds the stomach or the lower pos­

of a congested kidney that is pressing on the nerves. Here,

terior ribs

it is important to point out specifically that we are not

when sneezing or coughing, patient flexes the hip on

dealing with an engorged kidney. In this osteopathic dys­

the affected side, to compensate for the increased

function, the function of the kidney is not impaired!

•

pressure

What Factors Can Trigger Such a Dysfunction? Indications for Osteopathic Treatment

The right kidney is also known as the digestive kidney because the various organs of the digestive system can

•

ptosis

•

adhesions/fixations

irritate this kidney.The first organ to mention here is the liver, which lies on top of the right kidney. If the liver is congested, it transmits increased pressure posteriorly to the kidney, which subsequently develops a disturbance in

Contraindications for Osteopathic Treatment

the slide bearing. The transition from the superior part to the descend­

•

acute inflammation

ing part of the duodenum is located at the renal pelvis.

•

hematuria

This section of the duodenum is frequently affected by

•

carcinoma

osteopathic dysfunctions as the result of ulcers that form

•

cystic kidney

most commonly in the superior part. This condition then has a secondary detrimental effect on the kidney and its circulation. The ascending colon likewise has contact with the kid­ ney at its lower pole. The ureter is crossed by the root of the mesentery near the ileocecal valve; as a result, a ptosis of the small

144

14 The Kidneys

intestine can have a constricting effect on the ureter, which in turn can result in an osteopathic congestion of

Osteopathic Tests and Treatment

the kidney. The left kidney is also known as the genital kidney, which points to the fact that the primary sexual organs

The mobility of the kidney is more important than its position.

can affect this kidney. The reason for this is that the ovarian or testicular vein on the left side runs into the renal vein, while it drains its blood on the right side into the

Palpation of the Kidney according to Barra I

inferior vena cava. An increased blood flow into the renal vein can hence lead to signs of congestion in the kidney on the left side. On the other hand, however, a section of the colon has an effect on the left kidney that should not be underesti­ mated. The sigmoid colon has a mesentery that crosses both the ureter and the ovarian and testicular veins. Con­ stipation, diverticulitis, and irritable bowel syndrome are three common disorders that affect the sigmoid and therefore in turn cause secondary dysfunction in the kid­ ney. In all cases mentioned here, the kidney responds to the dysfunction of another organ. On the right side, it is the organs of the digestive tract that affect the kidney; on the left side, it is the sexual organs and the large intestine. In functional terms, however, its great compensatory capacity protects it from being impaired. Nevertheless,

Fig.l4.4

parietal symptoms can still occur, which could lead us to focus treatment on the kidney and regard it as the pri­ mary cause. According to the author's experience, the

Starting Position

other organs mentioned above are more likely to be the

The patient is in the supine position, legs bent. The prac­

cause of the complaints, so we should treat these first.

titioner stands by the patient's head on the contralateral

Afterward check to see whether dysfunction of the kid­

side.

ney is still present.

Procedure for the Right Kidney Make contact with the abdominal wall on the right side, roughly at the level of the ileocecal valve. Carefully push­ ing the loops of the small intestine aside, slide cranially along the medial edge of the ascending colon. Roughly at the height of the navel, you can palpate the kidney as a smooth solid mass (like a soap). Normally, it is the anterior surface that is palpable, as well as the inferior pole in the case of a ptosis or in slim people.

Procedure for the Left Kidney Make contact with the abdominal wall on the left side above the sigmoid in the caudal quarter of a line from the navel to the anterosuperior iliac spine (ASIS). Carefully pushing the loops of the small intestine aside, slide crani­ ally along the medial edge of the descending colon. The anterior surface or inferior pole is palpable roughly 1 em above the navel. You can also carry out either of these palpations with the patient in the seated position.

Osteopathic Tests and Treatment

145

Mobilization of the Kidney Variation for the Right Kidney

In the Supine Position according to Barra/

Starting Position The patient is in the supine position, legs bent. The prac­ titioner stands next to the patient on the side to be exam­ ined.

Procedure With the thumb of the left hand, carefully work your way from lateral into the abdomen at the level of the navel. The thumb then lies on the medial edge of the ascending colon. The right hand pushes the mass of intestines toward the palpating thumb to cause a fascial release in the area of palpation. The kidney is palpable as a solid mass.

Variation for the Left Kidney

Fig.14.6

Starting Position The patient is in the supine position, legs bent. The prac­ titioner stands next to the patient on the side to be exam­

Starting Position

ined.

The patient is in the supine position, legs bent. The prac­ titioner stands by the patient's head on the contralateral side.

Procedure Palpate the kidney as described on page 144.

Treatment During the exhalation, mobilize the kidney along its axis of movement in a cranial-medial direction. During inha­ lation, hold the position reached. Repeat this treatment several times.

Fig.14.5

Procedure With the thumb of the right hand, carefully work your way from lateral into the abdomen roughly 1 em above the navel. The thumb then lies on the medial edge of the descending colon. The left hand pushes the mass of intes­ tines toward the palpating thumb to cause a fascial release in the area of palpation. The kidney is palpable as a solid mass.

146

14 The Kidneys

In the Seated Position according to Barra/

With the Aid of the Psoas Major according to Barra/

Fig.14.8

Starting Position The patient is in the supine posttiOn, legs bent, head down. The practitioner stands at the head of the table. Procedure Find the inferior pole of the kidney. Flex the patient's ipsi­ lateral hip and hold the leg, while fixating the kidney with the palpating hand in a cranial-medial direction. Fig.14.7

Treatment During exhalation, guide the leg into extension, stretch

Starting Position

the psoas, and mobilize the kidney by switching the fixed

The patient sits in kyphotic position. The practitioner

and mobile points.

stands behind the patient.

You can combine this extension with an abduction or adduction of the hip to achieve an additional mobilizing

Procedure Stand behind the patient and make contact with the kid­ ney as described above. Treatment During the exhalation, mobilize the kidney along its axis of movement in a cranial-medial direction. During inha­ lation, hold the position reached. Repeat this treatment several times. In addition, you can facilitate a contralateral rotation of the torso. This action brings the kidney to the front. making it easier to palpate and therefore also easier to mobilize.

aspect.

Osteopathic Tests and Treatment

With Involvement of the Psoas Major and Post-Isometric Relaxation according to Barra/

147

Treatment of Grynfeltt Triangle according to Barral

Fig.14.10

Starting Position The patient is in the prone position, legs stretched out. The practitioner stands next to the patient. Procedure Using one or two fingers, one hand makes contact with rib 12 posteriorly. Palpate it caudally in the direction of the iliac crest. Medial to the internal oblique muscle of Fig.14.9

the abdomen,

you will find a muscle compartment

formed by the tendon sheet of transversus abdominis. The kidney is located anterior to this compartment and

Starting Position

should be treated via the Grynfeltt triangle. Leave your

The patient is in the supine position, legs bent. The prac­

fingers there and push anterosuperiorly to mobilize the

titioner stands next to the patient on the side to be exam­

kidney.

ined. Variation Procedure

You can place the other hand anteriorly onto the kidney

Place the patient's leg of the side to be treated onto your

and support the mobilization.

shoulder. With one hand, make contact with the inferior pole of the kidney. With the other hand, grasp the thigh of the leg on your shoulder from anterior. This hip bend creates tension in the psoas. During the exhalation, mobi­

Serratus posterior

lize the kidney in a cranial-medial direction. In addition, you can request isometric contractions of the psoas. During the exhalation and relaxation phase, finally mobilize the kidney. By approximating the psoas, you create a slide rail for the kidney posterocranially.

Internal oblique

Fig. 14.11 Grynfeltt triangle.

148

14 The Kidneys

Test and Treatment of Kidney Motility

Fascial Treatment according to

according to Barral

Finet and Williame

Fig.14.12

Fig.14.13

Starting Position

Starting Position

The patient is in the supine position, legs stretched out.

The patient is in the supine position, legs stretched out.

The practitioner stands next to the patient on the side to

The practitioner stands next to the patient.

be examined.

Procedure Procedure

Place your anterior hand on the abdomen on top of the

Place your hand with light pressure on the abdomen

projection of the kidney-the fingers pointing in a cra­

above the kidney, medial to the sigmoid or cecum. The

nial-medial direction. The posterior hand rests at a corre­

forearm of the palpating hand lies on the abdomen.

sponding height on the posterior wall of the torso-the

Testing Sequence

anterior hand, apply pressure posteriorly until you reach

Detect the motility motion and evaluate the amplitude

the fascial plane.

fingertips pointing toward the spinal column. With the

and direction of the inspiratory and expiratory move­ ments as well as the rhythm of the movement as a whole.

Treatment

If a disturbance is present in one or both aspects of the

During inhalation, both hands simultaneously pull cau­

motility movement, treat the patient.

dally.

During exhalation, hold

the position reached.

Repeat this procedure until you have reached the end of

Treatment

the fascial movement. Release the pull with the next

Motility is treated indirectly by following the unimpaired

exhalation.

movement, remaining at the end-point of this movement

Repeat the whole treatment four or five times.

for several cycles. and then following the impaired move­ ment to the new end-point. You can also try to increase the range of the free movement (induction), afterward checking whether the limited movement direction has improved. Repeat this movement again and again until the motil­

Circulatory Treatment according to Kuchera Arterial Stimulation Diaphragm techniques.

ity has returned to normal in terms of rhythm, direction, and amplitude.

Venous Stimulation •

liver pump

•

diaphragm techniques

Lymphatic Stimulation •

lymph drainage on thorax and abdomen

•

diaphragm techniques

Osteopathic Tests and Treatment

Vegetative Harmonization Sympathetic nervous system:

149

Posterior. Between the two transverse processes of T12 and L1, halfway between the spinous process and the tip of the transverse process (on both sides).

Stimulation of the sympathetic trunk T1 0-L 1 by: •

rib raising

•

inhibiting the paravertebral muscles

•

vibrations

Make contact with the reflex point. For this purpose, very

•

manipulations

gently place a finger on the point and press only lightly.

Treatment Principle

•

Maitland technique

Reflex points are often very sensitive, so it is important to

•

stimulating the aorticorenal ganglion (technique as for

proceed with caution.

•

diaphragm techniques

the superior mesenteric ganglion)

The finger remains on the point and treatment is by gentle rotations. The anterior points are treated first, then the posterior

Parasympathetic nervous system:

points. Continue with the treatment until you have nor­

Stimulation of the vagus nerve by:

malized the sensitivity or consistency of the point.

•

craniosacral therapy

To conclude, check the anterior points once more. If

•

laryngeal techniques

you fail to notice any change, it is possible that the organ

•

thoracic techniques (recoil)

pathology is too great to be influenced quickly via the

•

diaphragm techniques

reflex points, or other dysfunctions are present that must be treated first.

Stimulation of segments 52-54 by: •

iliosacra' joint techniques

•

ischiorectal fossa technique

•

pelvic floor

Recommendations for the Patient •

Head-down position on an empty stomach with self­ mobilization.

Reflex Point Treatment according to Chapman

•

Location • •

Anterior. Approximately 2.5 em to both sides of the median line and approximately 2.5 em cranial to the navel.

In patients with lax fixations, strong coughing or sneezing can promote a ptosis. Ensure a sufficient supply of fluids. Diluted lemon juice increases the effectiveness of kid­ ney manipulations.

150

15 The Urinary Bladder

Topographic Relationships

Anatomy

Female Pelvis

• Anatomy of the Urinary Bladder

Superior •

General Facts

peritoneum

•

small intestinal loops

•

uterus (depending on location)

The bladder's normal capacity lies at 500 mL, but strong urinary urgency occurs already with 300 mL. In patients with voiding dysfunctions after surgery, up to 2000 mL can collect.

location

Anterior •

pubis

•

peritoneum

•

when bladder is full: anterior abdominal wall

Inferior •

uterine cervix

The urinary bladder is located in the lesser pelvis behind

•

vagina

the symphysis. An empty bladder does not extend with

•

urethra

its superior pole beyond the symphysis; a full bladder can

•

pelvic floor (levator ani)

be palpated up to 3 em above the symphysis.

•

obturator intern us

Posterior •

uterine cervix and isthmus

•

vagina

•

ureter

Lateral.

Peritoneum, runs into the broad ligament of the

uterus.

Median umbilical fold with medial umbilical ligament (umbilical artery) Round ligament of the uterus

li'�:s.:-��--Proper ovarian ligament Broad ligament

-ff---11'7/hH!I----+-if--t­

Fallopian tube ---1/--;�'-/fH-+-.f--?-�;:f-+\\---1--+ Ovary----#��hK����r Rectum ---;'l---+l+i8ffill-'t-----h;..t---.