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Does Osteopathic Manipulative Treatment (OMT) have an Effect in the
Treatment of Patients Suffering from Gastro Esophageal Reflux Disease
(GERD)?
Publication History:
Received: May 25, 2016
Accepted: September 15, 2016
Published: September 17, 2016
Keywords:
GERD, Osteopathy, Pharmaceutical
treatments, Posture
Research Article Open Access
Introduction
e sensation of burning discomfort or pain behind the breastbone
is a frequently experienced disorder [1]. ese types of symptoms are
oen related to gastro esophageal reux disease (GERD), pregnancy
or cardiac disease [1]. GERD may develop when prolonged exposure
of the lower esophageal mucosa to gastric acid with a pH < 4 occurs
more than one hour per day. e corresponding symptom is frequently
referred to as “heartburn.” e increased exposure to gastric acid may
lead to a breakdown of the mucosal defence mechanisms, resulting
in inammation, erosions, and ulcerations, ultimately and scarring
brosis of the distal oesophagus [2].
For many years, antacids were the treatment of choice related to
GERD and peptic ulcers. ese treatments are frequently combined
with anticholinergic agents to reduce the output of gastric acid. e
main disadvantage with antacid treatment is the need for repeated
dosages during the day to relieve symptoms. e rst breakthrough for
pharmacological treatment came with the introduction of histamine
2(H2) receptor antagonists in the 1970s [3]. e second occurred with
proton pump inhibitors (PPI) twenty years later. PPIs are now the gold
standard in the treatment of GERD. However, medical therapy is not
curative and requires continuous treatment [1].
In 1955, Rudolph Nissen performed “gastro plication”, later denoted
as fundoplication(4). Surgery is an eective and curative approach.
Several minimally invasive operative methods have acceptable merits;
however, the disadvantages include the risk for severe side eects,
complications and the irreversibility of the procedures.
*Corresponding Author: Kjell Erling Bjørnæs, Nordic Osteopathic Research
Institute, Box 23, N-9501, Alta, Norway, Tel: 0047 90916488, Fax: 004778445031;
E-mail: kjellb@trollnet.no
Citation: Bjørnæs KE, Reiertsen O, Larsen S (2016) Does Osteopathic
Manipulative Treatment (OMT) have an Effect in the Treatment of Patients
Suffering from Gastro Esophageal Reux Disease (GERD)?. Int J Clin Pharmacol
Pharmacother 1: 116. doi: http://dx.doi.org/10.15344/2016/ijccp/116
Copyright: © 2016 Bjørnæs et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
International Journal of
Clinical Pharmacology & Pharmacotherapy
Kjell E. Bjørnæs1, Ola Reiertsen2 and Stig Larsen3
1Nordic Osteopathic Research Institute, Box 23, 9501 Alta, Norway
2Department of Digestive Surgery, Akershus University Hospital, Sykehusveien 25,1478 Lørenskog, Norway
3Norwegian University of life sciences, Faculty of Veterinary medicineUllevålsveien 72, 0033 Oslo, Norway
Int J Clin Pharmacol Pharmacother IJCPP, an open access journal
Volume 1. 2016. 116
Bjørnæs et al., Int J Clin Pharmacol Pharmacother 2016, 1: 116
http://dx.doi.org/10.15344/2016/ijccp/116
Is it possible to develop a treatment procedure, addressing some
of the possible reasons for the disease? e role of osteopathy in
understanding and treating the musculoskeletal system has been
known for over a hundred years [5]. During the last decades, this
understanding has greatly changed by integrating techniques, such as
the cranio-sacral and the visceral systems [6, 7].
One possible reason accounting for the development of GERD
might be an insucient closing of the lower esophageal sphincter
(LES) [1]. e eect of Osteopathic Manual erapy (OMT) of LES
has previously been described [8]. e objective of this study was to
compare pressure values in the examination of esophageal manometry
of the LES before and immediately aer osteopathic intervention in
the diaphragm muscle. irty-eight patients with GERD randomly
allocated to OMT or sham technique.e average respiratory pressure
(ARP) and the maximum expiratory pressure (MEP) of LES measured
by manometry before and aer OMT at the point of highest pressure.
Signicant dierence in favor of OMT detected on ARP,but not on
MEP. e study demonstrated a positive increment of OMT in the
Abstract
Background: During the last 50 years, the ecacy of medication in the treatment of gastro esophageal
reux disease (GERD) has increased with introduction of histamine 2 antagonists and proton pump
inhibitors. Surgical treatment is eective, but irreversibleand complications may occur. Is it possible to
develop an eective treatment procedure beside pharmaceuticals and surgery?
Objective: To describe Osteopathic Manual erapy (OMT) techniques and investigate the eect in
patients suering from GERD.
Design: e study performed as an open, single-centre, one-armed interventional trial.
Material: Eighteen female and four male GERD patients, mean age and disease duration of 47.4 years
and 20.4 months, recruited from one single OMT practice.
Method: e patients received three to 12OMT interventions consisting of thoracic spine and diaphragm
mobilisation, traction of the cardia and posture correction. e interval between interventions was
one week and the eect recorded as “none,” “slight,” “moderate” or “good.” e presence of heartburn,
retrosternal pain, acid in the mouth, epigastric pain and tension or pain in the lower thoracic spine
recorded before and three month aer the last treatment.
Results: e prevalence and total number of GERD symptoms were signicantly reduced (p << 0.01)
and only two patients reported an unchanged situation. A “moderate” or “good” eect reported by 77.3
% of the patients. In 19 patients with extended thoracic kyphosis and reduced extension, 78.9 % reported
a “moderate” or “good” treatment eect. No dierences detected between patients using and not using
additional GERD pharmaceuticals.
Conclusions: e results indicate a positive eect of OMT in the treatment of GERD.
Int J Clin Pharmacol Pharmacother IJCPP, an open access journal
Volume 1. 2016. 116
LES region soon aer its performance. e OMT described consisted
only of diaphragm stretching using breading techniques. However,
OMT includes several techniques that might inuence LES and
increasing the eect on the sphincter. It might be possible to use the
visceral techniques to stimulate the closing mechanism via the crural
diaphragm (9). In order to describe an OMT procedure in treatment of
GERD, a set of OMT techniques has to be combined and investigated
concerning the eect on the GERD symptoms.
Materials and Methods
Populations and subjects
e reference population consisted of patients of both gender
suering GERD dened asgastroesophageal reux, without erosive
disease and known eect of anti-reux medication.
e study population consisted of patients passed the age of 18 years
and suering from GERD withouthiatus hernia ≥ 5 cm, cancer and
uncontrolled bacterial, viral, fungal or parasite infection.e patients
had to have at least one of the ve following symptoms: heartburn,
retrosternal pain, acid in the mouth, epigastric pain and tension and
pain in the lower thoracic spine. Pregnant and breastfeeding women
and patientpreviously undergone surgery of the upper abdominal tract
were excluded. In order to avoid erroneously inclusion, endoscopic
investigation of the upper gastrointestinal tract was performby the
Department of Gastroenterology at Hammerfest Hospital.
Forty endoscopically investigated GERD patients,recruited by
local general practitioners (GPs) voluntarily received treatment at the
Osteopathic Clinic in Alta, Norway. Of these patients, 18 did not full
the criteria for inclusion or met the exclusion criteria.
e remaining 22 patients gave written consent for participation.
e study sample consisted of 18 female and four male patients. e
mean age and duration of symptoms were 47.4 years (range: 22-72)
and 20.4 months (range: 3-36), respectively. During the study, ve
patients used antacids, two H2 receptor antagonists and one used PPI.
e remaining 14 patients did not use concomitant GERD medication.
Study design
e study was performed as a retrospective, single-centre and one-
armed interventional trial using the patients as their own control.
Osteopathic treatment
e osteopathic treatment combined the four techniques: traction
of the cardia, mobilisation of the diaphragm and thoracic spine and
posture correction.
Between three and 12 osteopathic treatments were given by the
same therapist. All of the included patients were treated via the
musculoskeletal and the fascial system and given both diaphragm
mobilisation and traction of the cardia (Table 1).
Traction of the cardia
e ligament of Treitz is a structural connection with contractile
bres (Figure 1) between the right crus of the diaphragm and the
duojejunal junction. ese crura surround the LES and increased
tension might be a part of the closing mechanism (9, 10). is
technique should be repeated three times and supports the complete
closing of the LES.
Procedure:
• e patient is lying in a supine position on the table. e operator
is standing on the le side, at the level of the thorax, facing the
patient’s feet.
• e operator’s le hand stabilises the patient’s vertebral column
at the level of the 10th thoracic vertebrae.
• e operator’s right hand grasps the patient’s epigastric tissue
with an open palm.
• A longitudinal stretch is performed on this tissue while the
patient is inhaling.
• While exhaling, the operator’s hand slowly stretches the tissue in
the caudal direction.
• At the end of exhaling, the operator’s hand remains in this
position.
• When the patient resumes inhaling, the operator keeps his hand
in this position.
is procedure increases tension in the epigastric tissue and the
ligament of Treitz and completes the closure of the LES.
Mobilisation of the diaphragm
e patient is placed in a supine position, and the operator stands at
the head or at the side of the table. e margins of the lower rib cage
are gently grasped and pulled and pushed to its rotation restriction and
held as the patient deeply breathes in and out. Sometimes, a superior
Citation: Bjørnæs KE, Reiertsen O, Larsen S (2016) Does Osteopathic Manipulative Treatment (OMT) have an Eect in the Treatment of Patients Suering from
Gastro Esophageal Reux Disease (GERD)?. Int J Clin Pharmacol Pharmacother 1: 116. doi: http://dx.doi.org/10.15344/2016/ijccp/116
Page 2 of 6
Type of intervention Number
of
patients
Number of treatments
≤ 3 4 - 6 7 - 9 10 - 12
A:Traction of the cardia 22 6 3 4 9
B: Mobilisation of the
diaphragm
22 6 3 4 9
C: Mobilisation of the
thoracic spine
21 5 3 4 9
D: Postural correction 17 4 3 3 7
Table 1: Osteopathic intervention and the number of treatments
Figure 1: Ligament of Treitz illustration from Netter Atlas 5. e nger
pointing to the structural connection between Lower esophagealsphincter
and the duojejunaljunction
or inferior vector is added to the direct rotation of the thoracic cage
so there is a palpable movement of both sides of the diaphragm
during deep breathing, i.e., both leaves of the diaphragm move well.
e position is held for approximately three large breaths so that the
fascial preference is eliminated and the respiratory eort has redomed
the diaphragm [11].
Mobilisation of the thoracic spine
1. Both the le and right crura surround the LES, and their
contractions are important for closure (9). ese crura are the
muscular connection between the body and the transverse
of the second lumbar vertebra. Contractions of these muscle
bres support the closing mechanism of the LES. e following
technique must be repeated three times.
2. e patient is lying on the le side with the operator standing on
the right side, facing the back of the patient.
3. e le hypothenar is placed on the patient’s sternum, and
the right palm on the spine, at the level of the 10th thoracic
vertebrae. e patient is asked to inhale and then slowly exhale.
While exhaling, the operator’s le hypothenar puts pressure on
the sternum in a cranio-dorsal direction. e right palm moves
along the spine, at the level of the 10th thoracic vertebrae in an
anterior direction.
4. At the end of exhaling, both of the operator’s hands remain in
this position.
5. During the following inhale, the operator holds this extended
position.
6. During the next exhale, the spine is gradually extended and then
xated. At the same time, the sternum is pressed in a cranio-
dorsal direction.
Posture correction
An extended thoracic kyphosis is common among patients
suering from GERD. is position takes tension away from the
diaphragm crus and the closing mechanism of the LES [12]. oracic
kyphosis may disrupt gastric function and stomach acid can enter the
oesophagus. By forcing the lowered thoracic kyphosis into extension
and activating deep breathing, the tension of both crura will be
increased. e technique must be repeated daily and is performed as
follows:
• e patient is lying in a supine position on the bed or couch.
• A pillow, medium hard, not too large, is placed under the 8-12th
vertebrae, forcing this part of the spine into extension.
• e patient now tries to relax the back while slowly breathing in
and out.
• is position and exercise takes approximately 10-15 minutes
and should be repeated once a day, especially in the evenings.
Clinical procedure
Before the start of treatment, the patient posture was recorded
as“normal,” “thoracic kyphosis,” “reduced extension” or both “thoracic
kyphosis” and “reduced extension.”
A normal thoracic posture is a slight kyphosis, while thoracic
kyphosis, in this study, is an extension of the normal anatomical
thoracic kyphosis. Reduced extension is the loss of the ability to
extend the thoracic spine.
e occurrence of GERD symptoms related to “forward bending,”
“lying at,” and “consumption of orange juice or coee” was reported
by the patients.
e presence of symptoms of heartburn, retrosternal pain, acidin
the mouth, epigastric pain and tension and pain in the lower thoracic
spine was reported before, at the end of treatment and three month
aer last treament.
e treatment eect was recorded by the patients on a Fixed-point
scale (FPS) with the following 4 classications: “no eect” = no
change in symptoms, “slight eect” =some symptoms disappeared or
were reduced, “moderate eect”=periods with no symptoms, “good
eect”= relief of the symptoms [13,14]. e patient continuously
recorded concomitant GERD medication during the study.
All of the patients were given a special home exercise and four
were advised to avoid coee. OMT continued as long as improvement
between the two last treatments obtained. When the relief or absence
of symptoms occurred or a maximum of 12 treatments without a
sucient eect, the treatment discontinued. However, the participant
continued with the given home exercise. e observation time was
3 months aer the last treatment.e included patients gave written
consent for participation in the study.
Statistical methods
e continuously distributed variables and factors are expressed
as mean values with standard deviations (SD), 95 % condence
intervals or total range. e 95 % condence interval for the mean
was constructed using the Student procedure [15]. Categorical or
discrete distributed variables are expressed in contingency tables with
the number of patients or the prevalence with the 95 % condence
interval. e condence interval for prevalence constructed using the
theory of simple binomial sequences [15].
All the tests performed two tailed with a signicance level of 5 %.
Changes within and comparison between groups with regards to
categorical variables were performed by contingency table analysis
[16]. For changes within the groups, cross-table analysis was
performed by using McNemar’s test [16].
Results
Eect of the treatment
Nineteen patients reported three or more GORD symptoms before
the start of treatment (Table 2). Aer treatment, only one patient
reported as many as three symptoms.
Int J Clin Pharmacol Pharmacother IJCPP, an open access journal
Volume 1. 2016. 116
Citation: Bjørnæs KE, Reiertsen O, Larsen S (2016) Does Osteopathic Manipulative Treatment (OMT) have an Eect in the Treatment of Patients Suering from
Gastro Esophageal Reux Disease (GERD)?. Int J Clin Pharmacol Pharmacother 1: 116. doi: http://dx.doi.org/10.15344/2016/ijccp/116
Page 3 of 5
Tot al ree months aer last OMT
treatment
No. of
symptoms
Before
treatment
543210
00000000
20000111
10000102
100011533
40002114
50001405
220014125
Table 2: Change in the total number of symptoms from before and 3
month aer the last OsteopathicTreatment.
e number of GORD symptoms was signicantly reduced (p<<
0.01) from before to aer the end of the osteopathic treatment. Only
two patients reported the same number of symptoms before and aer
treatment.
e prevalence of heartburn, retrosternal pain, acid in the
mouth, epigastric pain and pain in the lower thoracic spine were all
signicantly reduced (p ≤ 0.004) from before to aer the treatment
(Table 3). e prevalence of heartburn and retrosternal pain aer
treatment was found to be 4.6 %. For both variables, the proportion
was reduced from 63.6 % to 4.5 %. e proportion of heartburn and
retrosternal pain was reduced from 63.6 to 4.6 % (95 % CI: 0.1 – 22.8
%). For acid in the mouth, the proportion was reduced from 44.5
% to 9.1% (95 % CI: 1.1 – 29.2 %) aer the end of treatment. e
proportion of epigastric pain and pain in lower thoracic spine aer the
osteopathic treatment was reduced from 95.5 % and 72.7 % to 45 % (95
% CI: 24.4 – 67.8 %) and 40.9 % (95 % CI: 20.7 – 63.7 %), respectively.
e subjective reported eect was registered as “moderate” or
“good” by 77.3 % (95 % CI: 54.6 – 92.2 %) of the patients (Table 4).
Eighteen patients reported forward bending to be the main
provocation factor for GERD symptoms while consumption of coee
was reported by 14 patients, “lying at” by 6 patients and consumption
of orange juice by 6 patients. Seven patients reported bending forward
and lying at as the only reasons for GERD provocation, whereas 3
patients reported acid-related reasons. e remaining 12 patients
reported both mechanic and acid-related reasons.
Lowered thoracic kyphosis and reduced extension was detected in
19 of the 22 included patients (Table 4). Of these, 78.9 % reported a
“moderate” or “good” osteopathic treatment eect.
e reduction in the number of GERD symptoms from before to
aer treatment was found to be in accordance with the subjective
reported eect (Table 4). e patients with lowered thoracic kyphosis
and reduced invagination achieved a reduction of at least two GERD
symptoms in 78.9 % of the cases during the osteopathic treatment.
Combined OMT and pharmaceutical treatment
A comparison of the patients receiving only osteopathic treatment
with those who received additional pharmaceuticals did not reveal
any dierences with regard to a reduction in the number of GERD
symptoms nor the reported eect (Table 5). e two groups were
found to be nearly equal before treatment.
Discussion
Eect of OMT in the treatment of GERD
e total number and the prevalence of all the ve GERD
symptoms were signicantly reduced during the OMT intervention,
and the reduction in prevalence was found to be most pronounced
for heartburn, retrosternal pain and acid in the mouth. In general,
the results from the present study clearly indicate an eect of the
included OMT techniques on the ve GERD symptoms. However,
the main variables are subjective, and the study was performed as an
open trial with the patients as their own controls. A large majority of
the included patients reported moderate or good eects, which are
promising results.
Int J Clin Pharmacol Pharmacother IJCPP, an open access journal
Volume 1. 2016. 116
Citation: Bjørnæs KE, Reiertsen O, Larsen S (2016) Does Osteopathic Manipulative Treatment (OMT) have an Eect in the Treatment of Patients Suering from
Gastro Esophageal Reux Disease (GERD)?. Int J Clin Pharmacol Pharmacother 1: 116. doi: http://dx.doi.org/10.15344/2016/ijccp/116
Page 4 of 6
Symptoms Before
treatment
Aer treatment Total
No Ye s
Heartburn No 80 8
Ye s 13 114
Retrosternal pain No 80 8
Ye s 13 114
Acid in the mouth No 12 0 12
Ye s 8210
Epigastric pain No 01 1
Ye s 12 921
Pain from lower
thoracic spine
No 60 6
Ye s 7916
Table 3: e prevalence of GERD-related symptoms before and aer
osteopathic treatment. For each symptom, the number of patients
reporting the symptoms before osteopathic treatment given horizontally.
e numbers of patients with and without the symptoms aer treatment
given vertically
Var iable Response
Posture
Tot al
oracic
& Red.
Ext.
Treatment
eect
None 0 0 0 1 1
Slight 0 0 1 3 4
Moderate 0 1 0 11 12
Good 1 0 0 4 5
Reduction in
no. of GERD
symptoms
during
treatment
0 0 0 0 2 2
1 1 0 0 2 3
2 0 1 1 5 7
3 0 0 0 5 5
4 0 0 0 5 5
1 1 1 19 22
Normal
oracic
Reduced
extension
Table 4: Subjectively reported eects and a reduction in the number of
GERD symptoms during the osteopathic treatment, related to posture
Var iable Response Treatment groups
Osteopathic Osteopathic +
pharmaceutical
Tot al
Treatment eect None 1 0 1
Slight 1 3 4
Moderate 9 3 12
Good 3 2 5
Reduction in
the number
of GERD
symptoms
during
treatment
0 1 1 2
1 3 0 3
2 4 3 7
3 2 3 5
4 4 1 5
Tot al 14 8 22
Table 5: Comparison of patients receiving osteopathic treatment only
and those who received additional medical treatment with regard to
subjectively reported eects and a reduction in the number of GERD
symptoms aer treatment.
It is reasonable to assume that the obtained eects include a
considerable placebo eect. Due to the lack of a control group, the
design and the performance in the present study, it is not possible to
estimate how much of the obtained eects are caused by placebo. A
placebo eect of up to 50 % in the treatment of upper gastrointestinal
tract diseases has been reported [17].
It is previously reported one placebo controlled clinical trial of OMT
on GERD patients [8]. However , this study did not include the eect
on GERD symptoms, but the results from this study actually support
present ndings. To the best of our knowledge, no controlled clinical
studies of OMT in this eld have yet been published. To establish and
verify the eect of OMT, double blinded placebo controlled studies
are needed.
Both the H2 receptor antagonists and PPI reduce the production
of gastric acid whereas antacids neutralise the acid. e reason for
reux oesophagitis in general is not obvious. e two main possible
reasons is either a ventricle or a LES disorder. When the disease is
related to a ventricle dysfunction, pharmaceutical GERD treatment
might have both a curative and palliative eect. However, it is well
known that discontinuation of the drug treatment results in the
relapse of symptoms [1]. is observation indicates that the eect is
more palliative than curative. If the cause of reux oesophagitis is a
LES disorder, the commonly used drugs are expected only to have
a palliative eect. e mechanism of action for the pharmaceutical
treatment of GERD is well documented [18], but what about the OMT
techniques used in the study?
e theory behind the chosen techniques is to stimulate and
optimise the closing function of the LES. One of the OMT techniques
used in the present study was mobilisation of the diaphragm. e
diaphragmatic crura curl around the oesophagus as it passes through
the hiatus. Flexibility in these structures governs the function of
muscular contractions and supports the closing of the LES [9]. e
traction of the cardia technique increases the tension in the oesophagus
and LES, which also supports tighteningthe closing mechanism [12].
e ligament of Treitz is a structural connection with contractile bres
between the right crus of the diaphragm and the duojejunal junction.
e diaphragmatic crura surround the LES, and increased tension is
a part of the closing mechanism of the LES. is technique supports
the complete closing of the LES [12]. More than 85 % of the patients in
the present study were found to have a lowered thoracic kyphosis and
reduced extension, demonstrating reduced mobility of the thoracic
spine. is eect was mainly observed around the area of 10 or
the level of the LES. e mobilisation of the spine in the direction of
invagination will increase the tension of the oesophagus and support
the closing ability of the LES. is mobilisation includes the corrected
posture which is obtained by straightening the spine.
e esophagus is normally under tension [19]. e function of
the closing mechanism of the LES might depend on this tension.
Anatomically, this mechanism is described as a sphincter but this
description is doubted by several other authors. Leonhardt, Tillmann
and Tondury describe the muscular architecture of the lower
oesophageal sphincter as “Wringverschluss” [19]. is mechanism
only functions when the longitudinal tension of the esophagus is
present.
If the tension loosens, the closing of the LES does not complete and
acidic uid can easily enter esophagus. is fact might explain why 18
of the participating patients reported “bending forward” as the main
provocation factor for symptoms, such as heartburn, retrosternal pain
and acid in the mouth.
e present study demonstrates a signicant eect of OMT on
GERD symptoms.To what extent will the eects continue aer
discontinuation of OMT? e available results do not give an answer
and must be investigated in future studies.
Pharmaceutical and osteopathic treatment of GERD
In the present study, eight patients were using pharmaceuticals
in addition to receiving OMT. No signicant dierence between
the patients receiving only OMT and those who used additional
pharmaceuticals was detected. In the case of dierences, the eects
favoured OMT alone. However, the number of patients in each group
was very small and the results might be additionally inuenced by the
way the study was performed. Based on the obtained results, one can
assume that OMT does not inuence the symptomatic eect of H2
receptor antagonists or PPIs. If the results from the present study can
be veried in future placebo-controlled and double-blinded studies,
OMT could be implemented as an additional treatment for GERD.
e pharmaceuticals commonly used today mainly have a palliative
eect in the treatment of GERD. By including OMT, a possible
curative eect might be added.
Conclusion
In conclusion; a combination of the described OMT techniques was
observed to have a positive eect in patients suering from GERD
symptoms and may be a promising therapeutic.
Competing Interest
e authors declare that they have no competing interests.
References
1. Cheskin LJ, Lacy BE (2002) Healing Heartburn. (1st edition), Baltimore:
John Hopkins University Press, London, 150-152 p.
2. Vaezi MF (2006) Esophageal Diseases. (1st edition), Clinical Publishing
Oxford, 69-75 P.
3. van Pinxteren B, Numans ME, Lau J, de Wit NJ, Hungin AP, et al. (2003)
Short-term treatment of gastroesophageal reux disease. J Gen Intern Med
18: 755-763.
4. Luostarinen M (1995) Nissen fundoplication for gastro-oesophageal reux
disease: long-term results. Ann Chir Gynaecol 84: 115-120.
5. Still AT (1995) Philosophy of Osteopathy. (7th edition), Indianapolis:
American Academy of osteopathy, 16 p.
6. Feely RA (1998) Clinical Cranial Osteopathy. (2ndition), The cranial
Academy, Indianapolis Indiana.
7. Barral JP (1988) Visceral Manipulation. Eastland Press Seattle.
8. da Silva RC, de Sá CC, Pascual-Vaca ÁO, de Souza Fontes LH, Herbella
Fernandes FA, et al. (2013) Increasing of lower esophageal sphincter
pressure after osteopathic intervention on the diaphragm in patients with
gastro esophageal reux. Dis Esophagus 26: 451 -456.
9. Pickering M, Jones JF (2002) The diaphragm: two physiological muscles in
one. J Anat 201: 305-312.
10. Borley NR (20005) Gray`s Anatomy. Elseviere Churchill Livingstone, (39th
edition), 1144-1145 p.
11. Kuchera M, Kuchera W (1994) Osteopathic Considerations in Systemic
Dysfunction. (2nd edition), Greyden press, USA, 215 p.
12. Mittal RK, Goyal RK (2006) Sphincter mechanisms at the lower end of
the esophagus Position and muscular structures inuencing the lower
oesophageal sphincter. GI Motility online.
Int J Clin Pharmacol Pharmacother IJCPP, an open access journal
Volume 1. 2016. 116
Citation: Bjørnæs KE, Reiertsen O, Larsen S (2016) Does Osteopathic Manipulative Treatment (OMT) have an Eect in the Treatment of Patients Suering from
Gastro Esophageal Reux Disease (GERD)?. Int J Clin Pharmacol Pharmacother 1: 116. doi: http://dx.doi.org/10.15344/2016/ijccp/116
Page 5 of 6
13. Larsen S, Aabakken L, Lillevold PE, Osnes M (1991) Assessing soft data in
clinical trials. Pharm Med 5: 29-36.
14. Aabakken L, Larsen S (1991) Visual Analogue Scales for evaluating
endoscopic nding after NSAID treatment: comparison with a Fixed Point
Scale. Pharm Med 5: 19-27
15. Altman D (2006) Practical Statistics for Medical Research. (2nd edition).
16. Agresti A (2002) Categorical Data Analysis. (2nd edition), John Wiley&
sons.
17. Bernstein CN (2006) The placebo effect for gastroenterology: tool or
torment. Clin Gastroenterol Hepatol 4: 1302-1308.
18. Harvey RA, Clark M, Finkel R, Rey JA, Whalen K (2012) Pharmacology.
(5th edition) Lippincott Williams & Wilkins, 351-357 p.
19. Leonhardt B,Tillmann B, Tondury G (1987) Rauber/Kopsch: Lehrbuch des
Menschen. (1st edition ) Band II. Stuttgart, New York, Georg ThiemeVerlag.
299 p.
Int J Clin Pharmacol Pharmacother IJCPP, an open access journal
Volume 1. 2016. 116
Citation: Bjørnæs KE, Reiertsen O, Larsen S (2016) Does Osteopathic Manipulative Treatment (OMT) have an Eect in the Treatment of Patients Suering from
Gastro Esophageal Reux Disease (GERD)?. Int J Clin Pharmacol Pharmacother 1: 116. doi: http://dx.doi.org/10.15344/2016/ijccp/116
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