1.
Pechek 1
London College of Osteopathy
The Effectiveness of Osteopathic Manual Therapies on Visceral
Lesions in Equine Patients
Rachel Pechek
Masters Certificate in Osteopathy
Dr. Konstantin Firsov

2.
Pechek 2
INTRODUCTION
In a quest to understand equine health and vitality, many horse owners have broken away
from traditional western medicine practices and veered towards other modalities such as manual
therapies in hope they will help improve the wellness of horses under human care (Lange). One
such modality is osteopathy. Often times, it has been found that physical conditions in horses
require physical assessment and therapy treatments that don’t come in a syringe or pill form. One of
the more recent undertakings in the field of osteopathy is the study of visceral dysfunctions and
their correlation with musculoskeletal dysfunctions that were once thought to be undiagnosable
(Barral Institute). A visceral manipulation is defined as the mobilization of visceral tissue and
surrounding tissues (Barral Institute). It is now becoming well-known that visceral manipulations
can have a wonderful effect on musculoskeletal function as well as other systems in the body. It is
thought to improve harmony throughout the entire being of the recipient, whether human or equine.
The application of osteopathic treatments on equine patients is a relatively new field of
study. This field has been around for about forty years, originating in France with Dr. Giniaux
(Equine Osteopathy). Within equine osteopathy, visceral manipulations in horses are a completely
new topic entirely. Only in the past few years have therapists and veterinarians ventured into
visceral manipulations. Throughout this paper, the topics discussed will include the usefulness of
osteopathic manual therapies (OMT) in treating visceral dysfunctions, the bridge between human
and horse OMT based on anatomy and physiology similarities, as well as compelling evidence that
OMT is an effective diagnostic and treatment method for visceral conditions in horses. The
discussion will be stemming from the belief that OMT can and has been effective in treating
visceral conditions in horses that show signs of dysfunction through the musculoskeletal system.

3.
Pechek 3
EFFECTIVENESS OF TREATING VISCERAL CONDITIONS USING OMT
OMT all began with Dr. Andrew Still in the mid 19th century. His four tenants of osteopathy
are the foundation of all osteopathic thinking (Pusey, p.2). After studying these tenants in depth, it is
clear that the main goal of osteopathy is to promote proper health of body, mind, and spirit using, in
part, manipulation of the bodies physical parts to enhance its overall health. By encouraging the
health of the body, the mind and spirit will also be effected because all three parts are
interconnected (Still, p.27). Included in his first tenant, Dr. Still also teaches that not only is the
body connected to the mind and the spirit, but that all parts of the physical body - which are often
viewed separately - are in fact interconnected (LCO, “osteopathic philosophy and principles”). The
nervous system, digestive system, circulation, musculoskeletal system and all other areas are
working together to serve the collective whole of the body (Still, p.21). This should then lead to a
logical conclusion that if one unit is dysfunctional, other units would be effected by this lesion. In
osteopathy, one values this connection and uses it to find the root cause of a problem within the
body (Still, p.215). If this is true, then the musculoskeletal system could act as a window to possibly
viewing the integrity of other systems in the body. In other words, if the musculoskeletal system is
in dysfunction, the reason may not be the musculoskeletal structures themselves but rather another
area of the body it is compensating for.
The fourth tenet of osteopathy is about the rule of the artery. In explanation, this is the
consideration that without proper blood flow there can be no proper function of a bodily system
(LCO, “Osteopathic Philosophy and Principles”). In western medicine, it is a well-known fact that
without blood supply the musculoskeletal system of the body will not be able to survive let alone
function properly (Boundless). If blood flow is restricted, this restricts the delivery of oxygen and
nutrients to the area. Without the ‘bread of life’ of the body, the structures will not function
properly. With this in mind, one could hypothesis that the circulatory system is heavily protected

4.
Pechek 4
within the body in order to preserve the bodies overall health (LCO, “Introduction to OMT”). Other
systems that are important to the survival of an organism as a whole are the CNS and visceral organ
systems. Without proper function of these systems, the result could be fatal.
Considering the bodies natural desire to survive, it makes perfect sense that it would place
great importance on protecting these vital systems even if it comes at the cost of other, more
dispensable systems such as the musculoskeletal system. In other words, if there is a potential threat
to a visceral organ, the body will sacrifice the functionality of the musculoskeletal system in order
to protect the visceral organ because it is more important to the bodies survival as a whole
(McMakin). This is seen, for example, when a person has flank/lower back muscle pain due to renal
dysfunctions. From an osteopathic perspective, this is a window of opportunity. If dysfunction is
found consistently in one area of the musculoskeletal system and treatment of the localized tissue is
not effective in the long term, it is possible that the lesion is a compensation for another lesion
found elsewhere (Still, p.215) (McMakin). If this is true, it means that the musculoskeletal system
can be considered as a tool for diagnosing visceral lesions or lesions in other systems.
After coming to this understanding, the next obvious question for an osteopath is if a
visceral lesion (or even an arterial lesion) can be treated using OMT. Many osteopaths would agree
that OMT can effectively treat or at least have some effect on visceral lesions, but the difficulty is in
finding scientific evidence. This is a widely discussed and debated topic with many different
theories. The biggest hurdle in explaining the effectiveness of OMT on the viscera seems to be
explaining how the musculoskeletal system is physically related to the viscera. There are many
theories pertaining to this topic such as anatomical similarities, physical proximity and
somatovisceral reflexes.
The physiological similarities discussion is a topic that has little to no research. One may
hypothesize that if arteries, visceral organs, and the musculoskeletal system are all formed (at least
in part) from muscle tissue, then they should be treatable with similar techniques. Although the

5.
Pechek 5
tissues are not identical in structure, they are quite similar and do have a similar contractile
function. When either skeletal or smooth muscles have lesions, they both produce unwanted
contractile motion, leading to a muscle spasm (Wedro). This idea could lead to the understanding
that visceral conditions can be directly manipulated using specific, direct OMT techniques such as
soft tissue techniques. Again this theory is faint, but intriguing.
Coming at the topic from a different angle, the discussion surrounding musculoskeletal
systems physical relationship with viscera takes an indirect approach to treating visceral conditions.
One of the main physical links often discussed is fascia. This connective tissue is a spiderweb-like
group of fibers that connects individual muscular units and entire muscular systems together (Chila,
p.74). Fascia is extremely important in the bodies overall function. Research on fascial development
during embryonic growth has been done and the findings show that organs and muscles will not
develop without a proper matrix of fascia present (Neil-Asher, p.10). This should be a clear
indication of the bodies dependence on functional fascia.
The fascia is also a very common system of the body that houses lesions that effect local and
peripheral areas (Total Motion Therapies). Just like a spiderweb being pulled, if a piece of fascia is
in spasm in one area, it will cause movement and tension in very distant locations of the body
(Mayo Clinic Staff). Often times, fascial lesions will impinge or inhibit movement of visceral
organs, resulting in decreased mobility and blood flow to that organ (Bordoni). To a patient, this
would cause possible signs and symptoms of a visceral lesion, when in fact those feelings are a
result of a myofascial lesion. By treating these fascial lesions with myofascial techniques, an
osteopath can cause release of a muscle, organ or even an arterial vessel distant to the restriction
itself (Mayo Clinic Staff).
Finally, somatovisceral reflexes and neural connections are possibly the most widely
discussed (and exciting!) research avenue as of now. This theory uses the knowledge that the
musculoskeletal system and the visceral systems share common neural pathways (Chila, p.121). If

6.
Pechek 6
this is true, it means a direct relationship between musculoskeletal function and visceral function. It
also opens the door to the idea that musculoskeletal treatment can cause direct effects on the
visceral organs it is associated with (Chila, p.119). Craniosacral techniques can be applied to
alleviate both conditions, or other techniques altering one neural pathway (ex. manipulating the
muscle) to get a response in the both (both muscle and organ relax) could be used.
Many osteopaths in the field today treating visceral lesions work with a mix of each of these
theories as seen later in this text. By studying the relationships between body systems, insight is
given to the osteopath of how to diagnose and treat lesions in areas of the body other than the
musculoskeletal system such as the visceral tissues. With this knowledge, it becomes possible to
treat a vast array of lesions and diseases using OMT including visceral dysfunctions.
TRANSFERRING OMT FROM HUMAN TO HORSE
Now that there is a clear understanding of the OMT treatment strategies used in the
treatment of visceral dysfunctions in humans, the notion of whether or not this type of treatment
would be effective and sufficient in treating similar conditions in horses is open for discussion. The
horse is one of the only other species on earth that are as highly trained in athletics as humans.
Often, studies are done on horses as well as humans when studying exercise physiology
(Capomaccio). This fact should be a strong indication of the importance and need for OMT in the
equine industry.
Because osteopathy relies on the understanding of proper structure and function of
anatomical parts, an osteopath must thoroughly understand the structures they are working with to
effectively treat a horse. Physically, the equine species is remarkably similar to humans from a
cellular level right up to large structures within the body including muscles, bones and neural
function (Pusey, p.4). During embryonic development for example, stem cells of both species begin

7.
Pechek 7
differentiating into the cells that will be necessary to produce a fully functional multicellular
human/horse (Gugjoo). Horses and humans share all of these differentiated cell types including
epithelial cells, neurons, blood cells and bone cells to name a few. These cells will further develop
to form the tissues of the body (Aarhus University). Each of these fully formed tissue types have the
same function in horses and humans which is why osteopathic treatment is so easily transferred
from one organism to the other.
When discussing similarities between horses and humans, it should be noted that the
musculature of both species is remarkably similar. In research, the total number of muscles in
horses and humans vary (Library of Congress) (Engfelt) though many of these muscles have the
same name and produce the same type of movement. Take the trapezius muscle for example. In
both species they are a triangular shape with attachments on cervical spinous processes, thoracic
spinous processes and the scapula (LCO “Spine and Trunk Anatomy”). Both work to relate the
spine to the movement of the shoulder (ex. scapular depression) (Adams, p.35). There are many,
many other examples of muscles like this between horses and humans if one takes the time to study
them.
Another similarity worth noting are the vertebrae. The horse has cervical, thoracic and
lumbar regions of the spine with similar structure to that of a human (Pusey, p.5). The cervical
vertebrae are located in the neck, have small spinous processes and have range of motion (ROM) in
all three planes (flexion/extension, lateral and rotational) similar to humans (Pusey, p.15). The
thoracic region is located in the main body of the horse and it has large, palpable spinous processes
with the ability to flex/extend, limited lateral motion and virtually no rotational ROM. The lumbar
region has thick, strong transverse processes used for stability during movement (Pusey, p.17). This
region is able to flex, extend and rotate to a similar degree as in the human. This lumbar region is
caudally attached to the sacrum via the lumbosacral joint. These lower back structures are a
common location for back pain in horses as well as humans.

8.
Pechek 8
To solidify the understanding of the physical similarities in horses and humans,
neurophysiological similarities in regards to pain and muscular response should be addressed.
Neurologically, horses and humans seem to express lesion symptoms in much the same patterns.
For example, muscular spasms occur in humans when muscles continuously contract involuntarily
(Mense). It has also been shown that neural pathways that are activated regularly become more
sensitive to a stimulus (Latremoliere). This is due to the plasticity of the nervous system. The neural
pathways that are constantly activated when muscles are in spasm become ‘stronger’ and are easily
excitable (Pusey, p.41). If a muscle is in spasm for a prolonged amount of time, the neural pathway
is altered and is left more excitable than it was previous to the lesion. This is why pain can often
persist long after the actual injury has been healed (Pusey, p.43). This response to injury is not
unique to humans. Studies have shown that many other species, including horses, have a very
similar neurophysiological reaction to prolonged pain and injury. (Pusey, p.43). This is good
evidence that lesions in muscles can result from a response to adverse neural signals in both horses
and humans.
Although the findings above show significant similarities between cell types, skeletal
structure, muscular structure and neurophysiology, it should still be noted that it is extremely
important to be well educated on equine anatomy before proper diagnosis and treatment can be
applied. There are some differences in placement as well as some unique qualities of visceral
structures.The similarities between the two species physical structures allow osteopaths the
opportunity to treat horses, but without the knowledge of exact location and movement of
anatomical parts, diagnosis will not be accurate and treatment will not be as successful. This could
potentially pose a danger to the patient as well. Just as knowledge of osteopathic practices are
essential for diagnosis and treatment, so are the distinct features of the equine patient.

9.
Pechek 9
EVIDENCE OF EFFECTIVE DIAGNOSIS AND TREATMENT IN EQUINE
VISCERAL OMT
Lastly, it is important to bring together the idea of OMT for effective treatment of visceral
conditions and the physiological similarities between horses and humans to discuss the possible
effectiveness of OMT diagnosis and treatment for the equine patient. Before a treatment plan can be
carried out, an osteopath must have a successful diagnostic protocol. Without this, the specifics of
the lesion cannot be addressed properly and effective treatment is not possible. Musculoskeletal
diagnostics for equine patients are thoroughly outlined by Another Pusey, Julia Brooks and Annabel
Jenks in their book Osteopathy and The Treatment of Horses. The protocol is much like a human
assessment with screening, scanning and segmental testing steps (LCO, “Introduction to OMT).
Starting off, the screening of a patient is done with static and active observation. The horses posture,
confirmation and symmetry is assessed along with active gait analysis in the walk and trot. Any past
injuries or abnormal confirmation is noted. In the scanning process, the practitioner begins by
placing their hands on the horse at the head and proceed caudally toward the horses tail. They make
note of any tissue texture abnormalities, asymmetries, hot spots, etc. After this the practitioner has a
strong indication of where osteopathic lesions may be held. In the final step of the process, an in-
depth palpatory examination is done of the whole body and specific attention is paid to the areas
that the scanning process perceived as lesioned. During this final palpation, the range of motion
(ROM) is tested of individual joints to determine skeletal fixations.
Diagnosis of visceral conditions in horses are often done using the musculoskeletal system
(Taylor Holistic Vet - Horses Overview). As previously deduced, when organs and surrounding
tissues are in spasm, certain musculoskeletal regions will also be in spasm. If an osteopath has
learned the muscular connections between visceral and somatic tissues, a proper diagnosis can be
made for visceral lesions using the musculoskeletal system. ROM is often used as a determining

10.
Pechek 10
factor for visceral lesions as well. If ROM of a joint is altered, this could indicate that the fascia
connecting that joint to a certain organ is dysfunctional. Examples of these diagnostic techniques
will be seen in the following paragraphs regarding treatment of visceral lesions.
In diagnosing a horse, it is paramount that the practitioner sees the horse’s behaviour as they
would a human patient’s verbal cues. Although horses can’t talk, they are sure to show signs of
discomfort with body language if the practitioner hits a tender point. It is relatively easy to
determine the tenderness of a tissue based on the behavior of the horse as well as feeling for tissues
bracing to protect the tender points. Often times a horse will stop blinking if a tender point is hit,
then close its eyes half way if a trigger point is held (TPT For Horses - Tutorial 3, 3:00-3:10). Other
times the horse will tell the practitioner if too much force is being used by moving its body away
from the practitioners touch. The location of the head, direction of the ears and action of the tail
should also be considered when a practitioner is assessing and treating an equine patient to
determine how the horse is feeling. This communication between horse and practitioner allows
practitioners to use almost all of the treatment procedures that are used on humans with exception to
muscle energy techniques.
Just as OMT can be used to treat visceral lesions in humans, there have been cases of equine
visceral dysfunctions being successfully treated using OMT be different veterinarians as well as
body work practitioners around the world. Tom Mayes is one such practitioner. He uses a unique set
of skills to treat all aspects of a horse’s body. One of his main techniques is the use of osteopathy
for treatment of visceral lesions (Tom Mayes - Osteopathy Equine Therapies). The ones he
considers the most common are those associated with the stomach and the lung (Melding With
Equus, 15:40, 38:04). According to Tom, each of these lesions are very closely related to
musculoskeletal dysfunction and can be corrected using OMT treatment. For example, stomach
lesions are often related to or even caused by spasms in the diaphragm (Melding With Equus,
38:04-39:02) as well as a loss of proper ROM in T12 vertebrae (Melding With Equus, 41:23-41:41).

11.
Pechek 11
After treatment, horses often make a full recovery and those that were once dependent on ulcer
medication to treat secondary effects to the lesion no longer require medication to control ulcers
(Melding With Equus, 39:24-39:35). Lung lesions, on the other hand, are associated with front end
trauma patterns caused by a strong blow to the front end of the horse. After clearing lesions in
musculature associated with the front end, musculoskeletal dysfunction will often come back due to
a lesion associated with the lung (Melding With Equus, 15:40-16:12). Through light mobilizations,
soft tissue techniques and myofascial releases, Tom is able to regain freedom of motion of the lungs
and all surrounding tissues leading to a positive, lasting effect on the health of the horse.
Dr. Taylor, a holistic vet located in Calgary, Alberta, also incorporates visceral
manipulations into her osteopathic practices (Taylor Holistic Vet - Horses Overview). Her
perspective on visceral release is that the mechanical tension around the organ is too great, causing
immobility and dysfunction of the organ itself. By releasing the tissues using fascial releases as well
as direct mobilizations, the viscera vitality can be restored resulting in improved function of the
musculoskeletal system. Specific organs that she finds to be treatable are the ovaries found in the
female reproductive tract (Taylor Holistic Vet - Horses Overview). During her assessment, she uses
the musculoskeletal system as a diagnostic tool. If a mare has ovary restrictions, she will present
with a poor ROM in her sacroiliac joint and L1-L3 restrictions. Her findings also concur with Tom
Mayes that with dysfunction of the fascia and muscles associated with the stomach, the mid-
thoracic region of the spine is fixated. She adds that there is often a left scapular restriction
associated with stomach ulcers as well. She is famous for saying “Osteopathy is the deep fix, not
the quick fix.” to her clients (Taylor Holistic Vet). Dr. Taylor’s cutting edge practice clearly pin
points the importance of visceral vitality and its relationship to skeletal muscle when assessing the
overall well-being of the horse.
Lastly, one cannot mention the use of visceral manipulation in equine OMT without
addressing the works of Janek Vluggen; the original founder of The Vluggen Institute. Janek is

12.
Pechek 12
world renowned for his research and practice in the field of visceral manipulation in equine patients
(The Vluggen institute - Background). He now teaches his techniques and shares his knowledge
with students around the world at one of the only institutes teaching equine osteopathy today. The
theory behind his visceral treatments is largely related to the autonomic nervous system (ANS) and
its effect on visceral organs. Due to this connection, he values craniosacral therapy as a successful
treatment method for some visceral conditions as well as myofascial and soft tissue techniques.
Craniosacral therapy is an avenue used in osteopathy to promote parasympathetic neural
propagation resulting in visceral organs receiving signals to “rest and digest” rather than becoming
tense and immobile as they often do under sympathetic neural control (Hancock). Through
activation of the parasympathetic nerves, viscera enter a state of rest and are able to heal properly if
any injuries are present.
CONCLUSION
Throughout this paper, the capacity of OMT and its usefulness in treating visceral conditions
was reviewed. It was found that there are scientific studies that support the connection between the
viscera and the musculoskeletal system which can be exposed using osteopathic techniques to
promote healing. With this knowledge, the question of whether or not humans are the only possible
recipients of this treatment was raised. It was argued that there is sufficient evidence that equine
patients can be treated with OMT based on their similar physiology and anatomy to humans.
Finally, we discussed leaders in the field of equine visceral osteopathy, common patterns used for
diagnosis, and well documented treatment protocols for each case. This paper confidently lays out
todays research regarding the usefulness of OMT in treating visceral conditions in horses.
Although equine OMT is a young practice, it shows great growth and promise for an
alternative method of treating equine athletes. Thanks to Dr. Vluggen and others, there is now an

13.
Pechek 13
emerging standard of practice for the treatment for horses with OMT including the treatment of
visceral conditions. There is still much to be studied and scientifically researched in order to
provide more quantitative data supporting the effectiveness of OMT in horses, but the current
evidence is compelling enough to lead many equine osteopaths and horse owners toward treatment
(Lange).

14.
Pechek 14
BIBLIOGRAPHY
1. Baxter, Gary M, editor. Adams and Stashaks Lameness in Horses. 6th ed., Wiley-Blackwell,
2011.
2. Bordoni, Bruno, and Emiliano Zanier. “Clinical and Symptomatological Reflections: the Fascial
System.” Journal of Multidisciplinary Healthcare, 2014, pp. 401–411., doi:10.2147/
jmdh.s68308.
3. Boundless. “Boundless Biology - Components of The Blood.” Lumen, https://
courses.lumenlearning.com/boundless-biology/chapter/components-of-the-blood/.
4. Brugman, Rebecca, et al. “The Effect of Osteopathic Treatment on Chronic Constipation – A
Pilot Study.” International Journal of Osteopathic Medicine, vol. 13, no. 1, 2010, pp. 17–23.,
doi:10.1016/j.ijosm.2009.10.002.
5. Capomaccio, Stefano, et al. “Athletic Humans and Horses: Comparative Analysis of
Interleukin-6 (IL-6) and IL-6 Receptor (IL-6R) Expression in Peripheral Blood Mononuclear
Cells in Trained and Untrained Subjects at Rest.” BMC Physiology, vol. 11, no. 1, 21 Jan. 2011,
p. 3., doi:10.1186/1472-6793-11-3.
6. Chila, Anthony, editor. Foundations of Osteopathic Medicine. 3rd ed., LWW, 2012.
7. Discover Visceral Manipulation, 2016 - 2019 The Barral Institute, https://
www.barralinstitute.com/therapies/index.php.
8. Eckley, Andy. TPT 4 Horses - Tutorial 3. Viewed 9 Dec. 2019
9. Engfelt, Camilla. “Massage and Muscles.” Positive Riding, Dressage Theory and Discussion for
Trainers, Instructors and Riders, http://positiveriding.com/resourcelibrary/Massage&Muscles-
Sec.pdf.

15.
Pechek 15
10. Gugjoo, Mudasir Bashir, et al. “Equine Mesenchymal Stem Cells: Properties, Sources,
Characterization, and Potential Therapeutic Applications.” Journal of Equine Veterinary
Science, vol. 72, 2019, pp. 16–27., doi:10.1016/j.jevs.2018.10.007.
11. Hancock, Ann-Marie. “Cranio Sacral Osteopathy.” Innovative Veterinary Care Journal, 6 Aug.
2019.
12. “History of Osteopathy.” Worldwide Alliance of Equine Osteopaths, https://
www.equineosteopathy.org/history-of-osteopathy.
13. “Investigating Back Pain in Horses.” Veterinary Ireland Journal, Focus, Feb. 2019, http://
www.veterinaryirelandjournal.com/focus/72-investigating-back-pain-in-horses.
14. Lange, Catharina D., et al. “Complementary and Alternative Medicine for the Management of
Orthopaedic Problems in Swiss Warmblood Horses.” Veterinary Medicine and Science, vol. 3,
no. 3, 2017, pp. 125–133., doi:10.1002/vms3.64.
15. Latremoliere, Alban, and Clifford J. Woolf. “Central Sensitization: A Generator of Pain
Hypersensitivity by Central Neural Plasticity.” The Journal of Pain, vol. 10, no. 9, Sept. 2009,
pp. 895–926., doi:10.1016/j.jpain.2009.06.012.
16. “Lecture Notes.” LCO, 2019 Copywrite London College of Osteopathy, https://
www.studyosteopathyonline.com/course/index.php.
17. Mcmakin, Carolyn R., and James L. Oschman. “Visceral and Somatic Disorders: Tissue
Softening with Frequency-Specific Microcurrent.” The Journal of Alternative and
Complementary Medicine, vol. 19, no. 2, 2013, pp. 170–177., doi:10.1089/acm.2012.0384.
18. Mayes, Tom, director. Melding with Equus. 2015.
19. Mense, Siegfried. “Muscle Pain – Mechanisms and Clinical Significance: In Reply.” Deutsches
Aerzteblatt Online, 2008, doi:10.3238/arztebl.2008.0510c.

16.
Pechek 16
20. “Myofascial Pain Syndrome.” Mayo Clinic, Mayo Foundation for Medical Education and
Research, 10 Oct. 2019, https://www.mayoclinic.org/diseases-conditions/myofascial-pain-
syndrome/symptoms-causes/syc-20375444.
21. Neil-Asher, Simeon. Trigger Points Theory. Neil Asher Healthcare.
22. Pusey, Anthony, et al. Osteopathy and the Treatment of Horses. John Wiley & Sons, 2010.
23. STILL, ANDREW S. PHILOSOPHY OF OSTEOPATHY. A. T. STILL, 1899.
24. Wedro, Benjamin. “Muscle Spasms Causes, Treatment, Medications & Symptoms.”
MedicineNet, MedicineNet, 18 July 2019, https://www.medicinenet.com/muscle_spasms/
article.htm.
25. “What Is Fascial Dysfunction?” Totalmotiontherapies, https://www.totalmotiontherapies-
counterstrainmilwaukee.com/what-is-fascial-dysfunction.
26. “What Is the Strongest Muscle in the Human Body?” The Library of Congress, https://
www.loc.gov/everyday-mysteries/item/what-is-the-strongest-muscle-in-the-human-body/.