Visceral Manipulation: What's It All About?
Posted on: August 03, 2013 by Dennis Doyle, CAT(C), BAHSc, BComm
In traditional osteopathy, the concept of "visceral manipulation", or treatment of the internal organs, is commonly taught during the course of osteopathic training. At the Canadian College of Osteopathy in Toronto, the final two years of the five-year program are dedicated to visceral manipulation. While it takes several years to develop the necessary skill level in palpation (touch), the payoff can be tremendous. Unfortunately for many therapists, the potential that exists for manually treating the internal organs is never explored. Visceral techniques can often provide a solution to a patient's chronic symptoms that treatment of the musculoskeletal system alone could not. This is because restrictions of the internal organs can bend and twist the skeleton, altering one's posture and biomechanics. Even subtle changes can, over time, cause unnatural wear and tear on the body, and result in painful symptoms at a distance from the original problem.
So when should someone seek manual treatment of the internal organs? There are three answers that immediately come to mind:
1) When you have developed symptoms directly related to impaired organ function (heartburn, irritable bowel, hypertension, etc.) and you want to investigate whether a biomechanical restriction is contributing to the problem.
2) When you have had trauma to the internal organs from a direct impact (e.g. seatbelt injury), or have experienced an inflammatory response to infection (e.g. pneumonia, food poisoning, intestinal parasites, etc.). *Please note: osteopathic treatment of illnesses should only happen after a medical diagnosis has been made and urgent health problems have been dealt with by your family physician and/or a specialist. Osteopathic manual practitioners should never be used as your primary care provider in these instances. Proceed with osteopathic treatment when your physician determines it is safe to do so.
3) When you have chronic pain or inflammation that is not responding well to musculoskeletal treatment. Again, a medical diagnosis by your physician in such a case is extremely important. However, if you have been recommended physiotherapy or chiropractic treatment by your doctor and these treatments have been ineffective after 4-6 weeks of therapy, your therapist may not be treating the root cause of the problem. In such cases, investigation by an osteopathic manual practitioner may reveal biomechanical restrictions that are internal, and are hampering your ability to heal properly.
Since receiving training in visceral manipulation, I find myself working on the abdomen or thorax of my patients for a variety of conditions. More often than not, patients will ask a question such as "why are you working there, when my pain is all the way over here?” At that point, I explain that symptoms can occur far away from the original problem, and my priority is to treat the area of greatest restriction. In some cases, the area of greatest restriction on that particular day might be the bowel, or the stomach, or the lung, or the liver (believe it or not). While many are skeptical of this treatment methodology, my answer is always the same - it is about ‘the proof of the pudding’. Results don't lie, and this is why traditional osteopathy in Canada has exploded in popularity in the past decade. Including visceral techniques in the overall treatment plan has allowed many patients to get the results they had been seeking for years, a fact that has not gone unnoticed.
Anyone who truly wishes to learn about visceral manipulation will find themselves reading the work of Jean-Pierre Barral, an Osteopath from France who is one of the originators of the visceral manipulation concept. More information about his methods can be found at: http://www.barralinstitute.com/about/vm.php
Barral & Mercier provide some great examples of how visceral manipulation can be used to treat chronic problems. It is worth noting that the authors use the terms mobility and motility when discussing organ movement. When they discuss mobility, generally they are referring to the practitioner's ability to move the organ manually during gentle mobilization. When they discuss motility, they are referring to the organ's ability to move on its own. Everyone is familiar with the phenomenon of motility; it is the driving force behind the growling or gurgling one can observe coming from the abdomen, as the smooth muscles of the digestive organs move spontaneously. A practitioner takes into account both mobility and motility when evaluating the movements of an organ.
An excellent case summary can be found in the book "Visceral Manipulation" (Barral & Mercier, 1988). The authors provide a clinical example of how the visceral manipulation concept was used to treat a patient with persistent tingling and numbness in the fingers related to disc degeneration in the neck. They found the origin of the dysfunction in this particular case to be at the level of the lung:
"Mr. X, 42 years old, presented himself complaining of a chronic right cervicobrachial neuralgia, which he had for ten years. This caused a constant discomfort interspersed by sudden exacerbations. The pain was particularly debilitating and demoralizing because he was a skilled joiner. He had been diagnosed with cervical disc degeneration, and then prescribed anti-inflammatory drugs and analgesics.
There was no history of trauma. Mr. X had never been ill enough to seek treatment (except for pain); he had a vague memory of several days of fever, without apparent cause, during his military service.
The mobility tests showed an articular costovertebral restriction of the T1 (1st thoracic vertebra) and rib 1 on the right, a restriction of the right sternoclavicular articulation, and a musculoligamentous restriction at T7/T8. The motility tests showed a visceral articular restriction (fixation) of the right upper lobe of the lung (the axis of motility was skewed), a right deviation of the mediastinum, and perturbed motility of the stomach.
Physical examination showed a decrease of the radial pulse when the right arm was abducted and externally rotated. There was considerable air in the stomach. Chest x-ray showed a scarred pleural adhesion on the lateral edge of the upper right lobe, which the radiologist attributed to a probable sequela of an asymptomatic pleurisy.
The pleural adhesion may have become the center around which the motion of motility occurred for the superior right lobe; the forces of intrathoracic pressure became modified; the mediastinum was drawn toward the restricted lobe; and the suspensory ligament of the right pleural dome became fibrosed. The cervicopleural fibers were retracted and this retraction fixed T1 (first thoracic vertebra), rib 1, and the clavicle which, in turn, disturbed all mechanics of cervical motion. Ligamentous tension compressed the intervertebral foramen and thus diminished the phenomena of fluid exchange.
The clavicle and 1st rib, fixed one upon the other, reduced the thoracic outlet, provoking vasomotor problems of the right subclavian artery by reflex and/or direct compression. The mobility of the superior right lobe had changed. The respiratory movements (over 20,000 daily) increased the mechanical disorder. The mediastinum, drawn toward the scarred lesion, exerted traction on the esophagus, changing it so much that the sphincter of the cardia became dysfunctional, facilitating passage of air into the stomach. The esophagus became irritated and went into spasm, causing symptoms similar to those of a hiatus hernia.
From this example, which is not unusual, one can draw several conclusions. Small causes can bring about important effects if the former are multiplied thousands or millions of times, even though many people seem to have difficulty comprehending this idea. A slight imbalance of the lower limbs can very quickly ruin even the best pair of shoes. The symptom may be only a manifestation of a far-off disorder; this requires the practitioner to search throughout the body for the cause. The patient is determined to bring the practitioner's eye to where the symptom is, because that is where the suffering is. In our example, the patient was most surprised, even nonplussed, when we said we wished to see a chest x-ray. The relationship between sore fingers and the lungs was difficult to comprehend - it even took us a while to figure it out!
The patient is well now, although the x-ray still shows a pleural adhesion. Obviously, we were not able to break it up and the cervicopleural tension still exists, although much lessened. But motility has returned to normal. This underlines its importance in energetic phenomena. It is of little importance if the organ is in an abnormal position as long as it has recovered its motility." (Barral & Mercier, 1988, p.24-25).
Barral, J.P., & Mercier, P. (1988). Visceral manipulation, Seattle, WA: Eastland Press.