This post was written by H&W instructor Ramona Horton MPT, who authored and instructs the Visceral Mobilization Series. Visceral Mobilization of The Urologic System & Visceral Mobilization of the Reproductive System will be presented throughout 2015.
As the instructor and developer of the curriculum for the visceral mobilization series, I am frequently asked for evidence of the efficacy of VMT. In order to gain an understand of why a physical therapist who has spent their entire career treating the somatic structures would possibly want to “manipulate” the internal organs one needs to understand a few basic facts. First: the visceral structures carry a significant mass within the human body and are subject to the same laws of physics as the locomotor system. Second: VMT is simply a form of soft tissue manual therapy that addresses the connective tissue and ligamentous attachments of the above mentioned visceral structures to the somatic frame.
There are multiple studies that demonstrate positive clinical outcomes from VMT, to mention a few are treatment of postoperative adhesions/ilius (Bove, Chappelle), chronic constipation (Harington, Tarsuslu), dysfunctional voiding (Nemett, Helge), mechanical infertility (Kramp, Wern) and low back pain (Michallet, Tozi, McSweeney.) I could write a multitude of paragraphs reviewing the above listed publications but that would steal all of the thunder for my upcoming lecture on the topic to be presented at CSM 2015 titled “Visceral Manipulation: Fact and Fantasy”. Therefore, the following is a completely un-scientific case study complete with visual demonstration… as the saying goes, a picture is worth a thousand words, besides we all love a good patient story.
CS is a 39 y/o G4 P3 female with complaint of chronic LBP and right flank/anterior hip/gluteal pain greater than 2 years in duration and deep dyspareunia. The flank pain would become constant low level ache when in a supine position, disturbing sleep and interfering with her exercise program.
PMHx: Three full term pregnancies, with two vaginal deliveries and one C-section. She experienced an abdominal pregnancy 1998 which culminated in miscarriage with right salpingectomy and partial small bowel resection. Abdominal hysterectomy in 2007 in which the right ureter was damaged, this resulted in multiple ureteral stent placements which failed and finally ureteral re-implantation 2012.
Previous treatment: monthly spinal manipulation and weekly massage for past 2 years, this provided temporary relief of LBP only.
Evaluation: Loss of trunk ROM all planes, with greatest restriction in trunk extension. Presence of exquisite trigger points in multiple regions bilateral abdominal wall, right iliacus, psoas and R quadratus, loss of mobility to spring testing R sacroiliac articulation and loss of tissue mobility at the R renal fascia, cecum, mesenteric root and peri-vesical fascia. Ultrasound imaging demonstrated asymmetry in dome of detrusor.
Treatment: Following evaluation consisted of five sessions of VMT targeted at improving tissue mobility of the peri-vesical fascia, R renal fascia to include mobility of the kidney and ureter, the cecum, mesenteric root and multiple manual therapy techniques to treat somatic dysfunction in the pelvis. At the beginning of session six, CS reported LBP, anterior hip, flank and gluteal pain were eliminated. She was able to return to her regular exercise program. Attention was turned to improving motor control of core stabilizers and treatment of deep dyspareunia.
Follow up: Five months following symptom abatement patient reported LBP, anterior hip pain continue to be fully resolved, she has returned to a regular exercise program and intercourse is pain free. Because of absence of ureteral valve, she does experience R flank pain secondary to ureteral reflux if her bladder becomes overly full and experiences has minor flank pain with first AM void.
This case by no means should be misconstrued as “evidence” of the efficacy of VMT however it is clear that a measurable change has occurred in the structure of this patient’s bladder. Most importantly, when the restrictions found in the visceral fascia were addressed, the patient experienced a timely resolution of symptoms that had been recalcitrant to prolonged intervention that the literature has shown to be effective in the treatment of LBP. As a musculoskeletal therapist, I cannot possibly understand how one is expected to treat bowel and bladder dysfunction, without addressing the bowel and bladder.
Bove G, Chapelle S (2011) Visceral mobilization can lyse and prevent peritoneal adhesions in a rat model. Journal of Bodywork and Movement Therapies doi:10.1016/j.jbmt.2011.02.004
Chapell S, Bove G (2013) Visceral massage reduces postoperative ileus in a rat model. Journal of Bodywork and Movement Therapies 17(1): 83-8.
Harrington K, Haskvitz E (2006) Managing a patients constipation with physical therapy. Physical Therapy 86 (11): 1511-1519.
Helge F, Hoesele K (2013) Osteopathic manipulative therapy OMT for treatment of lower urinary tract symptoms (LUTS) in women. Journal of Bodywork and Movement Therapies. 17: 11-18.
Kramp ME (2012) Combined Manual Therapy Techniques for the Treatment of Women With Infertility: A Case Series. Journal of the American Osteopathic Assn 112:680-684.
McSweeney TP, Thomson OP, Johnston R (2012) The immediate effects of sigmoid colon manipulation on pressure pain thresholds in the lumbar spine. Journal of Bodywork and Movement Therapies 16(4):416-23.
Michallet J-M (1986) Thesis for the Diploma in Osteopathy, in Barral J-P, Mercier P (1989) Visceral Manipulation II. Eastland Press, Seattle, WA.
Nemett DR et al. (2008) A Randomized Controlled Trial of the Effectiveness of Osteopathy-Based Manual Physical Therapy in Treating Pediatric Dysfunctional Voiding. Journal of Pediatric Urology 4:100-106.
Tarsuslu T, Bol H, Simsek I, Toylan I, Cam S (2009) The effects of osteopathic treatment on constipation in children with cerebral palsy: a pilot study. Journal of Manipulative Physiologic Therapy 32(8): 648-653.
Tozzi P, Bongiorno D, Vitturini C (2012) Low back pain and kidney mobility: local osteopathic fascial manipulation decreases pain perception and improves renal mobility. Journal of Bodywork and Movement Therapies. 16:381-391.
Wurn B, Wurn L, King R, Heuer M, Roscow A, Schari E, Shuster J (2004) Treating female infertility and improving IVF pregnancy rates with a manual physical therapy technique. Medscape 6(2) [online]. [Accessed Aug 13, 2006].