EVERYTHING Is Connected: What is Visceral Manipulation and How Does it Relate to the Pelvic Floor?

In Pelvic Floor Physical Therapy by Emily Tran4 Comments

Remember our earlier post on fascia? Simply put, fascia is a continuous sheath of connective tissues that lines everything in our body – the organs, bones, muscles, blood vessels, nerves etc. Healthy fascia is fluid and mobile. It allows everything in the body to slide and glide promoting healthy and balanced movement. Restrictions in fascia can impact the mobility of any of our internal structures and can consequently lead to dysfunction – including the pelvic floor. In this post, we’ll tangent from the fascia discussion a bit and focus on how motion of your organs a.k.a. the viscera are important in maintaining overall health and provide a few examples on how this may relate to potential pelvic floor dysfunctions.

We are familiar with the concept that our bodies need movement to be healthy. This same principle applies to every structure in the body including the viscera. Our organs have two types of physiologic motion, mobility and motility. Mobility refers to movement of the viscera in response to an external force. This force can be voluntary, such as when you are performing a pelvic floor contraction or involuntary, like the contraction of your diaphragm with respiration. Motility on the other hand refers to the intrinsic motion of the viscera. This is a little bit trickier to understand at first and even the father of visceral manipulation, Jean-Pierre Barral, DO (meet him here) has difficulties scientifically explaining this phenomenon. The embryological theory of visceral motility states that each organ traces the path of embryological development and migration and that this motion is inscribed in the viscera. Basically, the viscera has an innate motion. When there are restrictions or modifications in the motions of the viscera this can create changes in the organ itself and/or to any of its related structures. Because of the viscera’s fascial and ligamentous attachments, impaired motion can create tension at its origin or elsewhere along the body – remember, everything is connected. What impacts visceral motion? Inflammation. The tissues within the viscera lose their normal mobility when they become inflamed. The natural healing process of our bodies involves local disruption of normal tissue fibers that are eventually replaced with less elastic tissue fibers. What can create tissue inflammation? Many things! Infections, direct trauma, surgery, repetitive movement, diet, environmental toxins, emotional stress and so on.

Let’s use surgery, a Cesarean section, as an example. A C-section requires cutting through the abdominal fascia to access the uterus. The connective tissue or scar tissue that replaces this incision is less elastic than the tissue that was previously there. Early on postpartum, the C-section scar may be sensitive which may encourage the mother to move in a flexed trunk position. At first this may not seem problematic but could lead to a cascade of dysfunctions in the future. If we extrapolate Woff’s law to the fascia, the body will continue to lay down less elastic connective tissue in areas of tension. This flexed trunk position overtime could create weakness and decrease support of the abdominal muscle and back extensors leading to back pain. It could also potentially create myofascial trigger points in the adjacent muscles that refer to areas such as the clitoris or urethra. And what about the nearby viscera? This restriction in motion could impact the bladder or bowels leading to symptoms of urinary urgency, incontinence and constipation. Stephanie explains this well in her prior blog, C-Section Scar: Problems and Solutions, and also offers suggestions for managment (hint, pelvic floor physical therapy can help!). Mobilizing the C-section scar tissue is a great first step. This helps realign the scar tissue in a more organized fashion. But what if the motion of the viscera are affected?

This brings me to our topic of interest: visceral manipulation. Visceral manipulation is a type of manual therapy technique that is used to help initiate and restore inherent organ movement by increasing proprioceptive communication within the body. The two main overarching themes of these technique are that they are (1) gentle and (2) specifically placed. The idea of visceral manipulation is to facilitate and encourage normal movement of the organs. Visceral manipulation helps the organs “remember” this by activating reflexes within the nervous system. The intricacies of visceral manipulation techniques are beyond the reach of this blog, however, there are various organizations that offer educational courses that you as a provider can access. These include The Barral Institute, Herman and Wallace, and the Institute of Physical Art. If you’re a patient, you are welcome to “Find a Practitioner” via The Barral Institute. Note: this database only reflects providers who have learned visceral manipulation through The Barral Institute.  

Let’s jump back to our C-section example and assume the movement of the terminal portion of the large intestines, the sigmoid colon, is involved. The sigmoid colon articulates directly with a number of structures in the body: sigmoid mesocolon, jejunoileum loops, iliac fascia, Toldt’s fascia, external iliac vessels, left sacral plexus, left ureter, left piriformis, psoas muscles, bladder, uterus, obturator nerve, ovary and ductus deferens (in males). It’s okay if you don’t know what some of these structures are, the point is, the sigmoid colon connects to a lot of things! So what could this altered motion of the sigmoid colon mean for the body? Well, given its relationship to these structures, it could display symptoms in the viscera (such as the bowels themselves, the bladder, the uterus, etc.); it could display vascular symptoms (i.e. varicose veins); and/or it could display musculoskeletal symptoms (i.e. low back pain, sciatica, lower extremity joint pain). Does this mean that that annoying and stubborn left-sided sciatica may be coming from you large intestines? Possibly!

I can understand that at first glance this may sound absurd. Unfortunately, it is difficult to perform the gold-standard randomized controlled trials with visceral manipulation. Fortunately, there are hundreds of thousands of positive case studies and reports. Take a look at one such example presented by Romona Horton, MPT, with Herman and Wallace. Though we can’t assess the motion of the bladder in a still picture, you can see the difference in the shape and size of the bladder between the before and after sonograms.  

Visceral manipulation is another tool in the toolbox for the physical therapist and other educated providers but can provide great returns. As Romona mentions in her case study, she used other techniques to address comorbid somatic dysfunctions in the lumbopelvis such as working on the motor control of the patient’s core stabilizers and treatment of dyspareunia (pain with intercourse).  At PHRC we can also help with these and would be happy to see you! Check out “Our Services to see some of the conditions we treat.

 

REFERENCES:

Barral, Jean-Pierre, and Pierre Mercier. Visceral Manipulation. Revised ed., Eastland Press, 2005.

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.

Comments

  1. This is absolutely fascinating! Thank you for this post. Do you have any visceral manipulation therapists that you can recommend, esp for those with complex health issues overall, in or around San Francisco?

    1. Hi Sandy,

      Yes, please call our San Francisco office 415-440-7600.

      Best,
      Admin

  2. I need a visceral manipulation therapist in the triad, Greensboro, NC. Any recommendations?

  3. Do you have any recommendations for visceral manipulation therapists in Greensboro, NC?

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