What is Visceral Manipulation? An Integrated Part of Physiotherapy

photo: euskalanato

Visceral manipulation is the practice of an experienced therapist using his or her hands to move and release fascial restrictions in your abdomen and pelvis to encourage the normal movement and function of your internal organs.  Most people are familiar with the idea of joint and muscle restrictions causing tightness, pain and limited movement in their bodies, but don’t consider the role of their organs.  It is common place for people to go to their physio, chiro, or massage therapist to treat pain and alignment issues; unfortunately, many times these practitioners may just be treating the outer shell of the problem if they aren’t considering the mobility of your organs in your alignment and movement patterns.

I have been a physiotherapist for ten years and have continued to add layers of knowledge and skills to my tool belt.  Two of those skills have been real eye openers and game changers for me.  The first big one was the profound effectiveness of skilled dry needling called IMS acupuncture.  I trained with Dr Chan Gunn in 2008 and the skills I learned completely changed my practice for the better.  I recently took a course on Visceral Manipulation through the Barral Institute and feel like I can now properly treat the body as a whole.  I had previously learned how every joint in the body works, where all the muscles attach and which nerves innervate them, but had failed to properly learn how the inside of the body effects the outside.  Visceral Manipulation is helping me properly understand just how connected everything really is.

Your trunk and pelvis form a boney, muscular, fascial outer shell to protect and encase all of your internal organs.  Your organs are not just loosely floating around in there though; they are mostly supported by tissue called fascia and pleura.  The whole thing is a sealed system under pressure that squishes everything tightly together; each organ is wrapped in its own pleura and bathed in a little bit of fluid so it can slide and move around or over its neighbouring organs.  Things that affect the pressures in the system or the ability of the organs to slide and move around in their close quarters will affect the ability of the body to move and function properly.

Pregnancy, abdominal surgery, infection, jarring injuries and emotional behaviours can all affect the mobility of your organs or viscera.  Pregnancy involves a lot of stretching and reorganizing of most everything in a woman’s abdomen; this happens gradually over nine months and the body amazingly figures out how to create space for a whole other person in there.  The issues can arise more during and after labour when everything is asked to change in a relatively short period of time.  There is a huge pressure change and all of a sudden organs can start dropping back down; whether they find their proper, functional place to be depends on how the labour went, how much damage there was to the supportive muscles and if any surgery was done.
C-Sections are a much more invasive surgery than most people realize, but any abdominal surgery will create ‘stickiness’ in the viscera.  As I mentioned, your organs are bathed in a small amount of fluid to allow them to slide around as you move; any time you expose the abdomen to air and surgical lights it is bound to create some dryness or stickiness that restricts normal mobility of the organs.  A therapist trained in visceral manipulation by means of light touch can assess and treat any restrictions to help restore mobility.
Because the fascial wrappings of your organs are essentially one big continuous piece of connective tissue, restrictions in one area can manifest as symptoms in other areas.  A good analogy is to wear a relatively tight T-shirt and twist a piece in one corner up into a knot.  You will likely see and feel the pull from your lower left abdomen all the way up in your right shoulder; this same concept effectively happens inside you.  Your body will start to ‘hug’ or protect the area of restriction which leads to alignment issues and compensatory movement patterns.  Alignment issues and poor movement patterns tend to lead to pain and tension in the boney and muscular systems; treating these usually helps provide relief, but if the problem just keeps coming back, it is quite likely that the root of the problem may be a visceral restriction.

I am relatively new to using visceral manipulation as a treatment modality but have already found it to be the missing piece of the puzzle with many of my clients with stubborn, persistent pain issues.  It is a totally painless, light touch form of manual therapy that requires therapists to really know their anatomy.  Used in conjunction with other forms of manual therapy, dry needling and movement training it makes most conditions treatable by conservative means.

Jarring forces involved in sports, car accidents and falls can affect your organs just as much as your muscles and bones.  The shear forces can create tearing and scar tissue.  The impact forces can create bruising.  Your body does its best to protect vital organs during extreme forces but in doing so can create an aftermath of restrictions that can result in pain.  Therapists should consider that the driving issue behind their client’s pain could be coming from something inside that may be harder to get at than just treating the muscles.

The emotional piece was one of the most interesting parts of learning about visceral work.  To paraphrase the late Osteopath Dr. John Upledger, our organs echo our emotions.  You may have a ‘gut feeling’ or ‘butterflies in your stomach.’  In stressful or intense situations your brain passes the stress onto your organs and creates an organ-behaviour relationship.  Each person tends to have his or her own weak link in a particular organ and this relates back to their underlying personality traits.  A few examples taken from Upledger’s poster: Understanding your Organs:

The intestines:
-insecurity, melodramatic, overly chatty, hypochondria

The Stomach:
-Importance of appearance and self image, social status very important, sees power in extroversion, poor self esteem, frustration, spontaneous anger

The Bladder:
-Controlling, guilt, avoid tension, hard time making decisions

The Liver:
-Dependency on the past, pessimism, bad moods, fits of anger, depression

The Kidneys:
-Fear, feeling of being abandoned, insecurity, deep seated anger, a need to lead, generosity

These are only a few examples but the concept makes a lot of sense to me as a physiotherapist.  I see people all the time that seem to have a back or a shoulder that always ‘goes out’ on them at very inopportune times….before a big meeting, or trip, or Christmas time.  They have no idea what they did and don’t understand why it comes back 2-3 times a year.  They have done all the core classes they could find, but strength just wasn’t the issue.  Their chronic issue is where their body holds stress and how it protectively reacts around it.  Stress is a powerful thing and your organs are the crossover between physical and mental wellbeing.

The fascinating part of the osteopathic approach to treating pain is that it can provide explanations based purely on anatomy for very common, but poorly understood ailments.  Frozen shoulder can relate to a nerve irritation stemming from the visceral pleura.  Chronically cold feet can be your small intestines.  Persistent left sciatica or SI pain can be your sigmoid colon.  Right medial knee pain and instability can be an irritation of your obturator nerve near your large intestine.  Right shoulder pain can be a restriction in your liver.  Heartburn and gastric reflux can mean your stomach is sitting too high.  The list goes on and it is a bit more complicated than that, but the amazing part is that it is all treatable by a good manual therapist that knows his anatomy inside and out (literally).

Visceral Manipulation is unlikely to be the answer for everything, but it can be the missing piece of the puzzle for a lot of people.  If you want to find a practitioner that uses visceral manipulation you are best to start looking in this order for someone in your area: an Osteopath, a Registered Massage Therapist, a Physiotherapist, a Naturopath. 

Click here to search the International Association of Healthcare Practitioners website

Useful links from this article:

The Barral Institute Dr Jean-Pierre Barral
The Upledger Institute Dr John Upledger
Discover Physio- Diane Lee & LJ Lee
Institute for the Study & Treatment of Pain– Dr Chan Gunn

Please feel free to ask questions or leave comments about your experience with visceral work below.

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  • Carol

    I have lived the majority of my life with psoriatic arthritis. I have tried many things over the years and suffered with bone degeneration/deformity and the resulting pain. Over time I developed many drug allergies so drug therapy was not something I was interested in or an option. Having said that, with the ongoing deterioration rapidly advancing I was left to the mercy of pain killers and physio therapy as my only options. Thank God!
    My physio therapist is a godsend for me. We have been working on fascia release for a while now but the visceral release has only come recently and I would highly recommend it to anyone. The difference I have felt is beyond words.
    When you suffer with an underlying condition that is constant in your daily life you learn to accept that is it a part of your life and you do the best you can with it. I started going to physio therapy to maintain movement and reduce pain but what I am finding through these two treatments have surpassed my expectations.
    In the past I would be the first to say "ya right" and I don’t blame others that think that way but I can say, you owe it to yourself to try this. I am not nor have I been a mild case of psoriatic arthritis as a matter of fact when I was first diagnosed almost 30 years ago I read an article about one of the worst cases and my condition at that time was already more advanced. It was disheartening to say the least but I went through periods of remission and other times of rapid advancement. Disease of any kind is cruel but we still cannot give up the fight.
    To anyone out there considering options I say, put this at the top of your list. Not only for the overall relief of the disease symptoms but your overall mental and emotional health. I feel absolutely amazing!!



  • Brent

    It is possible, but I don’t have any experience with it. I would look at Dr Ron Mariotti’s website VisceralSynergy.com he may have more insight on the topic. He is a Naturopath in Seattle that is very experienced in Visceral work and i know treats cancer related issues….good luck!

  • Elizabeth

    I had visceral massage done 2 months ago and have had so much pain in my hips/groin/lower back. Is that normal?

    • Brent

      No that is not normal….talk to the practitioner about it or possibly find a new one.

  • Sami

    Hi, Brent!

    I came across your site while doing a bit of research on pain issue related to visceral restriction, and manipulation techniques to address that.

    (In case you’re curious: A few weeks after getting my first IUD, I woke up with SI pain on the left side, having done nothing to the joint that I know of. While PT and MT has helped manage it, they and my MD are kinda stumped. My MT can tell something is still off from diagnostic exercises, but not what’s /causing/ it; he was the one who mentioned potential visceral involvement. Especially since, as I understand it, the other areas one can feel discomfort if there are sigmoid colon issues are the lumbar and the left piriformis; those three areas are nearly the only places I’m experiencing pain. Your mention of the sigmoid colon and SI pain was especially interesting to me, especially since a) I’ve dealt with IBS-like symptoms for a while now [notable gassiness, gas discomfort.constipation/diarrhea], and b) I seem to have both become more sensitive to GI issues post-IUD /and/ experience more uterine discomfort when I have GI issues, possibly because of retroversion making my uterus more or less stand straight up.)

    So. 🙂 My questions for you are:

    1) Does my thinking — that perhaps my left SI, left piriformis, and lumbar pain might come from a visceral restriction in sigmoid colon, possibly brought on by some shifting and adjustment to an IUD when I already have digestive issues — seem /possible/? I’m not asking for a diagnosis, here. 🙂 I’m just wondering if you think it’s worth looking into.

    2) If so, do you have any good references for professionals in Eastern Massachusetts who might be able to sort out whether this is the case? Preferably someone who also does manual viscera manipulation?

    Thanks so much!


    • Brent

      yes it sounds entirely possible and worth looking into. I would try looking on this website for a therapist that has taken visceral manipulation level 3 and higher http://www.iahp.com/pages/search/index.php you can search by zip code and specialty. If you don’t get anywhere try having your IUD taken out and see if the pain subsides, you won’t want someone working directly on your uterus with the IUD in, but they can likely work around it.

      best of luck

      • Sami

        Thanks, Brent! I’ve found a Felice Lazarus in my general area, who seems to have listed all the core classes in visceral manipulation. I assume she should know not to work on my uterus with my IUD in?

        (My hope is to try this /instead/ of taking out the IUD, with the intent of taking it out in January if this doesn’t help enough.)

  • Felicity

    I have had a sigmoidectomy that ended in gangerine of the large intestine septacimia and hence a colostomy. Had gangerine surgery and lost large portion of large intestine and 24 hours later back in surgery for a wash out due to septacemia. Had a woundvac for 3 months and was in a bad way, After 11 months had to have 2 abdominal hernias repaired(sutchered not mesch) and a Hartmans closure of the colostomy. I now suffer with abdominal adhesions and severe rectal pain that transmits to the area of the vagina and uretha. As wind buikds up the pain is excrutiating and goes away the minute the wind is released. I do have a stenosis at the join which has been stretched twice ans had a stent which I passed 2 days after insertion. Will visceral massage help I am really desperate. Many thanks

    • Ruth

      My husband had to have mesh removed from his abdomen and spent 4 months fighting intense pain, infection and developed a fustula. His surgeon repaired the fistula ,removed a portion of his intestine and found his intestines to be “Kinked”. After surgery he had physical therapist manipulate his abdominal area and he felt immediate relief of gas pain, and I could see the shift from a stressed, conflicted patient, into a relaxed, peaceful state . It was amazing! I am so pleased to see advances in medical treatment utilizing the healing touch.

    • Brent Stevenson

      Hi Felicity….sorry for the long delay in my response, I missed your comment….it sounds like you have been through a lot. In short, yes I think visceral work could likely help your body make sense of everything it has been through. It would not be a miracle cure, but may make enough difference to make you more comfortable. Worth a try!

  • Finnegan Lewis

    There is an enormous amount of absolute nonsense perpetuated in the therapy world, and the fascial mobilization/craniosacral/visceral manipulation is as bad as it gets almost. I say “almost”, but it’s pretty bad. Lots written…. Ernst dismantles this here (http://edzardernst.com/2014/01/visceral-manipulation-you-couldnt-make-it-up/), and here (http://edzardernst.com/2012/12/up-the-garden-path-craniosacral-therapy/). Paul Ingraham does a wonderful job on his website dispelling lots of clinical nonsense using well-written and critically appraised research literature….(https://www.painscience.com/articles/craniosacral-therapy.php).and there are handfuls of others who have concluded that this is clinically worthless and intellectually dubious (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1564028/).

    Sadly the PT programs don’t seem terribly keen on teaching critical thinking (vs “critical appraisal”), perhaps because the profession would prefer not to have to deal with its own skeletons and flimsy evidence base…. but this stuff is snake oil by definition.

    • Thanks for your thoughts Finnegan. I have been a physiotherapist for 15 years now after graduating from McMaster University, a school and a program that prided themselves on their small group problem-based tutorials, evidence based practice and developing critical thinking skills. I learned the ins and outs of research, but at the end of the day my work was one of a clinician that was charged with the job of helping people. You can only learn so much from a research paper so I started seeking out experienced clinicians that had learned from decades of DOING more than reading other people’s summaries of yet other peoples research studies. I have approached every form of therapy that I have learned cynically and made sure to not ‘drink the Koolaid’ of any guru, but from each discipline there are numerous pearls of wisdom and very effective techniques. Visceral work won’t help everyone, but it can be very helpful for some people and if nothing else the process of learning it improves your knowledge of anatomy profoundly. Critics latch on to Barrals claims….to be honest, I haven’t bothered reading many of them. I witnessed the techniques effectiveness in experienced clinicians hands so I choose to judge it by learning it and have been impressed by how much better of a therapist it has made me. I respect and read clinical journals, but put far more weight into the wisdom of the experienced and the mentorship I have sought and that approach has made me very successful at helping my clients. Some people are comfortable thriving in grey areas while others need quantitative explanations and if they can’t find them, claim that you are a ‘snake oil’ salesman. Thank you for your thoughts and links, but I respectfully and sincerely disagree with your thoughts on the topic.

      • Finnegan Lewis

        I graduated from Mac in 1997 Brent…. Paul Stratford was there…. but that isn’t the issue. This stuff is absolute rot and honestly, this is why PT (and others mind you) has gotten itself lost…. zero critical thinking. To this specific issue, how do you ‘steer’ the appropriate force of just the right magnitude, just the right angle, when do you stop…. Talk to me about too much Kool-Aid…. PT is so searching for identity, so immature that it heo worships itself into silliness. But hey, whatever pays the bills.

        I stopped being a “believer”, and moved on to adult things…. PT is too Sesame St., too sophomoric… and far too naive about getting ripped off because it lacks critical thinking.

        Take care!

      • Finnegan Lewis

        If you ever feel like having a thoughtful and respectful exchange, I am happy to engage…. Critical thinking is always a positive exercise….

      • Finnegan Lewis


  • Hi Finnegan

    I don’t know much about
    you, but I am sorry you have become disenfranchised with physiotherapy as a
    profession. I, unlike you, as a
    physiotherapist in Vancouver, have seen physiotherapy really grow up and take
    on a much more prominent role independent of the medical model. It may not have a specific direction at the
    moment but I think that is an exciting place to be, a place of
    opportunity. The aspect of physiotherapy
    that I find the most appealing is its broad scope of practice, it allows us as
    physiotherapists to pick and choose some of the best tools from other
    professions, embrace them and make them our own, like only we can. I don’t think that trying to stuff an
    extremely broad profession like physiotherapy through the same filters as the
    extremely compartmentalized medical model is a fair way to evaluate it. There simply isn’t and won’t be the funding
    available to create high level research studies for the variety of therapies
    that physios use in conjunction with each other. Black and white surgeries and medications
    lend themselves to research. Therapy
    requires the practitioner using his/her tools to find a connection to a client
    and find a way to physically and cognitively help them. Every person is a different puzzle and trying
    to group them all together to measure effectiveness is of limited value to
    me. I don’t think that visceral work
    alone is very helpful and I also don’t believe some of the claims you and the
    link you provided refer to, but I genuinely believe that visceral work is an
    important piece of a good physiotherapist’s tool belt. I think a good physio should develop mindful
    communication skills, precise dry needling skills, understand biomechanics,
    anatomy, psychology and be able to make all of these things meaningful to their
    patients. There are a lot of older
    experienced physiotherapists out there still working, but you don’t hear from
    them because they have six month wait lists of people lining up to see them
    because they are good at what they do, people appreciate that and are willing
    to pay for it. Yes there is a commercial
    side that has arisen from physio, but there is also many clinical masters that
    are quietly pushing the profession forward one client at a time. I have found the most utility in seeking them
    out, I am sorry that you haven’t. I have
    engaged others in this same conversation regarding dry needling, chiropractors,
    evidence based medicine. I read your
    links, but I’m sorry you haven’t come close to shifting my opinion.

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