Visceral Mobilization: An Exercise In Sophistry

We could really step up our marketing game as physical therapists. Really crank up the fear. For decades, we have been telling our patients about the pure evil of the latest problem du jour; trigger points, spinal malalignments, tight fascia, overactive muscles, underactive muscles, poor posture, innominate rotations, leg length discrepancies, “suboptimal” biomechanics and more. And despite research that has cast doubt on the validity of detecting and correcting these problems, many in musculoskeletal rehab have added one more: organs! The ones inside you! You might have even seen a few up close in year one dissection, after physically cutting away other tissue to get to them. While visceral mobilization has had some purchase in physical therapy circles, it is more commonly performed by osteopaths, chiropractors, and alternative medicine practitioners. But seeing as there are healthcare practitioners on social media telling patients that their livers need to be mobilized, I can’t stay away from this one.

Visceral mobilization, as defined by its creator Jean-Paul Barral, of The Barral Institute, is “gentle manual therapy that assesses the structural relationships between the viscera (organs), and their fascial or ligamentous attachments to the various systems in the body.” Visceral mobilization practitioners claim to detect imbalances and restrictions within the viscera, and correct them via gentle soft-tissue techniques. What can this help with you ask? Literally name any problem a patient might have, and there is your answer. As you will very quickly learn after going to their website, The Barral Institute offers classes and certifications marketed towards “osteopathic physicians, allopathic physicians, doctors of chiropractic, doctors of Oriental medicine, physical therapists, occupational therapists, acupuncturists, massage therapists and other professional bodyworkers.” Members of my own professional family offer courses as well; the physical therapists from The Institute of Physical Art, have their own course on visceral mobilization. They suggest that visceral mobility has been shown to affect skeletal mobility, and presumably, learning to detect and correct these issues can improve a patient’s condition. It will be helpful now to sift through the claims made and evaluate the evidence individually.

Biological Implausibility

Let’s start with the basic claim: a painful experience a patient is having is due, in part, to dysfunctional internal organs, and we can manually detect and correct them. Is this even biologically plausible? Do we have any reason to think this is possible, let alone true? On a scale of “absolutely definitely true” to “absolutely definitely false”, I would have to put this near “most likely false because it is absolutely ridiculous.” There are too many problems with the basic claim before we even start looking at the research. The role visceral organs play in an average orthopedic case is debatable, we have enough of a problem palpating things on the surface of the skin, and we have no reason to believe we are making mechanical changes to tissue with manual therapy, at least in the short term. Visceral mobilization does not pass the biological plausibility test for anyone who has read modern manual therapy research. Biological implausibility has obviously not stopped some, so let’s look at some of the visceral mobilization research…

One Study

…that doesn’t really exist. There is a paucity of research on the subject. It simply hasn’t been studied that much, but here is one surprisingly well-conducted study from the Journal of Bodywork and Movement Therapies. In the study, researchers took 64 patients with back pain and allocated them to the visceral mobilization group plus standard care or a placebo group plus standard care. The researchers used the NPRS, the Roland-Morris Disability scale, and the Patient-Specific Functional Scale, and these outcome measures were taken after 6 weeks of treatment, as well as 52 weeks after completion. They found there were no differences between each group after 6 weeks on any outcome measure, although the participants in the intervention group had slightly less pain after 52 weeks (1-2 points on the NPRS). They conclude “our study suggests that visceral manipulation in addition to standard care is not effective in changing short-term outcomes but may produce clinically worthwhile improvements in pain at 1 year” (Panagopoulos, 2014). While the authors offer some hypotheses explaining why the true visceral mobilization group did slightly better, do we really care that we can alter a person’s pain rating by 1-2 points one year from now? In the one trial we have, visceral mobilization was not shown to be effective. I couldn’t find any other trials worth diving into. Yes, there are case studies showing beneficial results. But these are ultimately of little value when determining the effectiveness of a new treatment. Any treatment can have a case study where the patient reports feeling better, but these studies do not take into account any of the problems we have when studying treatments like placebo effects, regression to the mean, researcher and patient bias and many more. How about some studies investigating the reliability of palpation of the viscera? Don’t hold your breath. There are no studies at all on this, and given the problems palpating “easy” things, like bony landmarks, pelvic positions, and trigger points, I doubt any human being can accurately palpate restrictions in the abdominal cavity. Even if we can connect a dysfunctional organ to a painful problem, and we can accurately assess it, do we have any reason to believe manual therapy can help mobilize, release, or fix it in any measurable way, besides subjective reports of pain? That research certainly hasn’t been done, but we can assume from some of the manual therapy research that it is highly unlikely. In regards to manual therapy,

“lasting structural changes have not been identified, clinicians are unable to reliably identify areas requiring MT, the forces associated with MT are not specific to a given location and vary between clinicians, choice of technique does not seem to affect outcomes, and sign and symptom responses occur in areas separate from the region of application. The effectiveness of MT despite the inconsistencies associated with a purported biomechanical mechanism suggests that additional mechanisms may be pertinent” (Bialosky, 2009).     

In addition, the amount of force required for the deformation of fascia in the short term would likely upset the patient at the very least, and possibly kill them. According to Chaudry’s 2008 study, a human being cannot generate or receive the amount of force required to make short term changes to fascia. And it is even further leap of faith to suggest that we can do this through the many layers of skin and abdominal musculature that is typically in between us and any given internal organ.

We really have no reason to believe the claims put forth from purveyors of visceral mobilization. The entire idea is not biologically plausible, we have no way of objectively determining when an organ is dysfunctional, and even if we did, we have no studies validating examination procedures. We also have no reason to believe that manual therapy, which has not been shown to induce biomechanical and structural changes in superficial tissue, can affect the viscera. And even if we had all of those things, there are no strong trials to date that show that visceral mobilization has beneficial effects beyond traditional care.

Musculoskeletal Sophistry

Sophistry is defined as the use of “subtly deceptive reasoning or argumentation” or “a subtle, tricky, superficially plausible, but generally fallacious method of reasoning.” The use of visceral mobilization is an exercise in musculoskeletal sophistry; using plausible reasoning to subtly deceive patients about the cause of their problems and presenting yourself as the person who can fix it. These practitioners are linking things that cannot be linked, assessing things that cannot be assessed, and correcting things that cannot be corrected. Any person that uses this treatment is, at best, not being sufficiently critical, but at worst, actively deceiving our patients.

Here is a more plausible explanation: like many treatments for pain, if a treatment is delivered by a seemingly caring and knowledgeable therapist, has some sensory effects, and is sufficiently plausible to the individual, it will in fact reduce a patient’s reported pain level. It may have some specific effects, but a large percentage may be from a multitude of non-specific effects that have nothing to do with the physical treatment. This account is much more parsimonious than the specious explanations from the IPA and the Barral Institute. It is especially shameful, however, when it is suggested that this treatment can help with problems like infertility, traumatic brain injuries, PTSD, or “when nothing else helps”, as Perry Nickelston of Stop Chasing Pain has suggested. It is professionally irresponsible to suggest a treatment that has never really been studied in any serious way can help with these conditions. So if you are looking to stir up fear and drive in more patients, in addition to telling them their musculoskeletal system is dysfunctional, look inward to the organs. You may have to lie to them and pretend to be more confident in your assessment than anyone has the right to be, but they won’t even know it.

References

  1. Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009, 10). The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy, 14(5), 531-538. doi:10.1016/j.math.2008.09.001
  2. Chaudhry, H., Schleip, R., Ji, Z., Bukiet, B., Maney, M., & Findley, T. (2008, 08). Three-Dimensional Mathematical Model for Deformation of Human Fasciae in Manual Therapy. The Journal of the American Osteopathic Association,108(8), 379. doi:10.7556/jaoa.2008.108.8.379
  3. Panagopoulos, J., Hancock, M., Ferreira, P., Hush, J., & Petocz, P. (2014, 11). Does the addition of visceral manipulation alter outcomes for patients with low back pain? A randomized placebo controlled trial. European Journal of Pain, 19(7), 899-907. doi:10.1002/ejp.614
  4. http://www.barralinstitute.com/index.php
  5. https://www.instituteofphysicalart.com/

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