Top Ten Reasons To Learn Visceral Mobilization
I recently attended Herman & Wallace Pelvic Rehabilitation Institute's Level II Visceral Mobilization class in Columbus, Ohio, along with 25 other women's health PTs from all over the United States. Visceral mobilization is a form of manual therapy to the deep fascial structures, including nerves and organs (viscera) of the abdominal wall and pelvic area, in order to restore normal structure and function.
I have been using visceral mobilization in my private practice, where I treat men and women with pelvic pain and lumbopelvic dysfunctions, since I attended my first visceral mobilization course with physical therapist and educator, Ramona Horton. Ramona trained directly with Jean-Pierre Barral, a French osteopath and founder of the Barral Institute. In Level I Visceral Mobilization, we learned how to mobilize the fascia around the colon, bladder, diaphragm, kidneys, urethra, tailbone, etc. In this advanced Level II class, the emphasis was on the male and female reproductive systems and peripheral nerves. This 16 hour class consisted of a combination of lecture and lab time. As physical therapists, we are not given models or lab rats to work on, but rather we learn by practicing and working on each other! This is one of the only hands-on courses that I did not experience soreness afterwards. In fact, my experience after attending my first visceral mobilization class several years ago was so so profound, I use this manual therapy skill almost exclusively in my treatment approach.
Here Is My TOP 10 List to Learn Visceral Mobilization:
1. I have more tools on my belt to help patients with chronic pain and dysfunction. My experience is by using visceral mobiization, I save time and money for patients and the effects last longer, especially for those who have suffered with years of dysfunction. Visceral mobiization is very therapeutic and comfortable and has a relaxed effect on the nervous system. There are very few practitioners who work on the abdomen and pelvis, specifically at the level of the deep fascia. I find my patients are able to tolerate other techniques if I start with visceral mobilization. This has been demonstrated in a study by McSweeney et al, who showed a mean increase of 18.4% in pressure pain thresholds of paraspinal muscles at the level of L1 after mobilization to the sigmoid colon*. The effect of visceral mobilization on the somatic system results in relaxation of muscle tension in the area of the nerve distribution. The human body is so cool!
2. I learned more about fascia than I previously understood. While I was under the notion that my work as a visceral manual therapist was due to mechanical stretching of tight tissues to stimulate mechanoreceptors (nerve receptors in muscle fibers), I now undertand fascia to have contractile properties and to act in response to the BRAIN that determines its tone. My new motto, to quote osteopaths, is "find it, fix it, leave it alone." I realized I was working too hard and blasting past the barrier of tissue tightness.
3. My professional vocabulary grew with words and phrases like, nervi nervorum, parametrium, spermatic cord and more. Nervi nervorum, the fascial layer around peripheral nerves, explains tightness in the hamstrings when fascia covering the sciatic nerve is restricted. I didn't learn that one in PT school (maybe I was on information overload?). I will have to share with my children that "recta" means "straight" and is the derivative for "rectum" and "rectus abominus" muscles. We did not learn word derivatives beginning in grade school to the same extent as kids do today. Maybe my ACT score would have been higher?
4. Where else can you learn about your own female anatomy? Prior to this class, I have felt something near the opening of my vagina (we can use medical terms here) that I attibuted to my fallen bladder and rectum from years of chronic constipation. What I found out was my cervix is very low and I have a uterine and vaginal vault prolapse. As my OB/GYN would say, "well you had three kids," which I do not accept as the final answer. More core work, limitations in my daily tasks and some hands-on help is in my future if I want to avoid surgery...yikes! I now have a legitimate excuse to not lift heavy laundry baskets, groceries and trash cans; attending this seminar is working out in my favor! I do wonder, though, if ligamentous support could improve if my brain tells the fascia to contract and hold everything in place the correct way. I will have to seek help from one of my colleagues for some treatment to find out. Of course, it helps to EXHALE every time I lift something or get out of a chair so my diaphragm and pelvic floor piston can work as a team to hold everything up. More in a future blog...
5. Where else can you learn what it feels like to have a prostate? We didn't have any male participants to work on so we did what therapists do best: IMPROVISE! The prostate is about the size of a golf ball in middle age men and older, in the shape of a heart. In order to learn proper palpation and mobilization techniques, we needed to locate the prostate on each other. Where do you think we put the foam golf ball? Yep, like a tampon; that was interesting! No need to elaborate. As therapists, when we affirm your complaints and say we understand, we REALLY do!
6. My understanding of the reproductive organs grew immensely. As PTs, we are well equipped to understand the musculoskeletal and nervous systems. The ovaries are located close to the "sit bones" deep inside the pelvis. Eggs are equivalent to the size of a chia seed. The uterus can be palpated externally in the abdominal cavity or internally from the cervix. Fascial work, along with diet and a specific protocol can improve fertility, and there is growing evidence of the positive effect of visceral mobilization. My understanding of the male reproductive system grew also. I learned how to mobilize the spermatic cord, a line of fascia that extends into the abdominal wall from the testicles (our pipecleaner in class). After a prostatectomy, a portion of the urethra is removed, making the penis almost an inch shorter which can cause pain with an erection. Pelvic pain can be caused by swelling of blood vessels and congestion of blood flow behind organs like the prostate. The skills I learned will improve my ability to help male patients with chronic prostatitis and inflammation that disrupts sitting tolerance and sexual function.
7. I learned better ways of protecting my body while doing visceral work and becoming more comfortable treating men. Very little effort is required by my hands and wrists to treat the urogenital diaphragm or central tendon of the perineum with modification of my posture. I also feel more comfortable explaining to the men what I am doing and what to expect. I liked hearing suggestions from other therapists of how they avoid becoming uncomfortable treating males in an enclosed, private room. I have two men in my household, and if one of them were having pelvic problems, I would want them to get help from the best person! I also feel obligated to treat men, since I know how to help them and they really don't have a lot of options, other than more antibiotics to treat persistent prostatitis symptoms. In fact, only 5-7% of chronic prostatitis complaints are due to a positive culture from an infection (Anderson)*. However, it is common practice for treatment to include several rounds of antibiotics, which in 95% of cases is ineffective at alleviating the symptoms (Anderson and Wise)*. In addition, up to 88% of men with pelvic pain have pelvic floor myalgia (muscle pain) and pelvic floor dysfunction, according to a 1999 article in the journal of Urology. A large percentage of men do not need antibiotics after the original infection, or primary prostate inflammation is addressed, but rather visceral mobilization from a qualified manual therapist.
8. I learned that the brain's job is to keep the body alive and protect vital areas, like reproductive organs. For this reason, after an injury or inflammatory event like surgery, fascia contracts on its own and can adhere around nerves, organs and muscles. Because of the nervi nervorum, fascial tightness around peripheral nerves, like the obturator nerve that sits very close to the ovaries or testicles, can cause inner thigh and groin tightness. The only other effective approach I have used to treat persistent short groin muscle tightness is dry needling to elicit a twitch. Patients with urinary frequency and urgency and chronic SI (sacroiliac) dysfunction benefit the most from treatment to this area. I now have additional tools to treat chronically tight hip adductors and have more lasting results.
9. I met other like-minded and skilled manual therapists who share a passion for helping others with pelvic pain. Initially, we didn't know what to expect, other than our previous class and clinic experience. I certainly did not know how we were going to do the prostate lab, which was reserved for the last few hours of our weekend. By then, we were all pretty giddy and amenable to whatever was thrown at us! Physical therapists, by nature, are friendly and compassionate and share similar traits as "helping" professionals. The women I met and reacquainted with were no exception and motivated me further to be a better manual therapist and leader in my profession.
10. The skills I learned were user-ready and I was able to help some of my patients more than I could before, especially the men. I was able to significantly reduce pain in one of my patients with chronic prostatitis with a combination of techniques, especially releasing the central tendon of the perineum and the inguinal ligament. I taught his wife how to release the central tendon at home, when he is in a flare-up from his job. I helped another patient with persistent hip range of motion deficits that contribute to her pelvic floor dysfunction. Muscles appear to melt under my hands with these new techniques! In addition, I have helped my children with adhesions from surgery or contact sports and experienced almost a complete reduction in my menstrual cramps as a result of visceral work from these classes. That is reason alone to learn these techniques!
Visceral mobilization is not for wimps. It is labor-intensive and is not for every therapist nor everyone, including pregnant women (other than round ligament mobilization) and women with an IUD or foreign body in place. I am sounding like a drug info-mercial, but treatment is without adverse side effects. A disclaimer should be "certain side effects include a sense of purpose, improved mobility and bodily functions, improved sexual function, decreased muscle tension and an improved body image and core!" As a manual therapist, I often develop pain syndromes and I reserve the more strenuous techniques for select, appropriate individuals to conserve my energy. It is also one of the reasons I learned the skill of dry needling so I can treat my own overuse syndromes while continuing to help others. It is extremely rewarding work to be able to help men and women with quality of life issues and being a visceral manual therapist requires a great deal of maturity, humility and a sense of humor. My work is my ministry and I am extremely blessed!
*References:
Anderson RU (2008). The Role of Pelvic Floor Therapies in Chronic Pelvic Pain Syndromes. Current Prostate Reports. 6:139-44.
McSweeney TP, Thompson 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.
Wise D and Anderson RU (2010) : A Headache in the Pelvis: A New Understanding and Treatment for Chronic Pelvic Pain Syndromes, 6th edition, National Center for Pelvic Pain.
