Treatment styles and techniques amongst physical therapists can vary drastically. In some aspects this can be difficult as a client because you might not know what to look for or what techniques will work for you. In other ways, this can be helpful as there are many options and perspectives if treatment with one clinician did not give you the results you were hoping for.
Physical therapy is a field that is evidence based, anatomy driven, and distinguishable from other fields because of our training in clinical reasoning. As physical therapists, we develop a tool box so that we can offer up unique solutions to the individual in front of us, rather than a textbook solution with a cookie cutter protocol.
One of the more recent tools being utilized, particularly amongst pelvic health specialists, is something called visceral fascial mobilization. It is a loaded term that seems bewildering, but with a proper explanation you as a client may begin to value this and look for it in your practitioners.
When we think of the first word “viscera”, what we are referring to are the internal organs. This can be the organs of the gastrointestinal system, the reproductive system, and even the urinary system. (Think: liver, uterus, urethra, etc…)
The word “fascial” is referring to a sheath of connective tissue that forms beneath the skin to attach, enclose, and separate muscles and internal organs. Fascia is everywhere in our bodies and is arguably the only thing we as therapists are ever touching or affecting with hands-on work.
The word “mobilization” is important because it is not “manipulation” or “adjusting”. Language is very important and as physical therapists, it is important to acknowledge that we are not treating any organ pathologies nor are we “moving your liver” into a new or different place. The word mobilization embodies the idea that all we are doing is engaging with the fascia of that structure and inviting in a change in holding patterns, or even inviting in the natural movement that should be occurring at these structures.
This change occurs because the fascia has many mechanoreceptors that are sensitive to touch (light touch specifically) and pressure and communicate with the brain. When we are able to meaningfully engage with barriers in your fascia with these techniques, we light up the brain to make it aware that there are barriers and then the brain is able to start regulating that fascia through homeostasis. Homeostasis is the process of bringing your body back to equilibrium. When this work is done slowly and with breath regulation, the nervous system can then feel safe enough to gently allow for shifts to occur.
This is a powerful process because it reflects back the idea that it is your body that makes the change, not the physical therapist’s “magic hands”. All the therapist is doing is providing novel input to specific and meaningful anatomical structures. This is how the nervous system can begin to facilitate a change. It is only with your awareness and neuroplasticity (nervous system’s willingness to change) that the body is then willing and able to shift these holding patterns. This is radical as it goes against much of what we are taught healthcare is in this culture. With this work, something is not being done to you. Rather, you are reintegrating a new pattern into your nervous system with your mindful awareness and this can last beyond the treatment room. This is sustainable, cost-effective, and reteaches the important feeling of self-efficacy and agency that is essential in the healing process. The answer is not outside of you.
Why would working at the viscera instigate such meaningful change? The brain cares a lot about your internal organs!
When we think about being as effective as possible when in conversation with the brain and nervous system, we will have the best results when we get on the fascia of structures that are highly sensitized because they are vital to our survival. Our brain cares a lot more about our liver than our shoulder.
The scientific plausibility behind this work is that many musculoskeletal disorders and somatic pain have a visceral fascia component in origin.
Imagine this scenario: You fall suddenly on your right side while skiing. The shock to your trunk sends signals to your brain that there is a threat. The most threatened area to the brain will be the internal organs that took on some of the shock, in this case the liver. Even after the threat has ended, if that trauma to the body has not been processed, the body may hold on to a protective pattern of keeping fascia around the liver more restricted. You may notice weeks or months after this fall that you continually have right shoulder pain. Imaging is negative for findings and you even did standard orthopedic PT to address tight musculature in the shoulder girdle. However, a mild form of pain still persists. Due to the fact that the liver is right underneath the respiratory diaphragm, and the diaphragm is a major trunk and shoulder stabilizer, it is possible that the fascia of these structures is still over-recruiting and restricted to protect the liver. If this is not addressed and treated, you may continually have some form of pain that is being referred to the shoulder.
This highlights again how we are not treating organ pathology of the liver (aka liver disease). We are treating the fascia of the liver and looking at the internal organs as support structures to the trunk that play a vital role in musculoskeletal function.
When we think of a majority of musculoskeletal dysfunction, there is high probability that an aspect of treatment will link back to the trunk or the core. We are starting to move forward in conversations of the core, acknowledging that it is more than just the “six pack abs” or even just the abdominal muscles in isolation. Research and pelvic physical therapy are spearheading the conversation that the core is actually an intra-abdominal system- a canister made up of the respiratory diaphragm, pelvic diaphragm, transverse abdominus, and you can also argue the epiglottal diaphragm.
This system is a pressure management system that provides stability through properly coordinated pressure distribution and shock attenuation that is intimately tied in with breath. One major aspect that is not talked about as much is that this canister has contents- the viscera! We are not hollow. These viscera must be able to shock absorb as well as slide and glide around each other. They articulate just like other joint surfaces in our body and must have their full degrees of movement in order for us to have healthy movement patterning at the trunk.
Try this out: Stand up and move your trunk into extension. This means, hinge back from the hips and open up the front side of your body to the degree you feel comfortable. Note how that felt and how far you were able to go.
Now, try gathering and grabbing the soft tissue of your belly. Hold on to that tissue and try to extend again. Did you notice you were not able to go as far back?
This is an example of how fascial holding patterns at the abdomen and abdominal viscera can restrict our musculoskeletal movement. Again, think history of falls or blunt force trauma from sports. Think motor vehicle accidents. Think abdominal scar tissue from surgery. Think chronic inflammation from gut health issues. Think endometriosis. These all have plausibility of creating restrictions in the fascia of the abdomen because they are all threats to this vital part of our body. When the body detects a threat, it is hard wired to protect with fascia and muscular tightening.
The beautiful part of the body is that it is malleable. The body is always trying to come back to homeostasis and it is incredibly resilient. With the right environment and ability to truly regulate your nervous system, this work can be informative enough to call attention to areas that have been ignored and invite in the specific change that has been needed.
This is why it is important to work with a therapist that not only knows these techniques, but is also trauma and nervous system informed. Even if the correct anatomical structure is being worked with, if you are in a state of freeze or fight/flight, the body will be unable and unwilling to make the change in the tissue. It is vital these techniques are done in an environment that is therapeutic and not threatening.
If you are someone who has had orthopedic pain and done everything you can think of to alleviate this pain, this work may be appropriate for you. If you are someone with pelvic pain, this work may be appropriate for you. If you are someone with abdominal pain that is not originating from a major organ issue, this work may be appropriate for you. If you have endometriosis and even got the surgery but are still having pain, this work may be appropriate for you. If you have pelvic pain but do not feel ready to participate in internal techniques, this work may be appropriate for you. If you are someone who is on a somatic journey and wants to connect to these deeper structures in a more meaningful way, this work may be appropriate for you.
Just as pelvic health has been a stigmatized and overlooked area of healthcare, the visceral perspective is severely underutilized. This work is extremely safe, scientifically plausible, and effective. We live in a time that is radically pushing the envelope of what is means to be connected to your body and what it means to heal. If you are feeling stuck and you are ready to have the answer come from a place of empowerment and deep embodied self connection, visceral fascial mobilization may be the next step on your path towards healing.