Visceral Manipulation Embraced by the APTA

Many years ago, when I was a naïve and gullible teenager, I read about a home treatment for constipation that involved rolling a bowling ball around on the abdomen. I was intrigued, thought it sounded reasonable, and might even have tried it myself if I had been constipated or had had a bowling ball to experiment with. Many decades later, with the advantages of a medical education and experience in science-based medicine and critical thinking, I encountered a treatment that reminded me of the bowling ball: visceral manipulation (VM), a practice developed by a French osteopath and physical therapist, Jean-Pierre Barral. This time I was far more skeptical. VM may be more sophisticated than a bowling ball, but its effectiveness and safety are equally dubious.

Visceral manipulation (VM) will probably be unfamiliar to most of my readers, but its promoters say it has been adopted by osteopathic physicians, “allopathic” physicians, doctors of chiropractic, doctors of Oriental medicine, naturopathic physicians, physical therapists, occupational therapists, massage therapists and other licensed body workers. Its origin follows the path of many other alternative health systems. Like chiropractic, ear acupuncture, iridology, EMDR, and others, it was developed by one individual based on his personal observations and experiences without any kind of proper testing. Like the others, it started with a single patient: in Ignaz von Peczely’s case an owl with a spot on its iris, in D.D. Palmer’s case a janitor whose hearing allegedly improved after something was done to his back, in Barral’s case a patient who said he had felt relief from his back pain after going to an “old man who pushed something in his abdomen.” From a single case they extrapolated to a general belief about disease causation and a whole diagnostic and/or treatment system.

How is VM Done?

A video shows Barral demonstrating his skills.  He “listens with his hands” to detect tension (elsewhere the perception is designated as a thermal phenomenon). His diagnostic process begins by “listening with the hands” on the top of the patient’s head to determine the lateralization or general area of the problem. Then his hands “listen” to the areas of concern to further localize the problem.  In this demonstration he detects something in the stomach which he says could be from decreased acidity or emotional tension. Then he listens to the skull repeatedly with both hands, does something simultaneously to the neck and abdomen, and finally he is satisfied that his hands are telling him that he has corrected the problem.

The Underlying Rationale

From the Barral Institute website:

Therapists using Visceral Manipulation assess the dynamic functional actions as well as the somatic structures that perform individual activities. They also evaluate the quality of the somatic structures and their functions in relation to an overall harmonious pattern, with motion serving as the gauge for determining quality.

 The visceral system relies on the interconnected synchronicity between the motions of all the organs and other structures of the body. At optimal health, this harmonious relationship remains stable despite the body’s endless varieties of motion. But when one organ cannot move in harmony with its surrounding viscera due to abnormal tone, adhesions or displacement, it works against the body’s other organs, as well as muscular, membranous, fascial and osseous structures. This disharmony creates fixed, abnormal points of tension that the body is forced to move around. In turn, that chronic irritation paves the way for disease and dysfunction throughout many systems of the body – musculoskeletal, vascular, nervous, urinary, respiratory and digestive to name a few.

Barral says the organs remember physical and emotional traumas, and each organ is connected to specific emotions (!). He says “structural relationships” (peripheral, spinal, cranial) can self-correct after VM. He says that each internal organ rotates on a physiological axis. He says organ problems profoundly affect the spine.

Each organ has a regular intrinsic oscillatory motion that follows lines of embryologic migration. This motion resembles, but is distinct from, the craniosacral rhythm [a delusion accepted only by craniosacral practitioners]… If the kidneys are moving out of phase, with one moving inferiorly while the other moves superiorly, this side bends the spine every 3.9 seconds. This small motion is like water drop torture for the spine, resulting in a repetitive motion injury.

Strains in the connective tissue of the viscera can result from surgical scars, adhesions, illness, posture or injury. Tension patterns form through the fascial network deep within the body, creating a cascade of effects far from their sources for which the body will have to compensate. This creates fixed, abnormal points of tension that the body must move around, and this chronic irritation gives way to functional and structural problems.

Where’s the Evidence?

This is fantasy, not science. Adhesions do exist and certainly can cause problems, especially after surgery, but Barral claims they are widespread. For instance, he says they form around the heart in whiplash neck injuries. There is no evidence that they are responsible for symptoms of all the conditions Barral claims or are even present in those conditions, or that disrupting them improves health. And there is no evidence that Barral is actually disrupting adhesions and no reason to think that gentle manipulations like his could possibly do so.

The Barral Institute website  claims that “Comparative Studies found Visceral Manipulation Beneficial for Various Disorders” including a long list of everything from whiplash to PTSD, from menopause to urinary reflux; but I have been unable to locate any such studies.

I won’t even attempt any evaluation of the literature, because there’s nothing worth evaluating. The extensive bibliography provided on the website is not helpful. It provides links to popular articles by Barral, to published studies that are not pertinent to VM, and to a few uncontrolled pilot studies and case reports where the clinical significance of the reported changes is uncertain or where any observed improvement can’t be attributed to VM itself. The bibliography reveals that VM has suspicious bedfellows: it is related to energy medicine, craniosacral therapy, zero balancing, Upledger’s bizzare ideas, neurodevelopmental therapies, and other dubious concepts.

Is It Safe?

I think we can reasonably assume that any abdominal manipulation sufficient to disrupt adhesions would risk tissue damage and internal bleeding, but VM is not likely to do that. As practiced, VM amounts to relaxation, suggestion, and gentle massage; so it is not likely to cause physical harm unless it replaces other, effective treatments. It’s more likely to cause harm to the wallet and to critical thinking.

The APTA Goes Astray

The American Physical Therapy Association is trying to establish evidence-based clinical practice guidelines.   The Women’s Health Section  features a prominent link to CME courses on visceral manipulation offered by the Barral Institute.

J.W. Matheson, a physical therapist in private practice and a long-time APTA member, wrote the organization to protest their promotion of pseudoscience. He provided supporting documents and said,

Visceral Manipulation is a pseudo-scientific practice that belongs outside of the field of physical therapy.  The practice of visceral manipulation is not consistent with the vision and mission statements of the APTA.

Carrie Schwoerer, the Director of Education, replied with an astonishing letter. Here are some of her more alarming statements:

Our course offerings are based on the model of evidence informed practice, which Sackett defined as balancing clinical research with clinical experience and patient values. Some of our course offerings… were… based on extensive review of the literature and are clearly advertised as evidence based.

Other aspects of physical therapy practice reflect the clinical experience of the physical therapist providing care and the values, which the patient views as critical to their healing process… some of these techniques have not been validated by the more rigorous clinical research protocol because we have yet to develop measurement tools that could undergo appropriate testing… Adhering to clinical research as the only valid evidence is a disservice to patients who have responded time and again in case studies to so-called “pseudoscientific” interventions and threatens to undermine future innovation in the field.

The Board of Directors… embrace the instruction of visceral mobilization under the tenets of clinical experience and patient values. We disagree that this is pseudoscientific in nature but also recognize that clinical trials do not support its use and therefore do not advertise as evidence based. If individuals are not comfortable with the level of evidence supporting this coursework, there is no obligation to take it for any of the SoWH certificates or to sit for the WCS.

In other words, “We don’t need no stinkin’ science! We support any treatment that can provide positive anecdotes. We believe the plural of anecdote is data. Instead of offering guidance, we’ll let our members sink or swim: we’ll make them responsible for knowing ahead of time how much evidence supports a treatment and deciding whether they believe it is sufficient to merit a personal decision to study it.”

This is beneath contempt. I don’t think I need to elaborate. Another formerly respected organization has drunk the CAM Kool-Aid.