Key Point

• Removing the strain and tension caused by cumulative fascial forces on the internal organs, blood vessels, lymph, and nerves helps the body find homeostasis.

The massage therapist knows all too well about the multiple strains or complaints of pain that are found in each of their clients. The intensity of pain or the accumulation of strain patterns take a certain amount of force to hold it in the body. The primary tension, or the area with the most adverse force, will have the biggest effect on the fascial system. 

These fascial forces that accumulate in our body can remain in the superficial layers of our anatomy (skin, muscle, skeletal, or joint), which we can refer to as the container. These forces can also penetrate the deeper layers, causing increased mechanical tension that will compromise the contents within the container—the organs (retention of metabolic by-products, optimal nutrition), blood vessels (decreased oxygen, blood pressure challenges), lymph (edema, fluid flow), and the nerves (paresthesia, numbness, pain, muscle contraction).

If the client is not responding to your work that is focused on the container, then perhaps the strain might be coming from their visceral system, which has anatomical relationships with the musculoskeletal system via its ligaments and suspensory membrane system. The goal with visceral manipulation is to identify that an organ in good health has physiologic motion, which means there are no barriers to the function of biophysical or biochemical processes, homeostatic control mechanisms, or communication between cells. By removing these barriers, visceral manipulation can restore and maintain optimal function of the body’s structures, promoting homeostasis within.

Curiosity and Connectivity

The roots of visceral manipulation began in osteopathy under the guidance of Dr. Andrew Taylor Still in the late 19th century. Still was trained as a medical doctor but found he could treat most diseases by palpating dysfunctional areas and treating them with his hands. Osteopathy means to “begin with the bones.” He discovered when he found an area where the bones were not properly aligned nor moving adequately, this area became the first guide for the practitioner in performing a treatment choice. Still found that this “area” consisted of anatomy far beyond the bones and reflected where the forces of life are not moving properly. His findings included joints, fascia, blood supply, nerves, internal organs, and lymph flow. His ideas were very clear—all tissues need adequate fluid, nutrition, neurological exchange, and movement to be healthy.

In the 1970s, Dr. Jean-Pierre Barral, a French osteopath, became curious about Still’s findings regarding the visceral system and how it relates to structure and function. Immediately after receiving his osteopathic degree, Barral spent the next six months treating patients in a lung hospital. The experience was transformative. He realized that the tensions and strain patterns he felt in living patients were not just superficial or transient phenomena but were deeply ingrained in the body’s tissues, persisting even after death. This profound realization led him to further investigate the intricate relationships between the visceral organs and the musculoskeletal system.

Influenced by these findings, Barral began to develop and refine his techniques for what would become known as visceral manipulation. He dedicated himself to understanding how visceral dysfunctions could impact overall health and how manual therapy could be used to restore balance and function. His hands-on clinical experience and autopsy observations provided a unique and powerful foundation for his work, allowing him to bridge the gap between theory and practice.

This period of intense clinical observation and hands-on treatment solidified Barral’s belief in the interconnectedness of the body’s systems. It shaped his path by driving him to pursue further studies and develop new methodologies that could address the root causes of physical dysfunctions. His work led to a broader understanding of how internal organs influence the body’s structural integrity and vice versa, emphasizing the importance of treating the body as a whole.

Barral’s innovative approach and dedication to visceral therapy have had a lasting impact on the field of manual therapy. Today, the most current and largest curriculum of visceral manipulation remains under the guidance of Barral and the Barral Institute. The visceral manipulation curriculum has evolved as Barral has learned new strategies of treatment from anatomical relationships, case studies, his fellow colleagues, and his students. His techniques are now taught and practiced worldwide and have expanded the scope of osteopathy and manual therapy, highlighting the critical role of visceral health in maintaining overall well-being.

Visceral Dysfunction

In manual therapy, we identify visceral dysfunction when the fascial attachments and supporting structures of the viscera are restricted. If restricted, mobility (movement) and motility (inherent tissue motion) will not function to provide for biological exchanges (hormones, immune system), thermal changes (temperature control), or autonomic nervous system communication (spinal, sympathetic, or parasympathetic information). Understanding the autonomic nervous system and its visceral connections (Image 1) is one of the key reasons why visceral manual therapy treatments have such positive effects. 

The two components of the autonomic nervous system (Image 2) are complementary and function alternately most of the time. The sympathetic system readies the individual for action (fight, flight, freeze) and predominates during the day and in wakefulness. The parasympathetic system functions to protect and restore the internal environment. It counterbalances the effects of the sympathetic system and predominates at night and during sleep.

Visceral manipulation is organ-specific fascial mobilization based on the premise that free movement within the body is vital, and thus any restriction will adversely affect health. It relies on the palpation of normal and abnormal forces within the body, with the specific goal of encouraging normal tone and movements, both within and between the internal organs, their connective tissue, and other structures of the body where normal motion has been impaired.

Imagine scar tissue around the lungs, for example. Because of the pull of the adhesion, with every breath, the movement patterns of the nearby structures would be altered. This could shift rib motion and create pulls on the spine. These restrictions might then show up as mid-back or neck pain, as well as limited motion in the shoulder. This scenario highlights just one of many ramifications of a small dysfunction magnified by numerous repetitions each day. This scenario can also explain how pain can often be far removed from the actual cause.

Visceral Manipulation Protocol Example

So, what does a visceral manipulation protocol look like? 

It begins with “general listening,” which includes placing your hand on the head of a standing or seated client in such a way that you can gather information about the entire body.

Next comes local listening (Image 3), which identifies in greater detail the specific anatomy of the restriction found with general listening. Local listening to an organ or structure identifies the structure’s relationship with its attachments, surrounding tissues, or associated organs that might be causing the restriction. 

Motility evaluation is the next step, when the practitioner listens for energetic states of organs and directions of restrictions. If something is held in inspiration, it’s a problem of the organ itself; if it’s held in expiration, it’s a problem of fluid evacuation and structures (for fluid transit).

Mobility evaluation is the final evaluation step. Several musculoskeletal tests can be implemented for this, including:

• Glenohumeral test
• Straight-leg raise
• Listening through the feet
• Other specific tests 

For treatment, the practitioner chooses a body position for the client (supine, sidelying, seated) and begins communication with the visceral body through fascial load, all while maintaining mechanical dialogue. Treatment then includes induction of mobility or moving tissues in the direction of ease, direction of tension, or into a direct stretch. Re-evaluation is a primary component of the work, and relevant associated musculoskeletal tests may need to be readministered.

Cautions and Contraindications

While visceral manipulation can be highly beneficial, it is essential to be aware of certain cautions and contraindications to ensure client safety.

Cautions

• Acute inflammation—Avoid treating areas with acute inflammation or infection (e.g., appendicitis, diverticulitis).
• Pregnancy—Use caution during pregnancy, especially during the first trimester, and consult with the client’s health-care provider before beginning treatment protocols.
• Recent surgery—Be cautious around recent surgical sites and allow sufficient healing time.
• Chronic conditions—For clients with chronic conditions such as Crohn’s disease or ulcerative colitis, consult with their health-care provider before starting visceral manipulation.

Contraindications

• Active cancer—Avoid treating areas with known malignancies.
• Internal bleeding—Do not perform visceral manipulation on clients with active internal bleeding or severe trauma.
• Aneurysm—Avoid areas with known aneurysms.
• Severe osteoporosis—Be cautious with clients who have severe osteoporosis, particularly in the abdominal region.

Visceral manipulation is a profound and effective manual therapy that can address various conditions and improve overall health. However, it is crucial to be mindful of specific cautions and contraindications to ensure that treatments are safe and beneficial. Always consult with a qualified health-care provider before beginning any new treatment.

Visceral Manipulation Case Study

“It is a privilege to treat people with hands-on therapy and to be able to facilitate healing,” writes Barral in Manual Therapy for the Peripheral Nerves. “It requires skills, but also a continuous quest for anatomical knowledge and understanding.”

The following is a case study of a 39-year-old female client who presented with a history of chronic pain, which had not been resolved with conventional physical therapy, medical care, acupuncture, or chiropractic. The onset of her left sacroiliac (SI) pain occurred after completing a half-marathon run eight years prior. The pain returned, with on and off persistence after a surfing accident two years ago. Additional case notes include:

• Client is a data scientist, sitting most of the day.
• There were no pregnancy issues for the client last year, and she delivered her first baby six months before this office visit.
• Her labor and delivery were challenging with internal hemorrhaging and resultant cesarean section.
• Client had abdominal surgery after the C-section to repair hemorrhage.
• Postdelivery, the client had immediate indigestion, slow peristalsis, numbness in the abdomen, and could not feel any pressure variations in her abdominal organs.
• Her chief complaints included pain in the lower-left abdominal quadrant, constipation, low-back pain, chronic left SI joint pain, and moderate gastrointestinal (GI) symptoms.

Findings

The practitioner found the following issues:

• Adhesions from hemorrhage at the sigmoid, descending colon, jejunoileal, and ileocecal valve.
• Uterus was positioned to the right of midline while the rectum was posterior and inferiorly compressed with increased pain upon palpation.
• Client’s liver, large intestine, jejunoileal, and uterus/ovaries maintained low motility due to recent anesthesia (twice), hormone changes, breast feeding, and adhesions not allowing for proper movement leading to impaired function.
• Lymph congestion was evident in the lower left abdominal quadrant (lack of interstitial space for fluid flow).
• Sacral motion was restricted due to the uterosacral ligament restrictions, leading to low-back pain.
• SI joint pain was constant due to the sigmoid mesocolon suspensory system that is immediately anterior to the SI joint.
• Pelvic floor muscle tension, with left side greater than

the right.

Results After Treatment

After four sessions of visceral manipulation and other Barral manual therapies, the client:

• No longer complains of SI pain or dysfunction with activities of daily living.
• Has no constipation or issues with the gastrointestinal system.
• Has no complaints of lower-left abdominal pain.
• Still has low-back pain with prolonged sitting (parietal peritoneum restrictions)

The next session plan includes treatment of fascial compensations, the peritoneum, and pelvic floor restrictions.

Grow Through Visceral Manipulation

If you are interested in expanding your skills, enhancing your client outcomes, elevating your anatomy knowledge, and opening a new realm of possibilities for your clients, you might be interested in learning more about assessment of structural relationships between visceral, fascial, and ligamentous attachments to the musculoskeletal system. 

A Tapestry of Work

Over the years, Dr. Jean-Pierre Barral’s work has grown to include other disciplines, in addition to visceral manipulation.

Neural Manipulation

Neural manipulation focuses on evaluating and treating dysfunctions in the neural components of the body. It works to achieve extra-neural mobility and intra-neural mobility by restoring the slide and glide of the nerve and removing compression on the nerve imposed by the anatomical environment. Intra-neural mobility may also be restored by releasing specific intra-neural pressure congestion. By addressing restrictions in and around the nerves, this discipline aims to enhance the overall functioning of the nervous system, alleviate pain, and restore optimal neural communication.  

Visceral Vascular Manipulation

Visceral vascular manipulation is designed to improve blood flow and circulation by targeting the vascular system. This discipline addresses compression along vascular structures that creates restriction patterns and pain. Learning to locate and release restrictions along the vascular structures helps restore proper vascular function. By promoting better circulation, visceral vascular manipulation aids in reducing inflammation, supporting tissue healing, and optimizing overall health. 

New Manual Articular Approach

The new manual articular approach is a manual therapy discipline that applies a comprehensive approach to the treatment of joints. It integrates all aspects of the joint including the nerve, artery, bone, capsule, and ligaments, as well as visceral and emotional connections. It incorporates soft-tissue mobilization of the associated bones, while looking at direct and indirect relationships between all the bones of the body. The relationship between the viscera and the joints is not widely understood; this manual therapy shows how interconnected they are and that without addressing this visceral connection, many joint issues may not fully resolve. The application of these gentle techniques improves the body’s ability to heal and restore itself to optimal health. 

Manual Approach to the Brain

Manual approach to the brain is a discipline developed over the past 40 years, focusing on the manual treatment of the brain’s structures and functions. Because the brain is inherently plastic, manual therapy approach has been shown to help restore “inner bridges” within the brain, which is vital to the life of those facing difficulties due to brain dysfunction. The structural approach is aimed at the vascular, nervous, meningeal, ocular, barometric, and cerebrospinal fluid circulation systems. The functional approach explores the sense of smell, hearing, sight, language, coordination, proprioception, and emotions.

Visceral Manipulation Applications

Comparative studies found the visceral manipulation approach beneficial for people with various conditions such as: 

Acute Disorders

Chest or abdominal trauma (post-sports injuries)

Concussion, traumatic brain injuries

Whiplash, seatbelt injuries

Digestive Disorders

Bloating, constipation

Gastroesophageal reflux disease (GERD), acid reflux

Swallowing dysfunctions

Emotional Difficulties and Depression

Anxiety 

Posttraumatic stress disorder

Gender-Specific Issues

Chronic pelvic pain effects of menopause

Dysmenorrhea bladder incontinence

Endometriosis prostate dysfunction

Fibroids, cysts, referred testicular pain  

Orthopedic Problems

Connective tissue disorders

Headaches and migraines

Motor coordination impairments

Postural challenges due to visceral adhesions or postsurgical scar tissues

Spinal alignment issues, scoliosis

Spinal and peripheral joint pain

Other Issues

Chronic fatigue

Immune disorders

Sleep issues 

Pediatric Issues

Constipation

Gastritis, persistent vomiting, infant colic

Regulation challenges

Vesicoureteral reflux

For articles and case studies related to the conditions listed here, visit barralinstitute.com/therapies/index.php and barralinstitute.com/therapies/articles.php.