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I recently took a Visceral Manipulation 1 (VM1) course through the Barral Institute. Osteopaths have been manipulating the viscera since Still (techniques can be found in old books by McConnell and Goetz), and it was another area of OMT that diminished as HVLA got too popular in the schools. I have learned some at my school and the AAO Convocation. Jean-Pierre Barral, a French osteopath, apparently devised his visceral methods from scratch because this material wasn't available in Europe.
Barral's visceral manipulation argues that organ function is affected by mobility (ability to move around and slide across each other during breathing and voluntary movement), that organs have inherent motility separate from peristalsis, and that the visceral fascia participates in the body's proprioceptive systems, such that restricted motion and somatic dysfunction will occur elsewhere to protect a strain in the visceral fascia from going too far.
The Good:
VM1 covered the liver, gallbladder, stomach, duodenum, small intestine, large intestine, and various 'sphincters' (cardiac, pylorus, Oddi, duodenaljejunal junction, iliocecal valve). Each of these were in some detail (such as the loops, mesentery, and mesenteric root of the small intestines). There was enough material that we were always busy.
Techniques fell into three types. The first is probably most similar to myofascial (direct or indirect, with input as to what gave Barral better results for a particular organ) and treated the mobility of an organ. The second is induction, which is for the motility of an organ. The third was recoil (kind of the reverse of HVLA, taking something to the barrier and then letting go suddenly rather than thrusting through; see "Mechanical Link" by Chauffour & Prat), though we only learned this for the sphincters.
The techniques themselves looked like they were good and useful and we could demonstrate the increased range of motion elsewhere in the body from treating the viscera. We also learned general and local listening as ways to locate dysfunctions and inhibition as a way to determine which of two or more dysfunctions is primary to the others, including relative to somatic dysfunctions.
The Bad:
There was one instructor, with three TAs, for 31 attendees. Compare this with a 40-hour intro course from the Osteopathic Cranial Academy: 11 faculty for 40 attendees. If someone there needed to be treated, they took care of it ASAP; in a VM course it's not possible. So you can feel a bit mangled afterward, and your back too if you aren't careful leaning over too short tables for four days.
The instructor talked about knowing your anatomy well enough that you can spot errors in anatomy book illustrations, but he still made mistakes here, and especially with physiology. Such as lack of contact with stomach contents (from it not moving properly) causes anemia from decreased absorption of B vitamins (this was plural; not once did he or the nutrition-minded attendee mention B12 or where the absorption actually takes place). Also, for all the emphasis on fascia (Frank Willard, anatomist from UNECOM, told me that the French are notorious for finding a fascial thickening on a few cadavera and ascribing it as a "ligament" to everyone), they treated the ascending and descending colon as not being retroperitoneal. You will learn more anatomy in this course (to double check later...), but medical students are already beyond them. The triangular ligaments of the liver were testable material in our anatomy practicals.
The instructor insisted several times that there's no such thing as a "still point" in Visceral. Well, not only does Barral's book mention still points multiple times, but one "usually" follows induction of the sphincter of Oddi! Still points remained in Barral's revised edition of Visceral Manipulation. So there were internal inconsistencies too.
The Ugly:
"As a practitioner using therapies taught through the Barral Institute you are expected to administer treatment protocols within your scope of practice..."
The instructor, a physical therapist, told us about how he documents things to get around scope of practice issues: that he's releasing the fascia at X location in the body, making sure to never mention the liver or any other internal organ word that would be obviously outside his scope of practice. A Canadian student asked what to do if "visceral manipulation" were specifically disallowed in the licensing for a profession (apparently that's the case in British Columbia). He said that the osteopaths probably got that put in there to protect their turf and compared the fights between chiropractors and PTs over "physiotherapy" and manipulation. He recommended documenting it as releasing the fascia and being careful about talking about it there.
While the instructor for this course said he has never found a mass (and then criticized the resolution of CT and MRI for when they miss things), the faculty at my school have numerous examples of catching cancer based on their clinical and palpatory skills or the way somatic dysfunctions failed to correct with OMT.
Recommendations:
Every osteopathic student or physician should learn at least some visceral manipulation. Barral's is very thorough (get your money's worth) and in spite of my caveats above the techniques are probably reasonably valid and useful. I will be taking the rest at some point (VM2-6). If people are interested in other sources or styles (including if you prefer to be taught by physicians), I'll make a list. Every new technique you learn is also a new palpation skill. Now that I can recognize more specific abdominal structures and have a better set of landmarks, and can evaluate mobility and motility, I'm looking forward to seeing how these compare to other findings on clinical rotations. Maybe an attending will even let me try out some of the techniques too.
Never write a carte blanche "evaluate and treat" on a prescription to an allied health professional. Be as specific as possible about your goals and the treatment when you refer someone. You're extending your license to these people; whether or not you agree with visceral or want them doing it, you need to know what's going on.
Barral's visceral manipulation argues that organ function is affected by mobility (ability to move around and slide across each other during breathing and voluntary movement), that organs have inherent motility separate from peristalsis, and that the visceral fascia participates in the body's proprioceptive systems, such that restricted motion and somatic dysfunction will occur elsewhere to protect a strain in the visceral fascia from going too far.
The Good:
VM1 covered the liver, gallbladder, stomach, duodenum, small intestine, large intestine, and various 'sphincters' (cardiac, pylorus, Oddi, duodenaljejunal junction, iliocecal valve). Each of these were in some detail (such as the loops, mesentery, and mesenteric root of the small intestines). There was enough material that we were always busy.
Techniques fell into three types. The first is probably most similar to myofascial (direct or indirect, with input as to what gave Barral better results for a particular organ) and treated the mobility of an organ. The second is induction, which is for the motility of an organ. The third was recoil (kind of the reverse of HVLA, taking something to the barrier and then letting go suddenly rather than thrusting through; see "Mechanical Link" by Chauffour & Prat), though we only learned this for the sphincters.
The techniques themselves looked like they were good and useful and we could demonstrate the increased range of motion elsewhere in the body from treating the viscera. We also learned general and local listening as ways to locate dysfunctions and inhibition as a way to determine which of two or more dysfunctions is primary to the others, including relative to somatic dysfunctions.
The Bad:
There was one instructor, with three TAs, for 31 attendees. Compare this with a 40-hour intro course from the Osteopathic Cranial Academy: 11 faculty for 40 attendees. If someone there needed to be treated, they took care of it ASAP; in a VM course it's not possible. So you can feel a bit mangled afterward, and your back too if you aren't careful leaning over too short tables for four days.
The instructor talked about knowing your anatomy well enough that you can spot errors in anatomy book illustrations, but he still made mistakes here, and especially with physiology. Such as lack of contact with stomach contents (from it not moving properly) causes anemia from decreased absorption of B vitamins (this was plural; not once did he or the nutrition-minded attendee mention B12 or where the absorption actually takes place). Also, for all the emphasis on fascia (Frank Willard, anatomist from UNECOM, told me that the French are notorious for finding a fascial thickening on a few cadavera and ascribing it as a "ligament" to everyone), they treated the ascending and descending colon as not being retroperitoneal. You will learn more anatomy in this course (to double check later...), but medical students are already beyond them. The triangular ligaments of the liver were testable material in our anatomy practicals.
The instructor insisted several times that there's no such thing as a "still point" in Visceral. Well, not only does Barral's book mention still points multiple times, but one "usually" follows induction of the sphincter of Oddi! Still points remained in Barral's revised edition of Visceral Manipulation. So there were internal inconsistencies too.
The Ugly:
"As a practitioner using therapies taught through the Barral Institute you are expected to administer treatment protocols within your scope of practice..."
The instructor, a physical therapist, told us about how he documents things to get around scope of practice issues: that he's releasing the fascia at X location in the body, making sure to never mention the liver or any other internal organ word that would be obviously outside his scope of practice. A Canadian student asked what to do if "visceral manipulation" were specifically disallowed in the licensing for a profession (apparently that's the case in British Columbia). He said that the osteopaths probably got that put in there to protect their turf and compared the fights between chiropractors and PTs over "physiotherapy" and manipulation. He recommended documenting it as releasing the fascia and being careful about talking about it there.
While the instructor for this course said he has never found a mass (and then criticized the resolution of CT and MRI for when they miss things), the faculty at my school have numerous examples of catching cancer based on their clinical and palpatory skills or the way somatic dysfunctions failed to correct with OMT.
Recommendations:
Every osteopathic student or physician should learn at least some visceral manipulation. Barral's is very thorough (get your money's worth) and in spite of my caveats above the techniques are probably reasonably valid and useful. I will be taking the rest at some point (VM2-6). If people are interested in other sources or styles (including if you prefer to be taught by physicians), I'll make a list. Every new technique you learn is also a new palpation skill. Now that I can recognize more specific abdominal structures and have a better set of landmarks, and can evaluate mobility and motility, I'm looking forward to seeing how these compare to other findings on clinical rotations. Maybe an attending will even let me try out some of the techniques too.
Never write a carte blanche "evaluate and treat" on a prescription to an allied health professional. Be as specific as possible about your goals and the treatment when you refer someone. You're extending your license to these people; whether or not you agree with visceral or want them doing it, you need to know what's going on.
