PT Classroom - The Visceral Component of Musculoskeletal Pain by Peter Coppola, PT

Peter Coppola, PT, began his professional career in the public education arena in New York and Arizona, providing PT to developmentally delayed and disabled children and adults. He additionally worked in skilled nursing facilities, home care and hospital rehabilitation units that served post-surgical and traumatic brain injury clients. Early in his manual training, he realized the value of an osteopathic approach and manual techniques toward helping clients achieve goals previously not attainable. He established Prescott Specialized Therapy, PLLC in Prescott, Ariz., where he delivers a synthesis of osteopathic manual therapy and traditional physical therapy techniques to meet a wider variety of client needs.

The Visceral Component of Musculoskeletal Pain

I believe that as physical therapists we all are looking for new and better tools that will help us to be more effective for our clients. Visceral Manipulation (VM), developed by Jean-Pierre Barral DO, is one such tool that has become an integral part of my practice.

Visceral Manipulation is an osteopathic style of manual work that looks past the symptoms and compensations a client presents with and helps to identify more central issues. Once this area has been identified, there are VM tools used to develop a simple and extremely effective treatment plan—one that helps the client’s body promote better health and, most importantly, helps the client start to feel better.

Approaching the body as an integrated unit
At the beginning of my career, I found that I was decently effective with clients. I was primarily working with multiply handicapped children in school and home-care settings. I attempted to keep my athletic ortho mind sharp by moonlighting at the local hospital and outpatient clinics. Across the board, I had an underlying thought that kept me searching for more tools: What about the clients who weren’t improving with the usual treatments? What was I missing?

In a roundabout way I started to study Visceral Manipulation and found that the answer was simpler and more universal than I thought as a new grad. I wasn’t taking into account all of the systems of the body and how they affected each other.

Barral sees the body as one integrated unit rather than just separate systems. In doing so he has found that 80 to 90 percent of musculoskeletal issues have a visceral component, which if left untreated limits the effectiveness of treatment or will cause the problems to return. He believes that “mobility is the key to understanding pathology.” This key philosophy is taught during VM classes, where we focus on anatomy that PTs typically look past. By focusing on the restrictions where the balance between these systems has broken down, treatment allows balance to improve, and the body returns to a better state of health.

A case of recurring shoulder pain alleviated
No matter the setting or type of client, with VM work I see changes faster and better than I or my colleagues expected. This is especially true for the more complex or “chronic” client.

One case is an example of right shoulder impingement and pain that was about two years s/p rotator cuff repair. The client had experienced similar symptoms of pain, limited patterns of reaching and weakness prior to his rotator cuff tear. The return of these symptoms was showing a pattern that seemed to be leading him down the same path that he had been on leading up to his tear. The client was referred to my office by his physician because of my previous success with his clients who were in reoccurring patterns.

Before and after his surgery the client had been through traditional PT with ice massage, ultrasound, joint mobilizations, nerve tension “flossing” patterned movements, Theraband strengthening, stretching, etc. He was also one of the few clients who consistently kept up his home program since his surgery. His external rotation in supine and 90 degrees of abduction was 10 degrees, and internal was 15 degrees. Strength was 4/5 with forward flexion and 4-/5 with scaption due to pain. Posturally his (R) AC joint was lower than (L) AC by 1 inch. Also, (R) root of scapular spine was 3.5 inches form midline, where (L) was 2 inches. Clavicular elevation was absent with all upper extremity elevation motions.

My assessment with VM techniques found a key point of restriction at his (R) waist involving his diaphragm, (R) thoracic cage, and visceral ligaments with deeper attachments. Support into this area showed an immediate improvement in comfort during forward flexion and scaption. I utilized seated and sidelying techniques over a period of about 10-15 minutes to address this restriction. The client reported an immediate release of tension throughout his chest and clavicular area. He stated that he had previously undergone soft tissue treatment to his thoracic cage, but had not experienced any global improvement or relaxation into the shoulder. The specificity of the VM techniques allowed a local treatment with minimal force and effort to have a very large effect.

The client’s immediate changes included more comfort with all UE motions, external rotation 0-35 degrees, internal rotation 0-30 degrees, strength flexion 4+/5 and scaption 4/5. Posture noted root of scapular spine bilaterally 2.25 inches from midline and AC only lower on the right by 0.25 inches. This client was discharged after only two more sessions and was able to return to full activity after two months.

Every system is important in the balance of the body; missing one of them may cause return of faulty patterns and symptoms. VM has completely changed my clinical perspective and techniques to better my clinical outcomes.

For more information regarding Visceral Manipulation, how it can benefit your patients, and training seminars, please go to

Last revised: April 15, 2013
by Peter Coppola, PT

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