Abdominal massage and visceral manipulation for gut function

Abdominal Massage & Visceral Manipulation for Gut Function

What is abdominal massage? Is visceral manipulation different? Can either help improve gut function?

People with functional gut disorders such as IBS, functional constipation, and functional diarrhea are often frustrated by the treatments (or lack thereof) they are prescribed in the doctor’s office. Patients often turn to alternative strategies such as abdominal massage to find relief.

In this article we will discuss the difference between abdominal massage and visceral manipulation. We also dive into the research to determine if either are effective in gut symptom management.

Of note, I am a dietitian, not a massage therapist or doctor of osteopathy. But I feel that it is important to be aware of both diet and non-diet strategies for a whole-body (and mind) approach to the treatment of gut disorders. Please discuss any treatment with your doctor if you are interested in trying something new.

What is Abdominal Massage?

Abdominal massage for gut function

Massage therapy is one of the oldest methods of healing. It is usually considered an alternative or complimentary treatment. Abdominal massage has been practiced for constipation in the Unites States and Europe since the 1800’s. And it goes much further back in Chinese medicine.1 

In massage therapy, a practitioner uses his or her hands to provide rhythmic movements on tissues of the body, including nerves and muscles.2 Approaches to abdominal massage may include use of stroking motions, tapping, kneading, rolling, friction, vibration, skin brushing, and the use of gentle to moderate pressure.

Abdominal massage has been used for a variety of problems related to nutrition and gut function. These include the treatment of constipation, diarrhea, abdominal distention, incontinence, malnutrition, and prevention of gallstones. But what is the evidence that it works?

Effect of Massage on Gut Function

A review published in 2020 looked at ten studies investigating the effect of abdominal massage on various gut function issues2

Several of the studies included in the review involved very specific populations. They included critically ill patients, patients undergoing spinal traction, multiple sclerosis, and breast cancer patients. So unfortunately, the results may not apply to people outside of those populations. 

It is also important to note that most of these studies were small. However, a few of the studies examined provide data that may be relevant. And all of the studies examined had some sort of positive outcome on gut function2.

Much of the research on abdominal massage seems to center around constipation.  Evidence from a handful of small studies points toward promising results.

One study looked at the use of abdominal massage in patients taking laxatives. Study participants were mostly older women, over the age of 60. Over half of the participants in either group were taking laxatives daily. 

The researchers found that the group receiving abdominal massage had less constipation and more frequent bowel movements than the group receiving laxatives alone. However, laxative use did not decrease significantly in either group.  Those with the most severe constipation seemed to benefit the most from massage3.

Another study looked at the use of abdominal massage as a non-drug treatment option for the management of constipation in elderly patients. The group receiving massage had improvements in bowel function4.

Positive effects of abdominal massage included4:

  • Less discomfort with bowel movements
  • Fewer hard, lumpy stools
  • Reduced feeling of incomplete evacuation (feeling like they still had to go)
  • Decreased sensation of a blockage
  • Decreased manual interventions (this usually means inserting fingers into the rectum to stimulate a bowel movement)

It is important to note that participants in these studies received massage daily or nearly daily. The cost of daily massage can add up quickly and the time requirement might not be realistic for many people. 

Self-massage, below, might be one way around these barriers.

Self- Abdominal Massage

Some researchers have acknowledged that receiving frequent massage might not be practical for everyone3. After their study, Lämås and colleagues taught participants how to perform abdominal massage on themselves. However, it is not clear whether self-massage can achieve the same effects as receiving massage from a trained professional. 

Other Benefits of Massage

Most people associate massage with relaxation. There are exceptions of course, with some people feeling uncomfortable with the physical touch. But in general, massage can be helpful to induce a state of relaxation and stress reduction.

IBS and other functional gut disorders are so intimately tied to the gut-brain axis. So it should not come as a surprise that activities that are enjoyable and create a relaxed state may be beneficial for gut function.

Gut Brain Axis
Gut-Brain Axis

There is evidence to suggest that massage may be beneficial to help treat depression and anxiety5. Massage should not replace other treatment methods. But it can be a tool in the toolbox for many disorders of the brain, and so also perhaps those of the gut-brain axis. 

In addition, some studies have found a connection between massage and immune health. Benefits of massage may include a reduction in the inflammatory response5.  Inflammation is one of the proposed mechanisms in functional gut disorders.

There is no consensus on the type of massage that is most beneficial for psychological benefits. There is also no consensus on how often someone should go or how long the treatment should last5

But patients of massage can use their own judgement (see Questions to Ask, below) and the expertise of their massage therapists to help figure out the best regimen for them. 

What is Visceral Manipulation?

Visceral manipulation is sometimes referred to as visceral osteopathy or osteopathic manipulation. It uses massage-like techniques focusing on the movement of organs and the tissues that connects them. 

Some say the root of the practice goes back to traditional Eastern Medicine.  However, the French osteopath Jean-Pierre Barral developed and published his visceral manipulation techniques in the 1980’s. He is usually credited for modern day practices. 

According to the Barral Institute, visceral manipulation is defined as:

1: gentle manual therapy that assesses the structural relationships between the viscera (organs), and their fascial or ligamentous attachments to the various systems in the body.

2: assists functional and structural imbalances throughout the body including musculoskeletal, vascular, nervous, urogenital, respiratory, digestive, eliminatory, neuroendocrine and lymphatic dysfunction.

Let’s break that down in case, like most of us, you have no idea what any of that means!

The Viscera

Viscera refers to internal organs. 

The abdominal viscera are the organs within the abdominal cavity. They include the lower esophagus, stomach, small intestine, large intestine, pancreas, liver, and gallbladder.

The Theory of Visceral Manipulation

The theory behind visceral manipulation, or visceral massage, is this – trauma, disease, infection, or surgery can result in changes in organ movement.6  If one organ is restricted it may impact the movement of other organs, connective tissue (fascia), and muscles. 

It is believed that a trained therapist can detect these changes or restrictions through palpation (a fancy word for touching or feeling). Visceral massage may be performed by massage therapists, physical therapists, or osteopaths. 

Manipulation of these organs or structures is thought to restore natural movement. It is said to help relieve symptoms such as back or neck pain, pelvic pain, nerve problems, anxiety, depression, and gastrointestinal symptoms.

Is Visceral Manipulation Evidence Based?

Man with a magnifying glass:  "what does the evidence say?" about visceral manipulation

The evidence to support the practice of visceral manipulation is weak.  Few high-quality studies have been done, especially as it relates to gut function.  Many of the studies focus on outcomes such as back pain rather than gut function. 

A review published in the Journal of Family Practice noted that osteopathic manipulation can be helpful for back pain. However, the authors concluded that evidence is limited in other areas including IBS7. They acknowledge two studies with positive effects on IBS but with limitations in study design. 

One review found a high degree of bias in studies evaluating visceral osteopathy8. This means that the study design likely favored one result over another.

However, these findings do not suggest that visceral manipulation does not work. Rather, it means that more high-quality studies are needed to determine if it does work.

Studies on Visceral Manipulation and IBS

One randomized controlled crossover study found positive outcomes of visceral manipulation on IBS symptoms in patients who failed traditional treatments (such as medications). In this study, visceral manipulation was compared to a placebo of abdominal massage. 

Constipation, diarrhea, abdominal distention, and abdominal pain improved with visceral manipulation. Unfortunately the improvement in constipation was short term.  The placebo massage was also associated with improved symptoms, but visceral manipulation had a greater impact. 

Of note, some of the study participants felt that visceral manipulation was more painful than the placebo abdominal massage. Since some of these participants were able to tell a difference between the two treatments the study data may be skewed. The authors also acknowledge that larger studies are needed9.

Another small study looked at osteopathic manipulation vs sham (placebo) in the treatment of IBS10. As with the above study the placebo was massage. 

In this study both groups had improved symptoms seven days after treatment, but the improvement was significantly greater in the manipulation group. However, there was no difference between groups by day 2810.

And finally, an older study from 2007 also found positive results with osteopathic manipulation11. However, this study was small and had many weaknesses with its study design. 

One of the weakness was that the treatment group did not follow a standard treatment procedure. Rather the osteopathic techniques were tailored to individual needs. This makes it harder to draw conclusions on the effectiveness of the treatment if the procedure was different from one patient to another.

Another flaw is that patients in the standard treatment group (diet and medication) were encouraged to follow a high fiber diet. We now know that for some individuals with IBS a high fiber diet (especially one high in fermentable fiber) can worsen symptoms. And in fact, 17% of the participants in the standard treatment group had worsening symptoms11

Questions to Ask When Making a Treatment Plan

There are lot of unknowns when it comes to incorporating massage or osteopathy in the treatment of gut disorders. Some of the unknowns are “how often”, “how long”, and specifically “what type” of treatment to pursue.

When getting started with massage or manipulation, patients should discuss treatment plans with the practitioner. They should also run it by their doctor. Patients can also ask themselves some questions to decide on the type of treatment, frequency, and length.  These questions might include:

  • Do I feel better after a treatment?
  • Am I more relaxed?
  • How long do the effects seem to last?
  • How often can I afford to go?
  • What do I have time for?
  • What kind of massage feels right for me?
  • Do I like light touch or deep pressure?
  • Are there areas of the body I prefer not to have touched or treated?
  • Do I like and trust this practitioner?
  • Am I comfortable here?
  • What kind of training does my practitioner have?
  • Is my practitioner knowledgeable in the areas I need help?

Conclusion

Although there are studies to suggest abdominal massage and visceral manipulation are helpful treatments for digestive problems, the overall evidence is weak. However, this lack of evidence doesn’t necessarily mean it doesn’t work. Rather it means more studies are needed. 

The small amount of evidence out there suggests that visceral manipulation might be slightly more effective than massage. Both seem to be low risk. They are non-invasive and considered low cost compared to many medical treatments.

However, frequent treatments means high costs over time. The studies that looked at abdominal massage involved very frequent treatment- in some cases daily.  Self-abdominal massage may be an option if a trained professional can teach the techniques. Though, it is unknown whether self-massage will get similar results.

Finding a practitioner trained in visceral manipulation might be more difficult than finding someone who can do general abdominal massage. And if your practitioner of visceral manipulation is a doctor of osteopath, it might be more expensive than massage. 

Massage might have benefits beyond direct effects on the gut. Any treatment that induces a relaxed state might help calm the over-excited nerves of the gut-brain axis. We know that functional gut disorders, though physically real disorders, are also strongly impacted by mental health and wellness. 

Abdominal massage and visceral manipulation might have a place in the treatment of functional gut disorders. They might be most effective alongside traditional therapies like medication and diet. So, before you jump ship on traditional treatments, talk to your doctor about adding complimentary therapies such as these to help with symptom management.

References

1.         Sinclair M. The use of abdominal massage to treat chronic constipation. J Bodyw Mov Ther. 2011;15(4):436-445. doi:10.1016/j.jbmt.2010.07.007

2.         Dehghan M, Malakoutikhah A, Ghaedi Heidari F, Zakeri MA. The Effect of Abdominal Massage on Gastrointestinal Functions: a Systematic Review. Complement Ther Med. 2020;54(July):102553. doi:10.1016/j.ctim.2020.102553

3.         Lämås K, Jacobsson C. International Journal of Nursing Studies Effects of abdominal massage in management of constipation — A randomized controlled trial. 2009;46:759-767. doi:10.1016/j.ijnurstu.2009.01.007

4.         Baran A, Ates S. The Effects of Abdominal Massage in the Management of Constipation in Elderly People. 2019;35(2):134-140. doi:10.1097/TGR.0000000000000223

5.         Rapaport MH, Schettler PJ, Larson ER, et al. Massage Therapy for Psychiatric Disorders. Focus (Madison). 2018;16(1):24-31. doi:10.1176/appi.focus.20170043

6.         Namiranian P, Karimi M, Zahra S, Razavi E, Garoos AF, Ayati MH. Visceral Manipulation in Resources of Persian Medicine. 2021;6(2):158-165.

7.         Slattengren AH, Nissly T, Blustin J, Bader A, Westfall E. Best uses of osteopathic manipulation. J Fam Pract. 2017;66(12):743-747.

8.         Guillaud A, Darbois N, Monvoisin R, Pinsault N. Reliability of diagnosis and clinical efficacy of visceral osteopathy: A systematic review. BMC Complement Altern Med. 2018;18(1):1-12. doi:10.1186/s12906-018-2098-8

9.         Attali T Van, Bouchoucha M, Benamouzig R. Treatment of refractory irritable bowel syndrome with visceral osteopathy: Short-term and long-term results of a randomized trial. J Dig Dis. 2013;14(12):654-661. doi:10.1111/1751-2980.12098

10.       Florance BM, Frin G, Dainese R, et al. Osteopathy improves the severity of irritable bowel syndrome: A pilot randomized sham-controlled study. Eur J Gastroenterol Hepatol. 2012;24(8):944-949. doi:10.1097/MEG.0b013e3283543eb7

11.       Hundscheid HWC, Pepels MJAE, Engels LGJB, Loffeld RJLF. Treatment of irritable bowel syndrome with osteopathy: Results of a randomized controlled pilot study. J Gastroenterol Hepatol. 2007;22(9):1394-1398. doi:10.1111/j.1440-1746.2006.04741.x

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