Visceral pattern of the stomach. How can a functional problem manifest ?
- rehathink
- 4. maijs
- Lasīts 8 min
Autor: Mgr. Lukaš Kasala, physiotherapist, RehaThink instructor
Functional stomach disorders are very common. In practice, I encounter them several times a week, although the patient may not come to me with a stomachache, reflux, dyspepsia, an unpleasant feeling in the epigastrium, or a problem eating a whole lunch. A functional stomach disorder may only manifest itself in changes in the musculoskeletal system, which may or may not be painful. We call them reflex changes. Paradoxically, the patient may not have any pain, but from the posture and visceral pattern that we find during palpation and aspect examination, we will detect a stomach problem even before the patient starts to feel any pain. In this article, we will describe typical and atypical manifestations, but also signs that are associated with a stomach disorder in the musculoskeletal system or soft tissues based on the viscero-somatic reflex, i.e. an organ disorder has caused changes in the musculoskeletal system.
The stomach is innervated parasympathetically and sympathetically. Sympathetic fibers for the stomach originate from segments Th4-8. In gastric disorders, we find reflex changes in this area, with a maximum in Th 4-6. We find sensitive periosteum on the spinous process, which is painful to the touch on palpation. The most painful periosteum is on the process that is "fallen ventrally", the spinous process of the given segment is palpated more ventrally compared to the spinous process above or below. In these segments, we also find a change in joint mobility, joint blockades of the dorsal segments. A segment fallen ventrally indicates an joint blockade to the extension of the given segment. Other blockades are found sternocostally on the 5th-7th rib on the left.
Since the stomach is parasympathetically innervated by the vagus nerve, which comes out of the skull from the jugular foramen, we also find blockade of the AO joint.
The diaphragm, which is above the stomach and to which the stomach attaches, is innervated by the phrenic nerve, which originates from the C3-5 segments, we also find a blockade in this segment and a trigger point in the diaphragm on the left. In general, we can say that a C3-4 blockade irritates the phrenic nerve, creates a trigger point in the diaphragm and changes the biomechanics of breathing.
There are several trigger points that we find in stomach disorders or GERD. Since the stomach is located primarily on the left, the localization of trigger points is dominantly on the left side. A typical trigger point is in the upper left part of the m.rectus abdominis, m.obliquus externus, the associated painful attachment of the rectus abdomis and overall hypertonia of the left upper abdominal quadrant. Another trigger point, together with the periosteal point, is found in the 5th-6th and 6th-7th intercostal spaces on the ventral side of the rib cage near the costosternal articulation.
The picture of reflex changes also includes a change in the respiratory stereotype to the upper (load) type of breathing. This type of breathing overloads the auxiliary (auxiliary) inspiratory muscles, which become hypertonic, trigger points are formed in them and subsequently joint blockades of the upper thoracic and cervical spine. The upper type of breathing is generally found in organ disorders. This is because, in the case of a structural or functional disorder of the organ, the tension of the coverings, fascia, the suspension apparatus of the organ, but also the organ itself, changes, the receptivity and sensitivity of the receptors in general. The sensitivity threshold of nociceptors decreases, which, when irritated, send a nociceptive signal through sensory fibers to the spinal cord. During diaphragmatic (abdominal) breathing, the aforementioned structures are stretched, the position of the organ changes, and thus the receptors are irritated. To prevent this, the brain changes the type of breathing to the upper. The change in breathing and tissue tension leads to reduced mobility of the organ. The body wants to ensure that the organ is protected and healed. It is the same approach as, for example, with a shoulder problem, when the disorder also reduces mobility.
Following the upper type of breathing, we find trigger points in other muscles, namely pectoralis major, pectoralis minor, diaphragm, scalene, SCM. These trigger points are located ventrally. Therefore, if we find the upper type of breathing in any patient with any problem during the examination, we always have to examine the abdominal cavity.
The visceral pattern is not only present on the ventral side, but also on the dorsal side. Trigger points are found in the trapezius pars ascendens, rhomboidei and infraspinatus muscles on the left side.
The disorder of each organ is presented by the formation of so-called Chapman points. For the stomach, Chapman points are found in the 5th-6th and 6th-7th intercostal spaces ventrally on the left, dorsally between Th5-6 and Th6-7 on the left.
If there is a disorder of any organ, there is a change in the tension of the fascial complex, which osteopaths call the central tendon. The central tendon is a fascial string that runs through the body from the base of the skull to the pelvic floor, is located in front of the spine in the superficial and deeper fascial layers of the body, and works together as a functional unit that connects the skull to the pelvic floor. If there is a dysfunction in the body that should be protected in the global chain of protection, the fascia contracts towards the site of the dysfunction with the greatest tension. Increased tension around the organ acts as a protection, reducing the mobility and motility of the organ. Since the fascial organ envelopes (peritoneum, pericardium, pleura) are integrated into this system, a compensatory increase in tension is also found in this fascia. When circulation passes through the fascia, increased fascial tension disrupts the circulation of the organ. Specifically, this means that pathological tension in the central tendon disrupts circulation in organs and can be a trigger point for impaired organ function or can lead to a reduced ability of the organ to compensate for biological, physical or chemical noxious stimuli. Thus, increased tension in the central tendon, increased tension in the fascia, reduced circulation, reduced immunity, reduced organ resistance.
When the "central tendon" is shortened, posture changes occur. In patients, we find a forward head posture and a kyphotic position of the C-Th transition. In some patients, the kyphotic position may be only of the C-Th transition, in others, there may be increased kyphosis of the entire Th spine. These patients have a picture of upper crossed syndrome or sternosymphyseal syndrome. During functional examination, we find blockages of the C-Th transition (and associated blockade of the 1st rib ventrally) and the upper thoracic spine in these patients. If the functional disorder lasts for a longer period of time, there is a change in the blood supply of deep structures in the given area, which is manifested by whisker veins in the area of the C-Th transition.
Joint blockade of the C-Th transition has a significant impact on the shoulder girdle and upper limbs. There is a change in mobility, blood supply and pain radiating to the upper limb. Ultimately, a patient may only visit us with elbow pain.
In chronic stomach problems, we find spider veins around the stomach. In this area, we find a "bow" that looks like it copies the upper part of the stomach, or rather the edge of the diaphragm. This tells us that in this area there is chronically increased tension of the soft tissues and diaphragm, circulation in the tissues is impaired and the blood supply "looks for another way". We can also see something similar in other organs, e.g. the liver.
Each organ has its own reference zone, where the pathology of a particular organ manifests itself. They are called Head zones. In these zones, reflex vegetative changes occur such as changes in sweating, changes in skin blood supply and dermographism, changes in skin and subcutaneous temperature, changes in muscle tension, the formation of trigger points, fascia mobility, sensitivity to touch, etc.
Where does stomach pain occur? There are 3 most common areas. Ventrally in the xiphoid and left epigastric region, left shoulder girdle and between the shoulder blades. If the patient tells you that he/she has pain between the shoulder blades, take him/her by the word and ask: And does it hurt exactly between the shoulder blades, that is, on the spine, or between the spine or the shoulder blade? If he/she answers between the shoulder blade and the spine, the pain comes from a trigger point in the muscles: scalenii, latissimus dorsi, multifidi, rhomboidei, serratus posterior superior, infraspinatus, levator scapulae or middle trapezius.
However, if the answer is exactly between the shoulder blades, on the spine, it indicates the head zone of the stomach. In this case, it is necessary to palpate the stomach area and the reflex points where the stomach disorder manifests itself: Th4-6, Chapman points, trigger points.
But the things is, some of the trigger points mentioned above can be active because of the stomach visceral pattern.
However, a patient with a stomach disorder may only have a chronic headache. During the examination, we find joints blockades in the upper cervical spine along with trigger points in the short extensors of the neck, semispinalis capitis, splenius capitis, sternocleidomastoideus and digastricus muscles. Disorders in the above structures present as pain in the head area. These changes are caused by a change in posture and shortening of the central tendon.
So why does the patient not have to feel any pain, even though the examination reveals functional disorders, i.e. changes in muscle tension, soft tissue, joint blockages, changes in blood circulation, posture, i.e. the visceral pattern? It is important to realize that the body has a huge ability to compensate. It can adapt to a given situation by changing posture, changing tissue tension or biochemistry. For a long time, the patient may not have any major or serious problems, only minor ones such as occasional reflux, dyspepsia, abdominal bloating, reduced appetite, constipation, pain in the thoracic or cervical spine, shoulder, stiffness of the torso, etc. Often, such a patient ends up in a physiotherapist's clinic by accident or for something completely different. The physiotherapist, after examining and revealing the visceral pattern, should focus more closely on the medical history and functional examination, detect the first small signs mentioned above, and inform the patient that the stomach "has a problem". Because then the first manifestation may be, for example, a stomach ulcer.
Fortunately, most patients come to us in time and we can treat functional stomach disorders very effectively. Properly conducted physiotherapy has an effectiveness of between 80-90%.
You can learn a comprehensive look at organs, as presented in this article, and how to work with organs in the our very popular Visceral Manipulation course.
Sources:
Hebgen, E. (2011) Visceral Manipulation in Osteopathy. Edition Thieme Medical
Petr Bitnar - Changes in the activity of the upper and lower esophageal sphincter during changes in respiratory and postural conditions, dissertation, Prague 2022
Rehathink course Comprehensive approach to shoulder girdle therapy
RehaThink course Visceral manipulation - instructor Mgr. Lukáš Kasala
TRAVELL, Janet G. a SIMONS, Lois S., DONNELLY, Joseph M.; FERNÁNDEZ DE LAS PEÑAS, César; FINNEGAN, Michelle a FREEMAN, Jennifer L. (ed.). Travell, Simons and Simons' myofascial pain and dysfunction: the trigger point manual. Third edition. Philadelphia: Wolters Kluwer Health, [2019]. ISBN 978-0-7817-5560-3.
Physiology, Chapman’s Points - StatPearls Publishing; 2025,
ZDRHOVA, Lucie; BITNAR, Petr; BALIHAR, Karel; KOLAR, Pavel; MADLE, Katerina et al. Breathing Exercises in Gastroesophageal Reflux Disease: A Systematic Review. Available in: https://doi.org/10.1007/s00455-022-10494-6.
KOLÁŘ, Pavel. Rehabilitation in clinical practise. Second edition. Prague, Rehabilitation prague school, [2020]. Available: https://www.rehathink.com/tirdznieciba
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