As an experienced physical therapist, I have become more and more convinced about the importance of treating abdominal surgeries with physical therapy, similar to offering physical therapy after a knee, or shoulder surgery. During the first few years of my practice, I would occasionally see a client who had a sudden onset of low back pain after an abdominal surgery. These individuals did not often make the link between their back pain and abdominal surgery. However, the abdomen is the front of the back, and there are numerous direct and indirect links between our abdominal cavity, pelvis, lumbar, and thoracic spines. Many of these links are through ligamentous and other fascial connections to the pelvis, spine, diaphragm, and rib cage. It’s true, our abdominal and pelvic organs have ligaments just like shoulder and knee!
There is limited research in this area, but a recent study performed at Hacettepe University in Turkey studied if manual therapy applied to these “visceral fascial limitations” could help individuals with nonspecific low back pain in conjunction with other more traditional physical therapy type interventions (the article is sourced below). They compared the outcome of two groups- one who received visceral treatment in addition to other interventions, and one who did not. While the two groups showed improvement, they found the group that received visceral treatment showed greater improvement.
While more research needs to be done to make any scientific statement about visceral manipulation, I also believe in the truth of my clinical experience. Since I have been working at Evolution, I have treated many women for low back pain who have a recent or past history of cesarean birth.  Some women come to physical therapy with abdominal pain immediately after the labor and delivery process. Others have come many years later, and have developed low back or pelvic pain symptoms which I feel is directly or indirectly related to visceral fascial limitations after their cesarean birth. I would like to present three brief case studies of women who have had treatment after cesarean birth.  Permission was received from each patient for publication of their stories.
My first case study is a female who had a cesarean birth 27 years ago, and history of tailbone fracture when she was in her 20s. She presented with a symptoms of tailbone pain which was worse with sitting and standing, and radiating pain in the right leg, worsened with standing, as well as history of pelvic pain.  She did not see improvement with a round of physical therapy treatment for her pelvic pain.  She was only able to stand or sit 50{2bd103ee3922297dd26721aa2b4723f52b7c1e46e10078a5bb1f7638d0cbcf8c} of what she felt was her normal function.  Tailbone pain was ranging from 2/10-5/10.  I identified the tailbone pain, and radiating symptoms into the leg as being caused by restriction placed on the sacral nerve roots (called the sacral plexus) as they travel from the spine down the back of the pelvis, before they become the sciatic nerve, and among other interventions, provided treatment to this area.  After 12 treatments over the period of 5 months, she improved dramatically, so that she was able to sit and stand at 90{2bd103ee3922297dd26721aa2b4723f52b7c1e46e10078a5bb1f7638d0cbcf8c} capacity and had pain ranging from 0/10-2/10 in the coccyx, and 0/10 leg pain.  One year later, she has maintained the gains she made with physical therapy.
My second case study is a female  who presented two and a half years after her cesarean birth.  Her complaint was an insidious onset of abdominal and pelvic pain, which was worse with walking, running and working out.  She had been unable to work out, including walking for exercise, for about 1 month due to the pain.  She reported “ache”, “heaviness” and “stabbing pain” in the abdomen as well as bloating and heaviness in the abdomen.  She also reported pelvic pain.  I found restrictions throughout the layers of the abdominal wall, as well in the deeper ligaments of the pelvic organs, and provided treatment to improve mobility of those structures. Her treatment is ongoing, but after 3 physical therapy sessions she reports a significant improvement in her pain with daily activities, although she has yet to return to her full level of activity.
My third case study is a female  who presented to therapy fourteen weeks after her cesarean birth.  She reported lower abdominal pain first thing in the morning, mostly upon sitting up to get out of bed, but also with running, going to spin class, and sitting.  She was concerned about returning to Pilates classes.  After 3 physical therapy sessions focused scar tissue and visceral manipulation, she was pain free and had returned to Pilates classes.  
I hope the above case studies illustrate the potential impact of a cesarean birth on the present and future function of a woman’s pelvis and spine.  I do not think it is a coincidence that a longer course of treatment was needed for those women who were years away from their surgery.  Individuals that come to physical therapy are a self selected group who have painful symptoms which lead them to seek treatment.  I do not mean to say everyone who has had a cesarean birth is in significant danger of developing low back or pelvic pain, or that those of you who have had a cesarean birth are somehow damaged because of it.  Nothing could be further from the truth.  However, I also believe that many women might be dealing with pain after a cesarean birth and assume that nothing can be done, when indeed the opposite is true.  The three women in this case study agreed for me to use their information in the hopes that others might hear about the important work we are doing at Evolution to address this specific issue.  I hope this post helps reach others who might need this kind of help.  
This post was written by Michelle Downing DPT, OCS, CFMT, RYT a physical therapist and yoga instructor at Evolution PT and Yoga.  Dr. Downing has advanced training in pelvic floor therapy, functional manual therapy and visceral manipulation.
Seval Tamer, Müzeyyen Öz and Özlem Ülger
The effect of visceral osteopathic manual therapy applications on pain, quality of life
and function in patients with chronic nonspecific low back pain. Journal of Back and Musculoskeletal Rehabilitation 30 (2017) 419–425 419
Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey

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