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FASCIA SCIENCE AND CLINICAL APPLICATIONS e POST-SURGICAL VISCERAL MASSAGE:

ANIMAL STUDY

Visceral massage reduces postoperative ileus

in a rat model
Susan L. Chapelle, RMT a, Geoffrey M. Bove, DC, PhD b,*
a
b

Squamish Therapeutics, 108-41105 Tantalus Rd., Squamish, BC, Canada

University of New England, Department of Biomedical Sciences, 11 Hills Beach Rd., Biddeford, ME 04005, USA

Received 9 March 2012; received in revised form 2 May 2012; accepted 23 May 2012

KEYWORDS
Intestinal
obstruction;
Infertility;
Postoperative
complications

Summary Objective: Abdominal surgery invariably causes a temporary reduction of normal

intestinal motility, called postoperative ileus. Postoperative ileus extends hospital stays,
increases the costs of hospitalization, and may contribute to the formation of postoperative
adhesions. We designed experiments to determine if visceral massage affects postoperative
ileus in a rat model.
Material and methods: Forty female Long Evans rats were assigned to 4 groups in a 2
(surgery)
2 (treatment) factorial design. Twenty rats were subjected to a small intestinal
manipulation designed to emulate running of the bowel. Transabdominal massage was performed upon 10 operated and 10 control rats in the first 12 h following surgery. Ileus was assayed after 24 h using fecal pellet discharge and gastrointestinal transit. Intraperitoneal
inflammation was assayed using total intraperitoneal protein and inflammatory cell concentrations.
Results: The surgery consistently caused ileus. Compared to the operated group with no treatment, the operated with treatment group showed increased gastrointestinal transit and
reduced time to first fecal pellet discharge. Similar group comparisons revealed that the treatment decreased total intraperitoneal protein and numbers of intraperitoneal inflammatory
cells.
Conclusions: In this rat model, visceral massage reduced experimental postoperative ileus.
The data suggest that the effect was through the attenuation of inflammation. A similar study
could be designed and performed in a hospital setting to assess the potential role of visceral
massage as part of the integrated care for postoperative ileus.
2012 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: 1 207 602 2921, 1 207 294 7317, 1 207 590 8949; fax: 1 207 602 5931.
E-mail address: gbove@une.edu (G.M. Bove).
1360-8592/$ - see front matter 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2012.05.004

FASCIA SCIENCE AND CLINICAL APPLICATIONS e POST-SURGICAL VISCERAL MASSAGE: ANIMAL STUDY

Journal of Bodywork & Movement Therapies (2013) 17, 83e88

FASCIA SCIENCE AND CLINICAL APPLICATIONS e POST-SURGICAL VISCERAL MASSAGE: ANIMAL STUDY

84

Introduction
Abdominal surgery invariably causes a temporary reduction
of intestinal motility, called ileus. Ileus is characterized by
a lack of coordinated intestinal activity and a substantial
overall reduction in peristalsis, and is an important cause of
postoperative discomfort and prolonged hospital stays
(Bauer, 2010; Mattei and Rombeau, 2006; Person and
Wexner, 2006). The increased number of days spent in the
hospital places a huge financial burden on health care
delivery systems (estimated to be $0.75 billion per year in
the United States for colectomies alone) (Doorly and
Senagore, 2012; Iyer et al., 2009; Johnson and Walsh,
2009; Senagore, 2010). There remains no fully effective
treatment for ileus (Bauer, 2010; Engel et al., 2010; Mattei
and Rombeau, 2006; Zeinali et al., 2009), although recent
advances have been made by combining ileus-limiting
approaches such as laparoscopic surgery, epidural anesthesia, pain management, and new drugs (Johnson and
Walsh, 2009; Kraft, 2009; Person and Wexner, 2006).
The concept that visceral or abdominal massage and
mobilization could attenuate ileus was first published more
than a century ago (Coe, 1899; Haberlin, 1899), but the
topic received little further consideration. More recently,
abdominal massage using a mechanical device was shown to
reduce ileus (Le Blanc-Louvry et al., 2002). A systematic
records review supported that osteopathic manipulative
treatment reduced ileus (Crow and Gorodinsky, 2009),
however, there were few details related to the treatment
methods, and it cannot be gleaned whether the abdomen
was directly treated. Other supportive data include that
visceral massage is effective for constipation (Ernst, 1999;
Klauser et al., 1992; Lamas et al., 2009), and that it
increases bowel function in spinal cord injured patients
(Ayas et al., 2006; Liu et al., 2005).
We recently described the effects of visceral massage on
postoperative adhesions in a rat model (Bove and Chapelle,
2012). During these experiments, we observed that the
rats, who were fully accommodated to handling, consistently defecated during or soon after visceral massage,
suggesting a prokinetic effect on the intestines. We
designed the current study to determine if visceral massage
would decrease ileus in a rodent model of postoperative
ileus. Because inflammation has been shown to be the key
to postoperative ileus (Bauer, 2010; Mattei and Rombeau,
2006; Tracey, 2002; Wehner et al., 2007), we also performed assays of intraperitoneal inflammation to determine possible associations with visceral massage.

Materials and methods

Animals and surgery
All procedures were consistent with the Guide for the Care
and Use of Laboratory Animals (National Research Council,
USA), and were approved by the University of New England
Institutional Animal Care and Use Committee. Forty adult,
female Long Evans rats were obtained from Charles River
Laboratories (USA), and weighed 225 g when used. Rats in
the surgery group were anesthetized with isoflurane in pure
oxygen (4% for induction, 2% for maintenance), and their

S.L. Chapelle, G.M. Bove

abdominal walls were shaved and scrubbed with betadine
and 70% isopropanol. The surgical field was draped and
surrounded with sterile saline-soaked gauze. A 3 cm
vertical incision was made just lateral to the linea alba. The
small intestine from the distal duodenum to the distal ileum
was gently exteriorized using gloved fingers. Starting with
the distal duodenum and moving distally, the entire small
intestine was gently rolled between the thumbs and forefingers, enough to compress and move the luminal
contents, but not enough to fully occlude the lumen or
cause bleeding. This process took 5 min. The small intestine
was then covered with saline-soaked gauze, left for 10 min,
and then returned to the abdominal cavity. The incision was
sutured in layers (4-0 Monoweb; Webster Veterinary, USA).
The rats were injected subcutaneously with morphine
sulphate (0.3 mg/kg s.c.), and wrapped in a soft pad for
recovery. To control for the effects of the morphine, all rats
not subjected to surgery were also injected with morphine
sulphate (0.3 mg/kg s.c.) at the onset of the experiment.
The rats not subjected to the surgery were not anesthetized, because inhaled anesthetic agents do not interfere with gastrointestinal function after their cessation
(Condon et al., 1987).

Experimental design
Ten rats were randomly assigned to each of 4 experimental
groups in a 2
2 design: Surgery/Treatment (ST), Surgery/
No Treatment (SNT), No Surgery/Treatment (NST), and No
Surgery/No Treatment (NSNT). The start of the experiment
was defined as the time when the rats were injected with
morphine. Rats were placed in separate enclosures for the
duration of the experiment to facilitate fecal pellet counts,
with free access to food and water. The endpoint for all rats
was 24 h after the start of the experiment.

Treatment
Rats in the treated groups (ST and NST) were removed from
the cage and turned supine. One massage therapist (SLC)
performed all the treatments, which standardized the
procedures. SLC is a Registered Massage Therapist trained
in Canada, with 18 years experience, who has focused much
of her practice on postoperative care. The massage treatments consisted of gentle mobilization for 1 min. Treatments started with a side to side motion using the index
finger and thumb placed lateral to the descending and
ascending colon, respectively, for approximately 15 s. After
mobilization, treatment continued by massaging in small
circles with the index finger over the ascending, transverse,
and finishing with the descending colon in a clockwise
pattern, starting from the bottom right abdominal quadrant
to the bottom left abdominal quadrant, for approximately
45 s. These maneuvers were intended to mobilize the small
and large intestines and encourage metabolite exchange
within the intraperitoneal fluid. Treatments were performed at 15-min intervals for the first hour (4 treatments),
at 30-min intervals for the next 2 h (4 treatments) and
every 2 h thereafter until 12 h postoperatively (4 treatments). Rats in the non-treated groups (SNT and NSNT)
were picked up and handled for approximately 1 min to

control for possible non-specific effects of the treatment,

on the same schedule that the rats in the other groups were
treated.

Outcome measurements
Outcome measurements included time to first fecal pellet
discharge; fecal pellet counts at 6, 12, and 24 h; gastrointestinal transit time; intraperitoneal fluid total protein
concentration; and numbers of intraperitoneal inflammatory
cells. After counting fecal pellets at 24 h, rats were lightly
anesthetized and gavaged with w1 ml of a slurry of 10%
charcoal and 1% arabic acid in water, to measure gastrointestinal transit time. After 30 min, rats were anesthetized
with isoflurane, followed by replacement of the gases with
pure CO2 to cause death. A small incision was made in the
proximal abdominal wall, and 2 ml sterile phosphate buffered saline was injected into the peritoneal cavity. The
abdominal contents were gently mobilized for 10 s, and the
incision widened. Lavage fluid was collected with a gavage
needle, and placed in vacutainers coated with EDTA. The
small intestine was removed en bloc from the pylorus to the
ileocecal valve, and carefully placed along a tape measure.
The length from the pylorus to the ileocecal valve was
measured and recorded. The distance from pylorus to the
most distal visible charcoal was also measured, and used to
calculate the gastrointestinal transit over 30 min (expressed
as percentage of total small intestine length). The collected
lavage fluid was then centrifuged, and the supernatant
aspirated and used to assay total protein using a BCA protein
assay (Pierce-Thermo Scientific, USA). The pellet containing
cells was washed and suspended in phosphate buffered
saline, and the numbers of cells were quantified using
a standard hemocytometer. Trypan blue was added to
differentiate live from dead cells.

85
by Tukeys HSD post-hoc tests when appropriate. Time to
first fecal pellet discharge was measured in minutes and
reported in hours. Fecal pellet discharge during the first
15 min following anesthesia removal, or induced by the
morphine injection procedure, was disregarded. If there
was no discharge after 12 h, it was recorded as 12 h (n Z 5).
Alpha levels were set to 0.05.

Results
Although all rats in the treatment and non-treatment
groups were initially given a low dose of morphine to
simulate postoperative ileus scenarios, no further drug or
restraint was necessary. None of the rats struggled, vocalized, or bit during any treatment, consistent with our
previous experiences (Bove and Chapelle, 2012). The
therapist reported that the abdomens of the rats that had
undergone surgery had a deeper resistance to movement
than the unoperated rats.

Ileus model
Surgery significantly reduced gastrointestinal transit [main
effect of surgery; F (1, 33) Z 12.31, p < 0.001; Figure 1A],
and reduced fecal pellet discharge [main effect of surgery;
F (1, 34) Z 5.36; p < 0.05; Figure 1B]. There was no effect
of surgery on the time to first fecal pellet discharge [F (1,
33) Z 0.11; p > 0.10]. These data support that the surgical
procedure consistently induced ileus. To determine if ileus
remained after 24 h, the fecal pellet discharge of another
group of 10 normal rats was observed (these data were not
included in the statistical analysis). The comparison supported the presence of residual ileus after 24 h in all 4
experimental groups (Figure 1B). This was likely to have
been caused by the morphine.

Data analysis

Effect of treatment on gastrointestinal function

All data other than cumulative fecal pellet discharge were

analyzed using 2 (surgery)
2 (visceral massage) ANOVAs
(JMP 8.0 for Macintosh; USA). Cumulative fecal pellet
discharge data were analyzed using a multivariate ANOVA
(surgery, visceral massage, time). Analyses were followed

There was a main effect of visceral massage on gastrointestinal transit [F (1, 33) Z 12.56, p < 0.001, Figure 1A].
Post-hoc tests supported that visceral massage led to
significant increases in small intestine transit in the
surgery and treatment (ST) group compared to the surgery

Figure 1 Effect of visceral massage on postoperative ileus. A. Visceral massage significantly increased gastrointestinal transit.
NST Z no surgery, treatment; NSNT Z no surgery, no treatment; ST Z surgery, treatment; SNT Z surgery, no treatment. B.
Cumulative fecal pellet discharge was greater in the massaged groups (ST and NST). Fecal pellet discharge for a group of 10 normal
rats (NORM), is depicted to demonstrate the probable contribution of morphine to ileus in all experimental groups. C. Visceral
massage significantly reduced the time to first fecal pellet discharge. All noted differences were statistically significant by ANOVA
(see text for details). Data are presented as means  SEM.

FASCIA SCIENCE AND CLINICAL APPLICATIONS e POST-SURGICAL VISCERAL MASSAGE: ANIMAL STUDY

Visceral massage for postoperative ileus

FASCIA SCIENCE AND CLINICAL APPLICATIONS e POST-SURGICAL VISCERAL MASSAGE: ANIMAL STUDY

86

S.L. Chapelle, G.M. Bove

with no treatment (SNT) group (Tukeys HSD, p < 0.05,

Figure 1A). Although there was no main effect of treatment on cumulative fecal pellet discharge, there were
significant interactions between time and surgery (MANOVA, p < 0.005, Figure 1B), time and treatment
(p < 0.01), and time, surgery, and treatment (p < 0.05),
indicating that over time there was increased discharge
due to the treatment. Treatment reduced time to first
fecal pellet discharge [main effect; F (1, 33) Z 11.36:
p < 0.01; Figure 1C], which was also independent of
whether surgery had been performed (there was no
interaction between treatment and surgery; F (1,
33) Z 1.24; p > 0.10). These data support that visceral
massage significantly increased gastrointestinal function,
and reduced postoperative ileus.

Effect of treatment on total intraperitoneal protein

and leukocyte concentrations
To test the possibility that visceral massage may reduce
ileus through a suppressing effect on inflammation, we
performed peritoneal lavage on all rats just following
death, and assayed the concentrations of total protein
and numbers of inflammatory cells (leukocytes). There
was a main effect of surgery on total intraperitoneal
protein [F (1, 36) Z 49.08; p < 0.001; Table 1 and
Figure 2A]. There was no main effect of treatment [F (1,
36) Z 0.01, p > 0.10] but there was a significant interaction between the surgery and treatment [F (1,
36) Z 7.19; p < 0.01]. This highlighted that the effect of
the treatment differed depending on whether surgery had
been performed or not performed. Post-hoc tests were not
significant. The surgical procedure caused a large increase
in the number of inflammatory cells compared to normal
animals [main effect; F (1, 36) Z 5.40; p < 0.05; Table 1
and Figure 2B]. Although there was no main effect of the
treatment [F (1, 36) Z 0.87; p > 0.10], there was an
interaction between the surgery and treatment [F (1,
36) Z 10.93; p < 0.005)], supporting that that the effect
of the treatment differed in the surgical versus nonsurgical groups. Post-hoc tests supported that visceral
massage led to a significant reduction in the number of
intraperitoneal cells in the ST group compared to the SNT
group (Tukeys HSD, p < 0.05).

Table 1 Effect of abdominal massage on total intraperitoneal protein concentration and leukocyte numbers.
Group

Protein (mg/ml)

Cells/ml

NSNT
NST
SNT
ST

3.55
5.78
11.82
9.47

917
5673
12,192
3708

(0.63)
(0.47)
(1.13)
(1.01)

(249)
(2293)
(3190)
(736)

All data are presented as mean (SEM). NSNT Z No Surgery, No

Treatment; NST Z No Surgery, Treatment; SNT Z Surgery, No
Treatment; ST Z Surgery; Treatment. Protein concentration
and cells/ml data are graphically depicted in Figure 2. See text
for details on Statistical analysis.

Discussion
Our results indicated that visceral massage attenuated
postoperative ileus in this rat model. Massage significantly
increased gastrointestinal transit, augmented cumulative
fecal pellet discharge, and shortened the time to first fecal
pellet discharge. The comparison to a normal group of rats
suggested that ileus was maintained for 24 h. Because of
the chosen endpoint, it is not known whether the treatment
affected the time to complete ileus resolution; this could
be addressed in a future study.
We considered that the effects of massage on postoperative ileus could be simply mechanical; in other words,
did the treatment simply push the intestinal contents
along? This is very unlikely: directional propulsion of the
intestinal contents requires peristaltic waves, which are
highly coordinated. Mechanical effects of massage would
not likely be unidirectional, especially in the small intestine, where the contents are more liquid than solid and
where we measured effects. Furthermore, the improvement 12 h past the time of treatment cessation indicated
a lasting stimulatory effect of massage on postoperative
ileus, arguing against simple mechanical effects. However,
the possibility that the massage triggered effective peristaltic activity of the large intestine is supported by a case
report of a patient with spastic paralysis of the bowel,
where self-administered abdominal massage evoked transient rectal peristaltic waves (Liu et al., 2005).
Intraperitoneal inflammation is currently held to be key
to prolonged postoperative ileus (Bauer, 2010; Mattei and
Rombeau, 2006; Wehner et al., 2007). Increased parasympathetic activity decreases intraperitoneal inflammation by inhibitory actions that have been collectively called
the inflammatory reflex (for reviews, see Tracey, 2002,
2007, and Van Der Zanden et al., 2009), and has been shown
to ameliorate postoperative ileus (de Jonge et al., 2005;
The et al., 2007). We show that intraperitoneal protein
concentration and inflammatory cell numbers were
reduced by visceral massage, indicating a dilution of the
inflammatory milieu. Although the mechanisms of visceral
massages effects on intraperitoneal inflammation are
unknown, it is proposed that the reduction we observed
was reflex-mediated, through the vagus nerve. Inflammation sensitizes sensory receptors and axons to mechanical
stimuli (Beyak and Vanner, 2005; Bove et al., 2003; Habler
et al., 1988; Koda and Mizumura, 2002), but ileus reduces
mechanical stimuli to the gut sensory system. It is likely
that the mechanical stimuli of the massage increased
afferent input in this sensitized system. Reflexively,
increased afferent drive in this pathway will result in
increased parasympathetic activity to the affected area
(reviewed by Tracey, 2002). Interestingly, both total
protein and leukocyte numbers increased in rats not subjected to surgery, suggesting that under normal conditions,
the treatment is somewhat proinflammatory. This is
consistent with the fact that in the absence of pathology,
intraperitoneal receptors are relatively insensitive, and
thus would not be expected to initiate a substantial
reflexive response from the parasympathetic system. A
future study could be designed to investigate the role of
vagal reflexes in the effects of massage on ileus.

87

Figure 2 Effect of visceral massage on intraperitoneal inflammation. In rats with ileus, visceral massage decreased total
intraperitoneal protein (A) and the number of intraperitoneal leukocytes (B). In normal rats, visceral massage increased both
measures. Both effects were statistically significant by ANOVA (see text for details). Data are presented as means  SEM.

It has also been proposed that postoperative adhesions,

a side effect of most abdominal surgery (Parker et al.,
2007; Stanciu and Menzies, 2007), are fostered by ileus
(Fu et al., 2005; Springall and Spitz, 1989). We have
previously shown in a rat model that a visceral massage
immediately following surgery interfered with the formation of postoperative adhesions (Bove and Chapelle, 2012).
It follows that a reduction in postoperative ileus may limit
adhesion formation by promoting normal peristaltic movements, although these beneficial effects could also be due
to passive motion of the intestines while normal peristaltic
motions recover.
Assumptions could be made that in humans, postoperative abdominal pain and sensitivity will preclude such
treatment; this assumption was also made regarding
treating the rats prior to performing these experiments.
Our therapists experience with humans, and now with rats,
support that visceral massage is welcomed. It has also been
suggested that such mechanical stimulation could disrupt
intestinal surgical repairs. This notion has no experimental
support, but our preliminary observations with an experimental endeend colonic anastomosis in rat support that
vigorous visceral massage does not disrupt even very delicate sutures. This should be addressed in a future study.
With appropriate precautions, including clear communication with the physician regarding the procedures performed, care to prevent infections, and maintaining
constant feedback from the conscious patient, gentle
mobilization of the abdominal cavity immediately postoperatively should be safe.
The methods used in this study were scaled e down
versions of methods currently in routine use with humans,
based on our therapists best estimation and broad experience. Visceral massage, for constipation (Ernst, 1999;
Lamas et al., 2010) and other complaints, is a standard
part of massage therapy education in North America
(Kellogg, 1895; Salvo, 2009), and massage therapy is
available at a growing number of integrated medical
health care facilities. The primary outcome measurements
of ileus in humans are non-invasive (increased bowel
sounds, passing flatus) and are already monitored. There is
therefore no reason why a prospective study similar to this
study cannot be performed in a hospital setting to determine if postoperative visceral massage could complement
existing treatments for ileus. It is hoped that this report
will catalyze such a study, which has the potential to

reduce hospital stays, improve overall outcomes for

abdominal and pelvic surgical patients, and reduce
hospitalization costs.

Acknowledgments
Disclosures: Financial assistance for this project was
provided in part through a seed grant from the Massage
Therapy Association of British Columbia to GMB and SLC.
The authors acknowledge the generous assistance of
Dr. Michael Burman, Dr. Ling Cao, and Ms. Jennifer Malon.

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