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Physiotherapeutic interventions in Glenard's
Disease (Enteroptosis) – a case report
Magdalena Marta Mikołajczyk-Mańka1, Monika Kokot-Rauch1
Correspondence to:
DOI:
Received: Reviewed: Accepted:
Abstract
Background: Glenard's disease, also known as visceroptosis or gas-
troptosis, is characterized by the excessively low positioning of in-
ternal organs within the abdominal cavity. This rare condition is
accompanied by dyspeptic symptoms, persistent fatigue, and nerv-
ousness. There are few scientic reports on conservative treat-
ment, including physiotherapy management for this condition.
Aims: The aim of this study was to present the physiotherapeu-
tic management of a 9-year-old female patient with visceroptosis,
who presented with weakened abdominal muscles and chronic vis-
ceral pain.
Case report: This paper describes the physiotherapeutic interven-
tion for a patient with lower abdominal discomfort. The goal of
physiotherapy was to strengthen the muscular corset and attempt
to reduce pain symptoms. Both subjective and objective assess-
ments were conducted. Treatment included manual therapy of the
lumbopelvic complex and strengthening exercises for the pelvic
oor, abdominal, and gluteal muscles.
Summary: The result of the physiotherapy was a subjective im-
provement in the patient's health and a reduction in visceral pain.
The most effective techniques for alleviating pain symptoms were
transverse massage of the iliopsoas muscle and handstand exercis-
es. Individually tailored physiotherapy could positively impact the
child's quality of life. It is essential to thoroughly investigate the ef-
fects of various physiotherapy methods on patients with symptoms
of visceroptosis using objective research tools.
Key words
physiotherapy,
case report,
Glenard’s disease,
visceroptosis,
gastroptosis,
abdominal pain,
enteroptosis.
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Physiotherapy Review | Volume XXIX Issue 1/2025
Introduction
Studies conducted in various countries show that
abdominal pain is common among the pediatric
population [1]. Persistent abdominal pain (PAP) is
considered to be continuous or intermittent dis-
comfort lasting for at least 6 months and not re-
sponding to conventional treatment. The causes of
these issues can be either organic or functional.
Organic changes have clearly identied anatomi-
cal, physiological, or metabolic abnormalities [2].
Epidemiological data indicate that the preva-
lence of PAP is 22.9 per 1000 individuals (regard-
less of age, ethnicity, or geographic region) [3]. A
20-week observation of children in the USA re-
vealed that 32% of school-aged children reported
symptoms weekly, and over 50% of those studied
had symptoms lasting more than 4 weeks [1]. The
diagnosis of organic disorders as a cause of PAP
occurs in 5–15.6% of the pediatric population [4].
The rare Glenard's disease is characterized by
the excessively low positioning of internal organs
within the abdominal cavity. It most commonly
involves the lowering of the stomach, kidneys, liv-
er, and intestines. The syndrome of falling organs
(enteroptosis) was rst described by the French
physician Franz Glenard in 1885 [5].
Symptoms of the disease include chronic abdom-
inal pain, nausea, vomiting, diarrhea or constipa-
tion, abdominal bloating, secondary abdominal
wall accidity, weakened muscle tone, head-
aches, a feeling of constant fatigue, and nervous-
ness. Abdominal pain in the pediatric population
is also associated with school absenteeism, low
quality of life, functional disability, and psycho-
logical distress. There are few scientic reports
on the disease itself, as well as on the treatment
of such disorders, including surgical, pharmaco-
logical, and physiotherapeutic treatments [6].
Aims
The aim of this study was to present the physio-
therapeutic management of a 9-year-old female
patient with visceroptosis, who presented with
weakened abdominal muscles and persistent pain.
Case report
The patient, a 9-year-old girl, was referred by a
physician to the physiotherapy clinic for strength-
ening of the abdominal muscle corset. In her med-
ical history, the patient reported lower abdominal
pain, with the focal point located 3 cm below the
navel and running perpendicularly to the pubic
symphysis. The pain rst appeared between the
ages of 3 and 4, usually in the morning after wak-
ing up, and persisted throughout the day. Accord-
ing to the patient, the pain was at a level of 7–8
on the NRS scale, with episodes of greater inten-
sity described as level 10. Accompanying dyspep-
tic symptoms and constipation or diarrhea were
a signicant problem, often preventing her from
participating in school activities.
According to the history provided by the child's
mother, there was no similar condition observed
in the family, and the girl had not sustained any
injuries in the past. Initially, the patient was di-
agnosed and treated for ascariasis and irritable
bowel syndrome. She was administered Metro-
nidazole, Zentel, Helicid, Debritat, and Spastcol.
However, empirical pharmacological treatment
proved ineffective. Due to persistent abdominal
pain, lack of appetite, and weight loss, further di-
agnostics were performed, including testing for
tissue transglutaminase, measuring calprotectin
levels in stool, screening stool for occult blood,
conducting the WTO test with lactose and fruc-
tose, performing gastroscopy, and carrying out
an abdominal CT scan. Laboratory and imaging
test results showed no abnormalities. A psycho-
logical consultation was also conducted.
The nal diagnosis was made based on a stand-
ing-position gastrointestinal transit study, which
revealed low positioning of the stomach and small
intestine (Figs. 1 and 2) [7]. The lack of physiolog-
ical positioning of these organs caused postpran-
dial pain [8]. Consequently, a hypoallergenic diet
was implemented for the patient.
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Physiotherapy Review | Volume XXIX Issue 1/2025
Figure 1.
Figure 2.
standing position standing position
After completing the diagnostic process, the child
was discharged from the hospital in good general
condition with a recommendation for outpatient
follow-up. The patient was under the care of the
Pain Management Clinic and the Rehabilitation
Clinic, receiving occasional treatment with Par-
acetamol, Ibuprofen, and Drotaverine, and at-
tending electrotherapy sessions using TENS cur-
rents. According to the patient, these treatments
did not result in improvement. The patient was
referred to the physiotherapy clinic for strength-
ening the muscular corset [9].
During the interview, it was established that the
most signicant problem for the child was pain
symptoms persisting while walking and standing.
These symptoms occasionally diminished when
lying in the fetal position or sitting. The patient
rated the pain symptoms as 7–8 on the NRS scale
when standing and walking. Attention was then
focused on posture in the sagittal, frontal, and
transverse planes. In the frontal plane, the as-
sessment included foot positioning (Achilles ten-
dons), knee joints (knee gap, patella), pelvic girdle
(gluteal fold), waist angles, scapulae, and shoul-
ders from both the front and back. In the sagittal
plane, bilateral assessment included the position-
ing of the head, shoulder joints, chest, abdomen,
pelvis, sacrum, and knee joints. The positioning
of the head, pelvis, and spine was also examined
in the transverse plane. The results of the subjec-
tive assessment revealed numerous asymmetries
and postural disturbances. The patient’s posture
was characterized as sway back, and an asthenic
body build was noted. The anterior-posterior spi-
nal curvatures were assessed using the Saunders
TMX 127 Inclinometer (Baseline Digital Inclinom-
eter Saunders) according to Prof. Dobosiewicz's
methodology (Fig. 3).
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Physiotherapy Review | Volume XXIX Issue 1/2025
The kyphosis angle of the thoracic spine was 10°,
and the lordosis angle of the lumbar spine was 30°
[10]. The result of the Matthias test was 3 seconds,
indicating a lack of endurance in the postural
muscles [10,11]. Elements of the Kraus-Weber test
were used to assess abdominal muscle strength.
The patient was asked to move from a supine po-
sition to a sitting position (with hands clasped
behind the neck, legs straight, and in another
variant with knees bent) [12]. During the test, the
patient reported intense, short-term pain below
the navel (the main symptom) [13]. The strength of
the gluteal muscles was assessed in two bilateral
tests: single-leg standing—positive bilateral Tren-
delenburg-Duchenne sign. The activation test of
the gluteal muscles during hip extension in the
prone position also showed an improper sequence
of muscle work [14]. Next, global ranges of spinal
mobility, including exion (Fig. 4), extension, and
hip joints (internal and external rotation), were
examined [15,16].
The exibility of the iliopsoas muscles was as-
sessed using the Thomas test in the supine po-
sition on a couch, with the lower limbs extended.
The patient performed the movement by pulling
one lower limb to the chest while keeping the
other leg straight, ensuring that the lumbar spine
and shoulder blades remained in contact with the
couch. The test was positive for both lower limbs
(Fig. 5). Additionally, palpation revealed signicant
tenderness in the iliopsoas muscle area, especial-
ly on the right side [16,17].
In summary, the functional assessment indicated
signicant weakness in the abdominal and glu-
teal muscle groups and overactive tension in the
iliopsoas muscles. It was also important to note
the temporary increase in pain symptoms that
the patient experienced daily due to increased
intra-abdominal pressure [17,18]. Following the
examination during the rst visit, manual thera-
py was performed according to the OMT Kalten-
born-Evjenth concept (transverse massage of the
iliopsoas muscle – Fig. 6), and the patient was in-
structed on how to contract the pelvic oor, glu-
teal, and abdominal muscles [13,17,19]. After the
Figure 3.
Figure 4.
Figure 5.
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Physiotherapy Review | Volume XXIX Issue 1/2025
manual therapy, a re-test with subjective assess-
ment using the NRS scale (0–10) was conducted,
and the patient reported a noticeable reduction
in pain during standing and walking. At the end
of the rst visit, a treatment plan was proposed,
consisting of a weekly therapy session (60 min-
utes) and daily self-application of post-procedural
recommendations.
The main goal of physiotherapy was to reduce the
patient’s primary pain symptoms. The specic goal
was to strengthen the abdominal and pelvic oor
muscle corset, relax the tight hamstring and iliop-
soas muscles, and identify a pain-relief position.
Each visit began with a brief interview to in-
quire about the degree of pain at different times
of the day and to verify proper execution of the
post-procedural recommendations. At the be-
ginning of treatment, during each physiothera-
py session, the patient subjectively assessed the
intensity of lower abdominal pain using the NRS
scale from 0 to 10. The test was always conducted
in a relaxed standing position and during walk-
ing under the same conditions, as the symptoms
had the same intensity in both activities. This
procedure aimed to evaluate the therapeutic ef-
fects. A re-test was performed before and after
each technique and again at the end of the visit.
During physiotherapy sessions, elements of the
OMT Kaltenborn-Evjenth concept were rst ap-
plied, including transverse massage of the iliop-
soas muscle attachments, which was performed
for 10–15 minutes (Fig. 6) [19].
After the relaxing massage of the iliopsoas mus-
cle, the patient stood up again and assessed her
pain using the NRS scale. The effect of this tech-
nique was a signicant or complete reduction in
focal lower abdominal pain. Following manual
therapy, selected elements of kinesitherapy were
performed: movement exercises and medical
functional training [20]. The patient was taught to
properly contract the pelvic oor, abdominal, and
gluteal muscles [21]. Initially, the isometric con-
traction was maintained for 6 seconds (without
the onset of pain). The exercises were performed
with increasing difculty (Fig. 7). During the ab-
dominal muscle strengthening process, particular
attention was paid to the correct technique of the
exercise [22].
Exercises similar to the Kraus-Weber test were
not performed because improper execution of
lower abdominal exercises exacerbated the pain
symptoms [23]. A key element of physical exercis-
es was handstands. The patient performed assist-
ed handstands for a few seconds during the physi-
otherapy visit. A modied Trendelenburg position
was also used (Fig. 8), characterized by position-
ing the hips above the shoulders [24].
Initially, the patient maintained the position for
10–15 minutes (with a few-second breaks), grad-
ually increasing the time to 30 minutes over the
following days. The patient performed the above
exercises in the clinic and then at home, subjec-
tively analyzing their effectiveness. Each exercise
element was subjectively analyzed by the patient
both at home and at school. This allowed for sepa-
rate assessment of the impact of each exercise on
the intensity of perceived pain. According to the
patient, the best pain-relief effects were achieved
with handstands and relaxation of the transverse
abdominal muscle. The focal lower abdominal
pain that the patient experienced decreased in in-
tensity and frequency after each therapy session
(Fig. 9).
Figure 6.
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Physiotherapy Review | Volume XXIX Issue 1/2025
Figure 7.
Figure 8.
Figure 9.
NRS SCALE
WEEKS
9
9
PAIN IN ABDOMEN AREA
(NRS SC ALE ) after each
therapy session
PAIN IN ABDOMEN AREA
(NRS SC ALE ) before each
therapy session
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Physiotherapy Review | Volume XXIX Issue 1/2025
Discussion
Glenard's disease is considered a rare condition in
both the pediatric and adult populations. The di-
agnostic challenges in accurately identifying vis-
ceroptosis stem from the fact that the symptoms
are similar to those of irritable bowel syndrome,
such as constipation, diarrhea, and abdominal
pain, typically in the lower abdomen [5,6,8]. A
thorough interpretation of historical data, physi-
cal examination, and laboratory tests, along with
extending diagnostics to include imaging studies
such as gastrointestinal transit in a standing po-
sition, leads to an accurate diagnosis [8].
Excessive laxity of the abdominal wall with weak-
ened mesenteric attachments causes a disruption
in the support for internal organs and their func-
tion. The support system for the gastrointestinal
tract originates from the embryonic mesoderm,
the germ layer responsible for forming the skele-
ton, muscles, tendons, ligaments, and mesentery.
The mechanism of gravitational resistance
starts with musculoskeletal support and the dia-
phragm. The mesentery attaches to the posterior
abdominal wall at the level of the lumbar spine.
The gravitational force acting downward on the
mesentery is counterbalanced by the strength of
the lumbar spine muscles. Such action engages
the back muscles, stiffening the spine to coun-
teract gravity. With appropriate support, the an-
terior abdominal wall can bear the gravitational
weight of the internal organs, reducing the dis-
comfort caused by their abnormal positioning.
In the event of weakened abdominal walls, the
root of the mesentery deviates in the opposite
direction instead of toward the central axis of the
body. Similar to increased lumbar lordosis, mus-
culoskeletal dysfunction and a change in body
integrity occur. The lack of balance between the
digestive system and movement increases the in-
tensity and frequency of pain symptoms. There-
fore, musculoskeletal pain can serve as a direct
indicator of anti-gravitational management in the
body. Patients may experience acute pain at any
point in the abdominal structure due to excessive
tension between the tissue framework and the
gravitational load [25].
Chronic abdominal pain can be categorized into
visceral, somatosensory, and functional pain. Vis-
ceral pain is transmitted to the brain via vagus,
thoracolumbar, and lumbosacral nerves, origi-
nating from the deep internal structures of the
abdomen. Its nature is diffuse and poorly local-
ized, occurring with neurovegetative symptoms
such as nausea, vomiting, sweating, emotional re-
actions, and anxiety. It can result from persistent
inammation, vascular mechanisms, mechanical
stretching of the organ, or ow obstruction [26].
Somatosensory pain arises from nociceptors in
supercial tissues, including the skin and the
musculoskeletal system (bones, ligaments, and
muscles) [5]. Chronic visceral abdominal pain of
musculoskeletal origin is typically sharp, precise-
ly localized to a small area (usually within 2 cm),
and associated with movement rather than bowel
function or eating. In the patient's case, focal pain
below the navel intensied in the morning, with
symptoms persisting throughout the day, par-
ticularly during standing and walking. During the
examination, a signicant intensication of focal
pain was detected with increased intra-abdom-
inal pressure, often triggered by the incorrect
performance of abdominal muscle exercises and
activation of the iliopsoas muscles.
During physiotherapy, the iliopsoas muscle was
treated bilaterally according to the OMT Kalten-
born-Evjenth Concept. The patient reported im-
mediate alleviation of pain symptoms following
the release of iliopsoas muscle tension. While the
pain relief observed during the rst visit was rel-
atively small and short-term, subsequent sessions
resulted in a steady decrease in both intensity
and frequency.
After applying manual therapy techniques during
a single physiotherapy session, the treatment fo-
cus shifted to learning how to activate the pelvic
oor, abdominal, and gluteal muscles. Weak ab-
52
Physiotherapy Review | Volume XXIX Issue 1/2025
dominal muscles could lead to bilateral overload
of the iliopsoas muscle, so by appropriately bal-
ancing muscle tension and strength, secondary
symptoms of the disease were reduced [27-30].
Glenard's disease is characterized by secondary
increased laxity of the abdominal wall. Strength-
ening the muscular corset aims to provide a sup-
portive framework for internal organs, improve
the biomechanics of the lumbopelvic-hip com-
plex, and enhance gastrointestinal peristalsis
[17,18].
According to Sarangapani et al. [6], this is not a
life-threatening condition, but it causes abdomi-
nal discomfort, defecation problems, appetite dis-
turbances, and reduced quality of life [5,6,8,26].
There are few scientic reports on treatments for
visceroptosis other than surgical or pharmaco-
logical interventions. Previously used corsets and
bandages aimed at externally supporting the or-
gans rarely provided pain relief [5,27].
Physiotherapy aimed at improving the strength
of the abdominal muscle corset could serve as
an alternative treatment method, similar to ap-
proaches used for other gastrointestinal disor-
ders. Brands and co-authors conducted a study
on a group of 20 children aged 8 to 18 years who
suffered from chronic abdominal pain. Under the
supervision of a hatha yoga teacher, the children
participated in 10 training sessions. The exercises
signicantly reduced pain intensity and frequen-
cy in children with functional abdominal pain
(FAP) and irritable bowel syndrome (IBS) [24]. The
benecial effects of yoga exercises have also been
observed in other clinical cases and review stud-
ies [31,32].
The effectiveness of physiotherapy was further
demonstrated in a study involving 85% of chil-
dren (48 individuals aged 6–16 years) with chronic
abdominal pain. Paul and co-authors emphasized
that the benets might result from increased ef-
ciency of abdominal muscles in eccentric work
through concentric abdominal muscle training
[33].
Study limitations
This case report has some limitations that may
affect the interpretation of the results and con-
clusions. The rst limitation is the lack of objec-
tive assessment of pain symptoms before and
after therapy. The absence of access to objective
tools for measuring pain intensity led to the use
of the commonly utilized NRS scale in physio-
therapy. It should be noted that this scale was
previously employed by the patient during hos-
pital and outpatient treatment under the super-
vision of physicians. Additionally, a three-year
multicenter, randomized, controlled, retrospec-
tive crossover study on a group of children with
chronic abdominal pain demonstrated a high cor-
relation between the VAS, NRS, and FPS-R scales,
conrming their effectiveness in assessing pain
intensity [34]. The publication by Ginton et al.
[34] reinforced the recommendation of the Rome
Foundation, which identies subjective pain as-
sessment scales as essential tools [35,36]. There-
fore, it is recommended that future studies incor-
porate both subjective and objective assessments
of pain symptoms using validated tools, such as
the Modied Faces Pain Scale (FPS-R) [37], skin
conductance measurements, and the nocicep-
tion-analgesia index (ANI) [38].
Another limitation is the absence of repeated
gastrointestinal transit or other imaging assess-
ments. After completing physiotherapy, no fol-
low-up imaging was performed due to the lack
of indications from the attending physician, the
need to minimize exposure to ionizing radiation
and contrast agents, concerns about kidney func-
tion burden, and lack of parental consent. The
limited availability of other scientic reports on
physiotherapeutic management and its effective-
ness in this rare disease further presents a chal-
lenge. The choice of study methods was based on
an individualized approach to the patient and the
clinical experience of the physiotherapist.
The inability to compare the physiotherapy
methods used in this case to other available tech-
niques highlights the need for further research. It
53
Physiotherapy Review | Volume XXIX Issue 1/2025
is important to emphasize that this case report
involved a 9-year-old girl, and, in her subjective
assessment and parental observation, the de-
scribed methods contributed to reducing pain
symptoms. However, it cannot be denitively
concluded that these methods will be equally ef-
fective in other patients with visceroptosis.
Summary
This case report demonstrates that individual-
ly tailored physiotherapy can positively impact
the subjective pain perception and quality of life
of a child with Glenard's disease. Manual thera-
py and muscle-strengthening training are com-
monly utilized as treatment elements for various
conditions involving chronic abdominal pain in
the pediatric population. However, it cannot be
denitively stated that the described methods
will be equally effective for other patients with
visceroptosis. Therefore, further clinical stud-
ies using objective research tools are necessary
to comprehensively assess the impact of physio-
therapy on visceroptosis and establish standard-
ized treatment protocols.
Declarations
Ethical Consideration: The study was designed
and conducted in accordance with the Declara-
tion of Helsinki (1964) and Good Clinical Practice
(GCP) guidelines.
Clinical Trials: This study was not registered as a
clinical trial as it did not involve investigational
products or interventions that would classify it
under clinical trial regulations.
Conict of Interest: The authors declare no con-
ict of interest. The study was conducted inde-
pendently and without any inuence from exter-
nal organizations or entities.
Funding Sources: This research received no ex-
ternal funding and did not receive any grants or
nancial support from external sources, includ-
ing non-prot organizations. The study was con-
ducted using the internal resources of the insti-
tutions involved.
54
Physiotherapy Review | Volume XXIX Issue 1/2025
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