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Manual Therapy Decreases Pain and Dysfunction Due to Adhesions and Scars

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Adhesions form in all of us throughout life. They can form anywhere in the remarkable complex of our bodies, as the first step in the healing process after an infection, inflammation, surgery, or trauma.

As shown at right, our muscles, bones, nerves, blood vessels, and connective tissues are intimately involved structures within our body. Adhesions often join structures from different bodily systems with strong glue-like bonds that can last a lifetime. For example, a fall on your hip or tailbone can cause adhesions to form as the body’s first healing response to that trauma. And while you may only feel the pain at your hip or tailbone after the fall, the adhesions that formed to help you heal from your injury can bind nearby organs such as the bowel, bladder, fallopian tubes or ovaries.

Until recently, the only choice medical science offered to repair adhesive damage was a surgical procedure called “lysis of adhesions.” Whether performed by laparoscopy or open surgery, the lysis involves cutting or burning the adhesions. While adhesion lysis can be very effective, it has two major drawbacks:

1. surgeons must avoid areas where they might damage delicate underlying structures, a situation they cannot see until you are already under anesthesia, and
2. despite the best skills of the finest surgeon, the body creates more adhesions to heal from the very surgery designed to remove them.

This second concern was highlighted in a large study of surgery patients. Lancet: The British Journal of Surgery, 1999 (Ellis)¹ reported that 35% of all open abdominal or pelvic surgery patients were readmitted to the hospital more than twice to treat post-surgical adhesions, during the 10 years after their original surgery. Many follow-up surgeries (22%) occurred in the first year after surgery, and “readmissions continued steadily throughout the 10-year period” of the study.

Adhesion formation occurs after trauma to the tissues, and is caused by an inflammatory response to tissue damage. As the body’s tissues heal and adhesions are formed, the tissues begin to shrink and pull, which results in restricted movement of the area. This ‘pull’ creates more mechanical irritation, often perpetuating the cycle of adhesion formation. Like the patients in the study noted above, many of our post-surgical patients feel they are in a vicious cycle of surgery-adhesions-surgery – with no end in sight.

One reason for the recurrent nature of the problem is that adhesions tend to persist long after the original trauma has healed. In fact, the body does not have a natural remedy – nor does it have any way to decrease adhesions once they have formed. Once they form, adhesions may bind together organs, nerves, muscles, and other neighboring structures in a strong, glue-like straight-jacket, with a strength approaching 2,000 pounds per square inch.

Adhesions usually form after surgery, infection, inflammation, trauma, or radiation therapy treatment. As shown in the drawing above, adhesions are composed of strong, microscopic strands of collagen. Like a nylon rope made of a thousand tiny strands, these tiny collagen fibers (called crosslinks) bind together to create curtains, ropes, or blankets of tissue in areas of the body that have been injured by infection, inflammation, surgery, or trauma.

Whether the adhered tissues are called crosslinks, micro-adhesions, adhesions or scars, is all a matter of size. Whether they form ropes, curtains, or some other shape depends on how we heal, and how our body moves and pulls against existing adhesions, after trauma to the tissues.

Adhesions may be filmy or coarse, thick or thin. They may be small enough to join individual muscle cells, deep within a structure (as shown in the anatomical box below) or they may grow so large that they stretch down an aging person’s torso from neck to waist, bending that person forward so s/he literally cannot stand erect.

Adhesions may occur on the surface of our bodily structures, or deep within them. They can join any structure in the body to its neighbor, or to distant structures. In doing so, they can cause confusing symptoms, of pain or dysfunction – with patterns that can confound both patients and physicians.

When adhesions totally close an organ (e.g., bowel or intestinal obstruction), they can become life-threatening. In areas where they impose on pain-sensitive structures, they can cause constant or recurring pain. They may also pull into structures distant from the original tissue trauma, causing referred pain or distant dysfunction. In fact, we find that adhesions are often the cause of the unexplained or complex pain patterns we see in many of our chronic pain patients.

Remarkably, when adhesions form in areas that are not highly innervated, they may not cause pain at all. Thus, some people find themselves slowly losing function or range of motion over time, whether or not that loss is accompanied by pain.

When adhesions occur around the uterus, ovaries, fallopian tubes, or the delicate fimbriae at the end of the uterine tubes, pain or infertility may result. They may impose upon structures within the female reproductive organs, block a fallopian tube, cover an ovary, or cause inflammation on the walls of the uterus. While all of these may decrease reproductive function, they may not cause pain.

Tiny adhesions that form between muscle cells deep within the cervix may cause pain during sexual intercourse, when the partner hits the cervix. Whether or not they cause pain, these adhesions can cause cervical stenosis (closing) or fibrosis (tightness), decreasing fertility and the ease of sperm transport into the uterus.

The cervix is designed to be held in a midline position by four ligaments: to the pubic bones (in front), to the sacrum (in back), and to the pelvic walls (on each side). If any of these ligaments become adhered, the cervix is pulled by adhesions with each step a woman takes.

Clinically, we find that this constant pull can cause inflammation in the uterus. As we now know, the body’s response to inflammation is to send in adhesive crosslinks. In this case, adhesions form on the uterine wall, decreasing the chance for implantation.

Summary

In short, adhesions form as the first step of the healing process, whenever we undergo any trauma or inflammation to our bodily tissues. Crosslinks rush in and lay across each other in a random pattern to help protect and isolate the area that has been injured or inflamed. Adhesions join structures that should be free to move independently. In doing so, they can create unusual symptoms, whether or not accompanied by pain.

Once the body has healed, the adhesions remain in our body wherever we have healed. There, they persist throughout our lifetime, unless removed by a skilled manual physical therapist, or by a surgeon.

Causes of adhesions:

Surgery

Surgery is a primary cause of adhesions. A study in Digestive Surgery showed that more than 90% of patients develop adhesions following open abdominal surgery and 55% to 100% of women develop adhesions following pelvic surgery.² As noted above, surgery to remove adhesions has itself been implicated as a major cause of adhesion formation. Other surgeries that may cause adhesions or scars to form in and around organs include:

• bowel obstruction repair
• appendectomy
• episiotomy or C-section
• laparoscopy or laparotomy
• hysterectomy
• back or hip surgery
• abortion
• complete or partial removal of organs
• gastric bypass
• plastic surgery

Many people experience decreased function, increased tissue tension, or loss of range of motion after an injury, surgery, or infection. Like scars that form on the skin, adhesions create “internal scars.” They may become painful and inhibit proper function by adhering tissues and organs that are designed to move freely. Mechanical problems can occur in the body due to adhesions from the postures the body takes to compensate after the original injury, surgery, or infection.

When adhesions form around the abdomen, intestines, or digestive tract, dysfunction such as constipation or abdominal pain may result. While the patient may receive a diagnosis of irritable bowel syndrome (IBS), Crohns disease, or other descriptive name, adhesions are often at work, as a cause or perpetuating factor in these conditions.

Inflammation and Infection

Inflammation and infections are frequent causes of tissue damage, and adhesions form as the first step in healing. As the body starts the process of healing from inflammation, it can form blankets of collagenous crosslinks to contain the area that has become inflamed. Once the inflammation has passed, the blanket of adhesions remains, as a permanent record of the healing that occurred in that area.

Some inflammatory and infectious processes that are known to cause adhesions include:

• colitis
• diverticulitis
• gastritis
• gastroenteritis
• cholecystitis
• perforated ulcer
• pelvic inflammatory disease (PID)
• endometriosis
• cystitis or vaginitis
• perforated diverticulum, small or large bowel
• appendicitis
• hepatitis

Traumas

Adhesion-causing traumas include falls, accidents, or physical or sexual abuse. The trauma of radiation therapy can cause massive adhesion formation at or near the sites of cancer treatment. Inflammation following trauma or radiation therapy may cause adhesions to spread to neighboring organs unless they are removed or diminished by a surgeon, or a therapist trained to treat them. Symptoms sometimes appear far from the site of the original trauma.

Treatment

“Hands-on” Treatment Without Surgery or Drugs

We know adhesions well. We faced this situation personally 20 years ago when the physical therapist director of Clear Passage Therapies®, Belinda Wurn, developed severe adhesions after pelvic surgery and radiation therapy. Unable to work due to the pain, and having seen the devastating and debilitating effects of adhesions in the bodies of her own patients over the years, she was determined to find a non-surgical way to address her own adhesions, and get her life back. With her husband, massage therapist Larry Wurn, Belinda took a much deeper look at the etiology and biomechanics of adhesion formation.

The Wurns found that adhesions were composed of thousands of tiny strands of collagen, made strong by binding together like a rope or a cloth, made of thousands of individual fibers. As they investigated further, they found that the chemical bonds that attached each of the tiny collagen fibers to its neighbor appeared to dissipate or dissolve when placed under sustained pressure over time.

Looking back, this was not an easy process to learn or develop. After several years of study with some of the finest manual therapists in the US and abroad, the Wurns developed very specific techniques to address and dissolve the adhesive bonds which formed in the pelvis and abdomen, and in other parts of the body. As they used these on Belinda, she found her deep pelvic pain gradually dissipated, and her function returned. At last, she was able to return to work – this time opening her own clinic with her husband.

When physicians began referring their most challenging chronic pain cases to the Wurns, most of the patients reported significant decrease or total elimination of pain after therapy, despite years or decades of debilitating pain. Over the years, the Wurns built four clinics serving 650 referring physicians in 14 Florida counties. Then, they expanded their focus to research and provide female infertility treatment, as well as pain therapy. They now treat patients from around the world, with certified therapists in several US cities.

The primary goals of their manual therapy (The Wurn Technique®, patent pending) are to increase mobility and decrease pain. The physical therapists who were chosen for certification in the Wurn Technique® were already manual therapy experts when they applied for the advanced Clear Passage training. Each has now gone through a rigorous program of training and certification to learn the techniques that have been featured in several published studies. We test each of their abilities in each of the several hundred techniques, which are designed to find and decrease adhesions in tightened areas of the body. The work practiced at Clear Passage Therapies® clinics, has been shown in peer-reviewed medical journals to reduce adhesions, decrease pain, and improve soft tissue mobility, without the risks of surgery or drugs.

We have helped many men and women, and some children who suffer ongoing pain or dysfunction due to scars or adhesions. As noted above, we have spent most of our professional careers studying techniques and developing protocols to decrease abdominal and pelvic adhesions and restore patients’ bodies to a state of balance, harmony, and increased function. Our treatment sessions are individualized and last one to two hours based on individual needs. For more detailed information on treatment, visit our “what treatment is like” webpage, or click the link at the bottom of this page, to complete a medical history questionnaire and apply for a free, in-depth consultation.

1. Ellis H, Moran BJ, Thompson JN, Parker MC, Wilson MS, Menzies D, McGuire A, Lower AM, Hawthorn RJ, O’Brien F, Buchan S, Crowe AM. Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study. Lancet Br J Med. 1999; 353: 1476-80. PMID 10232313.
2. Liakakos T, Thomakos N, Fine PM, Dervenis C, Young RL. Peritoneal Adhesions: Etiology, Pathophysiology, and Clinical Significance. Dig Surg. 2001; 18: 260-273. PMID 11528133.

 

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