For months now I have been writing this article about scar tissue. I have found quite a lot of information, but as usual nothing on a deeper level. A lot of books and websites will say scar tissue can create blockages, but I want to know why and how. So I hope what I have written will provide some of these answers.

What is scar tissue?

In my line of work we tend to use other phrases like abdominal adhesions or fibrosis to accurately explain scar tissue.  Abdominal adhesions are pretty specific to internal workings of the body, usually linking an organ to an organ or tissue to an organ. Adhesions are fibrous bands that connect one tissue to another tissue, forming a connection that physiological shouldn’t be there. These bands are fibrous, meaning they are tougher and less flexible than their surrounding tissues to which they make the connection. Hence the phrase ‘fibrosis’.

When adhesions form between two different organs it can create a tethering, much like an anchor on a boat. One organ becomes partially fixed and therefore permanently struggles to expanded, stretch, move or glide. Sometimes a tether can also behave like a torsion and actually constrict an organ, creating a physical blockage. This is especially true in tubular organs. Within both of these examples, movement and physiological function is lost. I want to focus on the movement aspect first. Reduced movement in anything, especially with regard to the body, is a bad thing. Whenever there is a reduction in movement there is also a reduction in nutrient supply and reduction to toxin expulsion. Too much toxin build or not enough nutrient supply can lead to cell death. Any form of death in the body automatically triggers an inflammatory response. Similarly if stagnicity is present then there is a much greater chance of infection. Stagnicity indicates a lack of sufficient blood supply and therefore a lack of immune response to the targeted area via the blood supply.

So what happens?

In the case of surgery, the natural healing process is kick started by inflammation. Inflammation brings all the materials needed for repair and clears the site from harmful microbes. Fibrin is then laid down, acting like glue and eventually creates a fibrosis. Collagen is the last substance to be introduced.

Collagen is present in pretty much every tissue of the body and is usually laid down in a random, chaotic pattern [picture to the left]. 

However in scar tissue, collagen is laid down in heavy concentrations in a linear pattern or a straight line pattern. This is what gives scar tissue that white smooth linear look [pictures below].

When collagen is laid down in thick fibrous bundles the blood supply becomes very insufficient. Collagen is very inflexible and together with the poor blood supply, it makes an area of scar tissue quite lifeless. So the vitality that was once present in the healthy tissue pre trauma (operation) becomes a rigid, tense and almost lifeless area.

If you think that collagen is the primary ingredient in bones and ligaments you will begin to understand the far reaching consequences of putting a material like this directly into a healthy functioning tissue, especially an organ.

Here is an example to try and explain the consequences of abdominal adhesions:

Imagine taking a normal balloon, it blows up normally and evenly. Now imagine putting a strip of duck tape on it, like a plaster. When you blow up the balloon again, everywhere expands except the area of duck tape, which stays fixed. The balloon then expands around the duck tape and forms an asymmetrical blob. It no longer looks like a normal balloon. This is how scar tissue or collagen functions when laid down in places not originally designed for that purpose. This leads on to the model of Osteopathy I’ve tried to explain before. Everything is motion, moving, fluid, and breathing. Put a fixed, fairly lifeless structure into this system where it is not designed to be and it will start to become a stress on the system, all bit a minor stress to begin with.

So what are the consequences of surgery?

When surgery is performed external air will get into the abdomen and this dries out the natural lubrication and viscosity of the various abdominal organs and tissues. Often blood is split  and becomes sticky, producing the same consequences. When the layers become dry or lack lubrication, this will increase the friction of movement between the layers. The various layers are now pinned together, and the once free movement upon each other, is now dictated by the scar tissue. They can no longer slide and glide upon each other. This increases the friction between the various layers.
If you take two glass panels and put water between their two surfaces and slide them over each over, it is effortless. Remove the water and slide the glass again and it becomes a lot less smooth. This is the principle here. The viscosity changes after trauma or surgery and so in time this can add small repetitive stresses. [see video below - laparoscopic appendectomy].

I want to thank 'Kiplinght' for permission to use his video.

The other aspect here to consider is when an organ becomes unnaturally fixated its axis of movement changes. This has far reaching effects on the other organs because the organs all rotate and move to a certain rhythm. The ascending colon has attachments to the kidney, duodenum and liver. All these organs move and they move together, effortlessly and cohesively. When the axis of movement changes, say at the ascending colon for example, then instantly the colon will pull away from its natural pattern of movement and therefore pull on the other 3 organs just mentioned. In time this can put stress on these organs and they can go into dysfunction too.

If the axis of movement to which an organ rotates around changes, then this can also alter the dynamics of the mechanoreceptors. Mechanoreceptors are neurons that pick up changes to pressure or stretch. So if a stretch or distortion exists that shouldn’t exist, then this could unnaturally trigger the mechanoreceptors. The feedback goes to the spine/brain and comes back resulting in spasms to the muscles of the organ.

In the stomach, when the mechanoreceptors are triggered, the stomach begins to release hydrochloric acid (HCL). So if there is a fixation on the stomach, due to some external input, the mechanoreceptors can fire and produce more HCL acid. This increases the acid production which in time can lead to possible ulcerations or a hiatus hernia. The mechanoreceptors are designed in this case to be triggered when the stomach is becoming stretched as a result of food entering it, not through other stimuli.

So here comes the million dollar question; can scar tissue be treated?

Yes I believe scar tissue can be treated after surgery. But first we must look at scar tissue from a slightly broader perspective. When the body heals from a wound, it usually has some consequences that stick around after the healing processes have finished. The wound site is often bigger than the resultant collagen scar tissue. There is nearly always an affected area around the scar that usually presents with stiffness, reduced vitality and reduced function. It is this area that is treatable.

By pulling, stretching, twisting or lifting an organ we can release the tensions spreading in and around the site of scar tissue. During an appendectomy a cut is made down to the large intestine from the skin, through a fat layer, through fascial layers, through the abdominal muscles and then finally into the abdominal cavity (recently they have started using laparoscopy, which minimalises scarring). The cut to reach the Cecum is actually relatively small and often the resulting scar tissue is small. However we often find that the entire Cecum and ascending colon is fixated and has lost its functional movement. So the area of injury or trauma is no longer actually focused towards to the site of scar tissue. The aim would therefore to be to lift the Cecum off the posterior abdominal wall, stretch the iliocecal ligaments located inferiorly and to also stretch the ascending colon. This often nearly always clears up the problem and functional movement returns to almost normal. I do not believe however that the physical scar tissue, made of collagen is treatable. But this is just my opinion.

Bag It!!!

I recently watched a very profound documentary on plastic called 'Bag It'. It talks about how we are struggling to deal with the waste of plastic, the problems we are  facing with global consumerism and the health effects of using plastic in our foods. Although its delivery and presentation was ok, the underlying story and information was fantastic. I would strongly advise purchasing this DVD, albeit an expensive one, and give your support to the works of this organisation. As usual the link is above.

The North Pacific Gyre

I have recently been reading about some issues regarding plastic and general waste. During my search I found the above expression, the north pacific gyre. I was shocked at what I discovered.  

This is a huge area in the north pacific ocean that has accumulated a huge volume of trash, mostly plastic as it does not biodegrade. Check out the link above for more information, it's scary stuff.

Principles of scar tissue:

Firstly I want to highlight a principle I think is the most important in my line of work. If you read ‘what is Osteopathy’ in the ‘Osteopathy’ tab on this blog you will see I have written about what I believe Osteopathy is.  There I remark on the principle of motion and that the body is constantly moving.  It is very important to have this in the back of your mind as I try to explain the consequences of an appendectomy or scar tissue in general.

When the appendix is removed an incision is made in the right lower quadrant of the abdomen.  This cut slices through a lot of different layers of tissue.  The appendix is then cut away and the large intestine is stitched up.  More recently they have started using a laparoscopic procedure to remove the appendix – link here. 

The point I want to highlight though, is when the various incisions are stitched up scar tissue will form.  Scar tissue is non flexible, it doesn’t stretch.  All the other layers and tissues that have been cut through can stretch; they expand and relax with the various motions of the body.  They adapt, they live and by this I mean there is cellular exchange and interaction. Scar tissue however cannot move or stretch, it is considered ‘dead tissue’.  I’ll explain more about scar tissue in a different blog.

When you have something that is not flexible blend into something that is flexible it will create tension throughout the tissue that is trying to expand, it will act like an anchor.  When this occurs constantly every minute of every day, stress will eventually build in the surrounding tissues in connection with the scar tissue.  A good picture to paint here is normal tissue acts like a healthy runner.  It can jog for hours not draining the system.  When you get scar tissue the healthy tissue continues to jog, but now it is dragging a car tire behind it.  Stress builds, compensation occurs, function is reduced and ultimately injury can occur. 

Another feature of scar tissue is the production of adhesions.  In very simple terms this basically means that different layers of healthy tissue can stick together and this stops the natural function and mobility of that tissue. 

On an interesting note, injuries can develop years later after surgery or any other kind of trauma.  Just because there are no symptoms now, it does not mean compensation and adaptation patterns are not already occurring due to the increased task load of that tissue.  It is also common to have an apparently non-symptomatic scar tissue trigger into a symptomatic problem when another injury/trauma in the body occurs later on.  This is why someone can often develop a shoulder problem years later after a pelvis or leg injury for example.  Years of compensation build over time and then a new trigger in the form of a new injury/trauma can occur.

Conversely, do not fear that all of a sudden you are going to get serious problems just because you may have had surgery in the past.  I am merely highlighting why sometimes things can suddenly become symptomatic years down the line, when apparently there has been no problem.

So what can happen after an appendectomy?

With an appendectomy, the cecum (beginning of the large intestine) can become fixed to the back wall of the abdomen and the back wall, in this case, would be the transverses abdominis or iliacus muscle.  The cecum is also the junction between the small and large intestine and in some woman it attaches to the right ovary via the ligament of Cleyet.  When I talk about attachments I'm referring to either ligament, fascial or membrane connects between various organs or bodily structures. 

Higher up as part of the ascending colon it attaches to the duodenum (the beginning of the small intestines), the right kidney, liver, gallbladder and finishing up fixing to the diaphragm.  I highlight all these attachments because these can become potential areas of compensation, irritation or sites of 'injury'/symptoms.  So when the inherent movement of the cecum has stopped due to fixation caused by the scar tissue it creates what I call drag.  This is another principle resulting from scar tissue.  This drag almost acts like a gravity field.  Not only is the inflexibility of the scar tissue causing tension to spread through the structure, it also causes other nearby structures associated with it to get pulled towards the scar tissue or fixation. 

[The picture above shows all the attachments of the large colon - indicated by arrows].

Knee and ankle problems can develop:

The cecum attaches to the iliacus muscle of the pelvis, which works to produce flexion and internal rotation of the hip.  If the cecum becomes stuck (it's lost its inherent movement) it can cause the iliacus muscle to pull towards the area of fixation.  It is almost like the two structures start to act as a single structure.  Ultimately this causes the muscle to become chronically contracted and the hip to become more and more internally rotated and flexed.  This will lead to internal rotation of the femur and then internal rotation of the knee joint.  The knee joint will also stay further in flexion.  Both these actions result in the tibia shifting further forward on the ankle joint and inwards towards the medial arch of the foot.  This can predispose to stress on the medial arch, which over time can lead to collapsing of that arch known as over pronation.  Conditions like plantar fascitis and heel spurs can develop.  So with just this simple chain we can see the potential of knee, ankle and foot problems occurring just from a fixation due to an appendectomy.  Remember these are all potentials and NOT definite compensations that will happen to everyone that has had an appendectomy.

Neck problems can develop:

So going back to the other structures that attach directly or indirectly to the cecum.  I'm going to leave out the duodenal and kidney attachments here otherwise I'll end up writing a book rather than a blog.  But let's focus on the liver and diaphragm attachments.  So through fixation of the cecum, the ascending colon is gradually being drawn down towards the cecum area via the drag and this directly pulls on the liver and diaphragm.  Remember the image of the car tire.  Suddenly the liver is having to move with an unnatural force pulling it constantly downwards towards the hip.  The liver has massive attachments to the diaphragm and then with the direct attachments of the ascending colon as well we suddenly find the diaphragm is struggling too.

[The picture directly above and left shows how high the ascending colon goes, sitting directly under the liver and diaphragm.  The picture to the right shows the pleura of the lungs, the grey membrane sitting on top of the red muscle (diaphragm)].

Now on the upper surface of the diaphragm you have the pleura of the lungs (the membrane that covers the lungs) which blends directly into the diaphragm.  On the upper surface of the lungs, the pleura attaches to the vertebral bones of the neck via a fascia called Sibson's fascia.  So with the pull of the diaphragm down, you also get a pull of the pleura, which pulls on the neck.  Neck pain, stiffness and tension can occur. 

I think it is important to clarify here that although I’m talking about one structure pulling on another structure and then that other structure pulling still further on another structure; it is slightly different within the body.  We have to remember the body is living and everything is connected, even if it is not physical, it is still connected by blood, nerves, emotions, hormones and gravity.  It is very difficult to highlight how this represents in the body via words.  It is something I have just learnt to feel – perhaps it is intuition.  In the medical world when we learn anatomy we cut everything down and separate everything to its basic level, so we can learn.  But to grasp how the body truly works we need to build up that anatomy again and see a whole living body once more.  It is very easy to think “how is it possible for the Cecum, which is all the way down near the hip to affect the neck – the two structures are so far away?”  In the body these structure are not far away.  In fact they are touching, but perhaps not in a direct way, but rather in an indirect way.

Low back pain is common:

Here I am going to talk about a structure called ‘toldt’s fascia’.  This structure is a membrane type structure or for understandings sake let’s just say it acts like a piece of ‘cling film’ or ‘shrink wrap’.  This membrane starts from the spine, spreads out and wraps around the ascending colon to then travel back to the spine again.  So when the colon becomes fixed, this can lead to stress and tightness spreading through the fascia, resulting in a pull on the spine.  Over a prolonged period of time it puts a greater demand on the spine and it gradually stiffens up.  This is what happened to the patient I had recently; refer to the ‘Bob the builder story’ on my blog.  The Cecum became fixated due to the scar tissue and adhesions.  This created tension to spread through toldt’s fascia and then lead to tightness and pain in the lower back.  This is why after 4 treatments of manipulation, stretching and pulling on the spine, no improvement was achieved; because all the while his colon was still fixed causing the tightness in the spine to remain.

Signs and symptoms of cecum fixation:

The large intestine works to absorb the remaining water (about 10%) and take in the remaining vitamins (mainly E, K & B12).  Interestingly the large colon has a very high percentage of bacteria which ferments the food (this is very healthy for the body).  This increases gases and therefore smell, but this is normal. 

Depending on whether the fixation of the cecum is in a state of irritation or a state of passivity will depend of the symptom.  An irritation is more an excitatory response and the speed of which peristalsis occurs increases.  Therefore diaherria and dehydration can occur, simply because the stools pass through too quickly for the water to be absorbed. 

If it is passive then think stagnicity.  Constipation, bloating and flatulence can occur because the stools are not passing through quick enough, all the water is absorbed leading to harder, firmer stools, which are difficult to pass.  Stagnicity leads to longer fermentation periods and this obviously produces more gas and bloating, also known as trapped wind, which actually is extremely painful.

Bob the builder: 

I treated a recent patient of mine, Bob (not his real name of course), for a very typical low back problem. After four treatments of the normal stretching, pulling, manipulating, pushing and bending he improved to perhaps 60-70%.  We unfortunately could not breach that final 30%, which would have returned him back to his normal quality of life.  He has tried the usual therapies in the past and they too were getting the same sort of results.  We were all hitting an invisible wall it seemed.

So on one of his treatment I sat down pondering his situation/condition.  He was your typical stiff builder type with very little flexibility and had been suffering with low back pain on and off for 1-2 years.  No neurological symptoms or anything else untoward.  I had been treating a lot in his upper back, rib cage and breathing mechanics too.  On the third treatment I looked at his legs and feet.  Always there was an improvement, but never beyond that 70% mark.

On the fifth treatment I was working on his lumbar spine (low back) when I noticed how stiff it was considering he had had four treatments earlier of stretching, bending and all the above.  It suddenly struck me how odd this was and so I decided to re-read his medical notes, starting with the list of his operations and medical conditions.  This was when I came across his appendectomy (removal of his appendix) some years earlier.  So I sat him down and checked his abdomen.  Sure enough he had a lot of tension around the cecum (beginning of large intestine and appendix.  I treated this area very simply and then stretched toldt’s fascia on both sides.  When I had finished completing these 2 easy techniques the patient remarked on how relaxed his back felt.  
[The picture on the left is an overview of the large and small intestines.  The picture below is a close up of the cecum and appendix; the appendix being held by the metal tweezers].

Sure enough he came back to his next treatment nearly 100% better; the best he had felt since the beginning of his low back problems.  Although this has been a great success, it has also been a solid reflection.  I almost missed this because I assumed he just needed a good stretch and manipulation, which in most cases is exactly what this type of patient needs.  But it was that feeling I felt in his back that just made me very uncomfortable, as if something was wrong.  A back that is stretched and manipulated regularly for a few weeks should change in vitality and composition.  This back however stayed the same since the first treatment. Something completely different needed to be done.

In another blog that will follow shortly in the next few days I will explain the mechanics of what happens to the body after an appendectomy and the reasoning to why this caused Bob a lot of back pain for a year.