EP.136/ 8 Strategies for Loosening Adhesions and Freeing a 'Frozen' Pelvis
As some of you may know, I’m doing a lot of work at present to free up my pelvic area from adhesions and tightness caused by pulled fascia and a tight pelvic floor, which in physio speak is a hypertonic pelvic floor.
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So I thought this would be a great time to talk about some strategies you can bring into your daily life to help loosen adhesions and a frozen pelvis.
I’ve talked about adhesions and fascia before, but let’s do a quick recap of what adhesions and fascia are.
So fascia is a thin sheet of tissue made from collagen that sits beneath your skin and holds your organs and muscles in place. It also surrounds all the organs, nerves, blood vessels, etc.
Fascia surrounding the body is like a bed sheet, if you pinch it or one end, the rest will wrinkle. So what can happen when we’ve had surgery is that these incisions create puckering and scarring in the fascia, which ends up tightening the fascia and pulling it in other directions. Fascia can also become distorted from inflammation, injuries and muscular problems like pelvic floor dysfunction.
Adhesions are a form of scar tissue. They are web-like structures and bands of collagen that grow in response to injury and trauma, to ‘knit’ back together a wounded area and as part of the healing process from infection and inflammation. Collagen strands bond together to protect the damaged area to allow healing to occur in a safe and isolated environment, and if an infection is present, they protect the rest of the body by preventing the spread.
Adhesions occur in nearly all cases of abdominal surgery, the results vary from study to study but one large and long study found that between 55% to 100% of women who had pelvic surgery developed adhesions, and up to 90% of people who had major abdominal surgery - so something like a caesarean - developed adhesions. So, if you’ve had one or more surgeries for endo, it’s very likely that you have some adhesions.
Adhesions can also form from inflammation, which we know occurs in those of us with endo due to the lesions and can occur in those of us with SIBO, because the body sees it as an infection. Again, as you probably know by now, research has shown that up to 80% of us with endo may have SIBO, so this could be an additional cause of your adhesions and frozen pelvis. It’s also worth noting here that adhesions can actually cause SIBO too, because they prevent the normal flow of gut.
So, what can we do about it? Thankfully, there are numerous ways to loosen adhesions and free up a frozen pelvis, and as a result, lower the pain and other challenges associated with them. So let’s dive in to my top 8 strategies. This list isn’t exhaustive by any means, and you don’t need to do them all! Just pick those that feel the most helpful for you and suit your lifestyle and budget.
1. Foam Rolling
Number one is foam rolling, which is an effective and affordable at home strategy which you can use every day if you’d like to! With foam rolling, we’re really looking at loosening the fascia rather than working on the adhesions directly. As I said earlier, fascia can get tight, pulled, puckered, and wrinkled, and if it’s experiencing it in one place, it can affect other areas in the body.
Foam rolling helps to release a distorted fascia and is when we literally use a long foam cylinder to roll back and forth across various areas of our body. With foam rolling for endo or other pelvic pain issues, we’re not just rolling back and forth on our pelvis, we’re rolling across our hips, bums, back, upper back and legs.
In the show notes I have linked to videos on how to do this, by physiotherapist Dr. Nicole Cozean.
You can order foam rollers from Amazon for about £11 and in the beginning, I would suggest starting gently with a soft roller that’s smooth, especially if you’ve experiencing a lot of pain.
Now with all of these methods, listen to your body. Some discomfort is normal when we’re working with releasing facia and adhesions, but if it’s really painful, ease up and go lightly or if it doesn’t feel right at all, appreciate that this may not be the right approach for you at first.
In an ideal world, we’d use these strategies under the guidance of a physiotherapist, but I know that’s not always an affordable option for everyone, so carefully watch the tutorials and if you’d like to do some further research to be really comfortable, I suggest reading Know Your Endo by Jessica Murnane, as she interviews Heba Shaheed, who I’ve had on the podcast before as well, and they talk about foam rolling extensively in the book.
2. Visceral Manipulation
Next up is visceral manipulation, which honestly, if you can afford it, I really believe is worth a try! Visceral manipulation is a form of organ massage which was designed by physiotherapist Jean-Pierre Barral with the particular intention to free up organs from adhesions and other structural issues that are restricting them. Organs are supposed to be able to expand and move gently as our body moves, and glide smoothly over muscles and nerves as we go about our day. When adhesions or some kind of other structural problem is keeping them stuck, that’s when we can experience pain and organ dysfunction.
Visceral manipulation is very effective for releasing these organs and loosening adhesions and I’ve seen some incredible results with my clients. What I will caution here is that it can feel quite intense and aggressive at times, and if your pelvis is very stuck, you may be better off starting more gently with a different type of massage like some kind of womb massage such as the one I’m going to suggest in the next point.
If you’re going to try visceral manipulation, make sure you’re comfortable with your therapist and be very clear with them about the pain or discomfort you experience within the session, so they know when to ease up or when to stop working on an area if it feels too much. I can tell you from personal experience that gritting your teeth and baring it does not always end well!
Other greats forms of organ/abdominal massage include Mercier Therapy and Clear Passage. Clear Passage is really the holy grail with lots of research behind it for endo and SIBO, but it’s incredibly expensive, so you may be better off trying the other techniques first. However, I do highly recommend it if you can afford it!
I’ve linked in the show notes how to find practitioners for all of these that I’ve just mentioned.
3. Arvigo Massage
Third on our list is Arvigo Therapy, which is a form of abdominal massage that is much more gentle than the ones I just mentioned previously. The benefit of Arvigo Therapy is that you only need one session, which can be done over Zoom, to learn it from a therapist, and then you can just practice it daily at home every evening.
Now in my conversation with Tara Ghosh, who is an Arvigo Therapist and actually taught me personally, she shares that whilst Arvigo Therapy doesn’t directly loosen adhesions like visceral manipulation does, it does encourage circulation to the area and helps to relax the muscles and organs in the area, which can then have the indirect effect of loosening a frozen pelvis.
However, I have seen some articles by therapists claiming it can loosen adhesions, perhaps they mean indirectly or perhaps there are differing opinions, but you can listen to the interview with Tara in episode 127 to learn more.
I highly recommend working with Tara because she’s just the loveliest person, and you can reach out to her directly via the details she shared in the interview (and I’ll put her Instagram in the show notes) but if you want to find another therapist, I’ve linked to the directory in the show notes. I’m pretty sure Tara sees clients from all over the world.
4. Breaking up your time sitting down
Number four is all about breaking up the time you spend sitting down at your desk, specifically by using a standing desk and by taking regular breaks.
Now, there’s been a lot of debate and controversy over this in the past few days. You may have seen in my stories I posted about my standing desk, which I use at varying intervals during the day, alternating between sitting and standing. I do this because my own physios and my colleagues, many of who are pelvic floor physios and my pelvic pain training, have always taught me that sitting for long periods of time without a break can worsen pelvic floor dysfunction symptoms through shortening and weaking the muscles in the area and restricting blood flow.
My understanding was that sitting down for long periods of time without breaks shortens the muscles in the front of our hips and pelvis, which means when we stand, walk or do anything else that isn’t sitting, we have restricted movement, tension, tightness and are more likely to experience pain. And if we have adhesions in the area, sitting down for long periods of time lessens the opportunity to stretch them and release them, making their hold on our organs stronger and tighter.
However, I had quite an strongly worded message form a physio informing me that this simply isn’t true and that muscles don’t shorten or lengthen, which absolutely threw me. So I went away and spoke to some colleagues and they all said that yes, muscles shorten and that sitting for prolonged periods of time causes this and can worsen pelvic floor issues. So I was quite confused!
I wanted to dig a bit deeper to understand why this physio said they don’t and I think what it boils down to is terminology, and oversimplification to make physio language easy for patients to understand. From what I gather through my own research and conversations is that the muscles don’t actually change length, but they lose their ability to stretch so they become restricted. Here’s how one of the PTs I spoke to put it.
Martha Spalding PT, NTP, CMEP, CYT, PI of Circle of Health Physical Therapy, CA: “Muscle length stays the same so no, they don’t elongate but they can be contracted, weak in both eccentric and concentric contractions, strained, sprained, torn and severed. Ligaments can be overstretched and they can have laxity, which is common during pregnancy and some people just have genetic ligamentous laxity. Prolonged sitting is stressful on the entire spine and pelvic floor as it is a prolonged static position in weight bearing on the pelvis. The pelvis is generally rotated posteriorly. Depending on the muscles, you can determine the stress component in the sitting position. This prolonged position does impact the fascial slings which can become restricted.”
So to help understand this better, eccentric contraction means when muscle length increases from tension during a movement, like a stretch. In contrast, concentric contraction is when a muscle shortens and tenses in order to bear weight and counteract resistance, so think about lifting a dumbbell in a bicep curl. So in short, the ability to perform these contractions can become weaker.
Laxity is defined as ‘looseness of muscle’, but I wouldn’t say this would be occurring here, it’s just an example she’s providing to demonstrate how muscles change.
After these conversations, the physio who originally contacted me also replied to say that sitting all day without any movement would cause joint and muscle stiffness, but she was also very clear to state that there are no detrimental effects on the pelvis with sitting.
So clearly there are some cross overs here, but also some differing of opinions. As I’m not a physio, I can’t really give you a definite answer so I’m providing you with the information I have gained and also what I have learned in my own time in training and working with physios. To my knowledge, yes, sitting without breaks and movement can have an impact, but I’ll leave it to you to decide.
My practice is to alternate between sitting and standing throughout the day, as I feel comfortable. When I start to feel tired and my legs need a break, I sit down, and when I feel like I’ve been sitting for long enough, I stand. And every 30 minutes to an hour of sitting at my desk working, I get up and do some form of movement, usually it’s a couple of minutes of rebounding, stretching, walking around the house or a few minutes of exercise and literally it’s just like 3 to 5 minutes.
Now I appreciate that if you have chronic pelvic pain and a weak core from pelvic floor dysfunction and from living with chronic pain, that using a standing desk can be difficult to do. So I suggest starting when only you’re ready with smaller periods of time to build up the strength in the core and to also have a cushioned mat under your feet or cushioned slippers to soften the impact. If you need to first spend some time just practicing taking breaks with gentle movement to build up your strength, or if you need to do some physio first or work on pain alleviation, do that first. This is just an option and you have to do what feels right for you – don’t rush into using a standing desk just because I’ve talked about it today, make sure it’s the right choice for you.
If you do buy a standing desk, you should also be swapping your positions when you’re standing up, so you’re not just constantly bearing down on your joints. I’ve linked to a helpful article in the show notes on different positions to adopt and how to stand in a healthy way when using a standing desk.
There’s now mounting information on the health risks of sitting for long periods of time without breaks or movement, including heightened inflammation, which you guys know is super important for us to keep on top of, so if you’re employed by a company, they really shouldn’t be surprised by you asking for a standing desk. And in fact, it should fall under reasonable adjustments to help make you feel more comfortable when living with endometriosis. If you have trouble getting your company to agree, I suggest having a listen to my interviews with Vickie Williams and Clare from See Her Thrive, which are both about your rights as an employee with endometriosis in the workplace. If you’re curious to learn more about the health considerations and research behind prolonged sitting, I’ve linked to a couple of articles in the show notes.
If you’re self-employed like I am, you can easily order a standing desk online. Prices range dramatically from whole desks which adjust to become either a seated or standing desk at about £1000 or cardboard desk toppers that you just put on top of your desk, and that you rest your keyboard and computer or laptop on, and these are around £15.
If you’re not quite ready for a standing desk or you’d like something extra to support your pelvis further when sitting, it’s best to take a quick break from sitting every 30 minutes if possible. I recently spoke to Rachal Dutton, The Period Whisperer, and she suggested getting up and doing hip circles both clockwise and anticlockwise for a minute or so or doing cat cow stretches whilst still in your chair. There are tonnes of movements you can do whilst seated to give your pelvis a quick break, so if you’d like more options, do some extra research until you find some that suit you!
To bring this unusually controversial tip to an end, I want to reassure you that if you need to sit down or lay down regularly, it’s okay. The key really is about trying to add in healthy movement as and when your health allows, and to take frequent short breaks from the sitting position, again as and when your health allows. I understand that there are days when all you can do is stay curled up, I’ve been there too! But on the days when you feel stronger, consider some small movements like rotating your hips or a quick cat cow to break things up a bit.
5. Pelvic floor stretches
You knew I was going to go there. Pelvic floor physio stretches are essential, in my opinion, to loosening adhesions and freeing up a frozen pelvis.
Of course, in an ideal world, we’d all go to pelvic floor physiotherapists who can give us tailored stretches to do daily at home, but that’s not an option for some people on smaller incomes. So if that’s you, you’ll be pleased to know that there are so many pelvic floor stretches for endo and chronic pelvic pain available online and in books.
I’ve linked to videos, articles and books in the show notes for you to choose from, and all of these are designed by professional and specialised women’s health pelvic floor physiotherapists.
What I will say is to listen to your body here. If you’re experiencing pain, or you have a strong reaction, ease up or try a different stretch – you may be currently too tight or ‘frozen’ in the pelvic area to attempt certain stretches for the time being, so start slower and allow some space and flexibility to build before attempting those pain triggering ones again.
You could add these in during your day, as part of your break from sitting, or in the morning as a way to wake your body up, or in the evening to help you to wind down. Whatever it is, find a time that suits you and don’t worry, you don’t have to spend half an hour on this! Ten or even five minutes is fine! Just start and try to get them in as often as possible, daily if you can – but don’t stress if you can’t!
Now of course, I don’t know your personal circumstances, so if stretching isn’t the right choice for you right now, don’t worry, try something else from this list that is.
6. Proteolytic enzymes
Alright, number six is proteolytic enzymes. Proteolytic enzymes are enzymes which break down proteins into amino acids. Proteolytic enzymes, when used for healing, help to reduce inflammation post-surgery and aid in clearing waste products from the wound site, and help to reduce adhesion formation. This is because of course, the building blocks of tissue are proteins!
However, because they reduce adhesion formation, there is the risk that if there is an infection at the site of the wound, that it could spread, as adhesions play a role in isolating infection sites from the rest of the body. This is rare but has been known to happen. Another thing to note is that the research is limited, with most of the research being in oral surgery or sports related injuries.
The only study we have on enzymes for endo specifically is one we use commonly at IWHI and that’s Wobenzyme. Wobenzyme was shown to reduce pain and inflammation post-surgery and inhibit the formation of new blood vessels, reducing the chances of further endo development and adhesion formation.
The dose used in the study was the label dose for 40-60 days pre-op and then 60 days post op. You need to take Wobenzyme away from food, otherwise the enzymes will just be used for digestion.
Now most of the studies on adhesion formation are conducted pre and post-op, so I really can’t say whether they’d make a difference if you surgery was five years ago for example, my instinct is that they wouldn’t aid with the adhesions but they might help with inflammation.
7. Castor oil
So number seven is castor oil and this one is also a little controversial, so I’ll provide you with the info and you can make your own decision about it.
I know countless leading women’s health practitioners who use castor oil to soften and break down adhesions and who experience great success with it with their clients. However, it’s generally considered that more research needs to be done, though there is research on castor oil’s abilities to lower inflammation, reduce symptoms of constipation, improve circulation, and stimulate muscle relaxation.
You may have heard Arvigo Therapist Tara Ghosh break it down in my interview with her. She explained that castor oil actually triggers the immune system, due to some of its chemical components, however, on responding to the call and finding no poison to clear, the immune system goes about utilising its tools on repairing and healing the pelvic area, which in turn helps to break down and clear adhesions. She also emphasises that the lowering of inflammation and improving of blood flow to the area, thanks to castor oil, is part of how this process works.
She’s not the only fan either. I had a conversation about castor oil with my colleagues and so many of them used castor oil packs to break down adhesions, and Nicole Jardim is a fan of using them for endometriosis and period pain.
So if you want to learn how to make your own castor oil pack and how and when to safely use them, I advise listening to my interview with Tara who has a really quick and easy method as opposed to the often messy and sticky traditional approach!
8. Heat Therapy
Last up is heat therapy. Yet another controversial one.
Heat therapy is often used by practitioners to help loosen fascia, muscles and break down adhesions. I recently spoke to Rachel Dutton who strongly recommended it to me to help with the lower right side of my pelvis, which is really stuck and isn’t responding well to body work therapy because it’s just too frozen and so I need to start with a gentler approach. She explained to me that heat therapy stimulates blood flow, which as a result helps to break down scar tissue and suggested this as one of the first options I should try.
Additionally, increased blood flow will allow the muscles to relax as more oxygen is delivered and so any muscles which were contracting due to restricted access to oxygen, which is common when you have a tight, bunched up pelvis, can start to loosen and become more mobile.
There’s also research showing how heat therapy can prevent adhesions from building up so much after injury.
Unfortunately PubMed was down at the time of writing this, so I haven’t got a tonne of studies to stick in the show notes but I’ve put in a few articles and one or two studies, and of course you can do some of your own research as well.
So now the controversy comes in. Some sources, but not many, claim that heat can loosen adhesions and fascia and then as they cool, they stiffen up again, and become stiffer than before. I dug into this further and honestly, I couldn’t really decipher how they sources came to that conclusion, and I spoke to multiple colleagues about this who were equally as baffled and looked at the articles with me, and didn’t really feel the claims were fully supported.
However, one research paper does discuss the rebound phenomenon, where the positive effects of heat therapy are actually only present for 20-30 minutes. So for 20 to 30 minutes, blood vessel dilate and blood flow increases, but afterwards, the blood vessels actually start to constrict again, preventing blood flow, so this is definitely worth taking into consideration.
After I raised this to my colleagues, they all agreed that they only use heat therapy for 20 to 30 minutes in terms of hot water bottles, normally applied alongside castor oil packs and perhaps alongside a massage therapy treatment. They were also very keen to stress that they never use boiling water in a hot water bottle, only warm water.
However, I’m curious about whether we can go a step further than hot water bottles.
For a long time now, I’ve been very interested in the research behind infrared therapy, which has been shown to heal muscle injury, tissue damage and lower inflammation. For this reason, I’ve been really curious about infrared sauna belts and infrared heat pads for my chronic bladder pain, because they have so many benefits, but I just haven’t bought one yet as I’m spending so much on SIBO healing. The prices that I have seen range between £50 and £60, so not that expensive, but for some of us a hot water bottle is the more affordable choice.
So whilst I can be sure about the theory that adhesions and muscles get worse after heat therapy, clinically, heat therapy seems to achieve remarkable results, especially when combined with castor oil packs and massage. Of course, if you’re going to use hot water bottles, just keep it to less than 30 minutes and don’t use water straight off the boil.
I think a wonderful way to try heat therapy is to use heat 30 minutes prior to a home massage, like Arvigo Therapy, to relax and soften the muscles so they’re more pliable and open to movement and stretch.
So I hope that has given you some ideas to help you soften your fascia, loosen adhesions and release a frozen pelvis. Remember, what works for one may not work for another, always listen to your body and be guided by what it’s telling you and ideally, consult a practitioner if you can afford to do so.
I would love to hear which strategies you try and how you get on!
Please remember I am not a physiotherapist or a masseuse. This information comes from my training as a health coach, my conversations and interviews with leading pelvic floor physios and my experiences a patient. This podcast is here for educational purposes only.
Show Notes
Adhesions
https://pubmed.ncbi.nlm.nih.gov/11528133/
Foam Rolling
https://www.youtube.com/watch?v=xJOzcFS6fGE
https://www.youtube.com/watch?v=umTObqSYay0
https://www.youtube.com/watch?v=V6cR3knKFIA
Visceral Manipulation
https://www.iahp.com/pages/search/index.php
https://clearpassage.com
https://www.merciertherapy.com (You currently need to email them directly for a referral)
Arvigo Therapy
https://www.arvigotherapy.com/team-members
Sitting
https://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/sitting/faq-20058005
https://www.nhs.uk/live-well/exercise/why-sitting-too-much-is-bad-for-us/
https://www.startstanding.org/standing-desks/10-standing-desk-mistakes/#positions
Stretching
https://www.youtube.com/channel/UCXigFK5hLLF82uZ72jzTvmg/videos
https://www.harpercollins.com/products/beating-endo-iris-kerin-orbuch-mdamy-stein-dpt?variant=32903931691042
https://thepelvicexpert.com/blog/6-simple-exercises-to-ease-endometriosis/
Heat Therapy
https://pubmed.ncbi.nlm.nih.gov/31115522/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6214933/
https://www.researchgate.net/publication/300270473_Superficial_Heat_and_Cold_Applications_in_the_Treatment_of_Knee_Osteoarthritis
Castor Oil
https://nicolejardim.com/castor-oil/
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