Whether we are dealing with a sports injury or a motor vehicle accident we have to ask ourselves two questions.

• What can we do to facilitate and accelerate the healing process?
• Are so called un repairable tissues such as articular cartilage really un repairable?

Correct and adequate nutritional support accelerates the recovery and healing process. Interestingly, connective tissues that was once thought to be un-repairable, is now found to be repairable. There is now scientific evidence to support that micro-environmental stimuli (nutritional therapy) is a key factor in connective tissue repair. For example, chondrocytes were once thought incapable of producing new articular cartilage. But this is apparently not the case (3). By creating the correct nutritional environment we can stimulate new growth and accelerate the repair process. (3)

The key to treatment includes an understanding of the normal physiology of connective tissue injuries, adequate support of the appropriate healing responses, and the suppression of any inappropriate responses.

Connective tissue repair is a elaborate process that encompasses biochemical and cellular reactions that start with inflammation. Although inflammation is a natural response to injury, it is important to keep it in balance. While prolonged inflammation causes pain and dysfunction, complete pharmaceutical suppression of the inflammatory response results in delayed healing. (1)

Inflammation

There are three phases of inflammation:

	In the first phase, there is an increase in capillary permeability in the area of injury. This increase in permeability causes a corresponding increase in osmotic pressure, resulting in movement of protein and fluid from the blood vessels to the area of injury. This protective mechanism inhibits further tissue damage. (4)
	In the next phase, fibrin begins to coagulate and becomes trapped resulting in fluid retention. This process, if continued, inhibits the bodies ability to initiate healing.(4)
	In the final phase, fibrin and its cofactors break down. As a result osmotic pressure is decreased, this in turn decreases the associated pain. Obviously it is advantageous to reduce inappropriate inflammatory responses to break the pain cycle and initiate remodeling of connective tissue. (3,4)

Controlling inflammation

In addition to joint manipulation and soft tissue techniques, the following methodologies are recommended for the control of inflammation.

Proteolytic Enzymes	These anti-inflammatory, protein-dispersing substances assist in the displacement of protein exudate from the damaged area (8). Example of these substances include: Papain, Trypsin, and Chymotrypsin. Typically these should be taken 4-5 times per day during the acute phase and reduced to 2 times during the sub-acute phase.
Vitamin C	Vitamin C has powerful anti-inflammatory properties especially when combined with the proteolytic enzymes. In fact, the combination of these two may be stronger than many prescribed anti-inflammatory drugs without the adverse side effects. Vitamin C should be taken to bowel tolerance as described in the following section.
Zinc	Zinc is one of the major trace minerals that is needed as a regulator for enzymatic reactions that result in the reduction of inflammation and tissue remodeling. (2) Take 50 mg. of zinc pincolinate per day for 2 weeks. Note: Prolonged intake of zinc at high levels may cause immune suppression.

Tissue Remodeling

Connective tissue remodeling and repair requires chondroycte activity, the production of ground substance, elastin, and collagen fibers. By understanding the constituency of these substances we can better determine the recommendations for nutritional support.(5)

Ground Substance	Proteoglycans are one of the major constituents of ground substance. Proteoglycans are long chains of carbohydrates attached to a protein. It is the proteoglycans that give connective tissue its compressional strength and pliability. These substances are also referred to as GAG’s (glycosminoglycans). The GAG’s found in connective tissue are keratin sulfates, chondrotin sulfates, and hyaluronate.(5)
Elastins	These substances are proteins which provide elasticity and pliability to connective tissue. Approximately one third of elastins fibers are comprised of glycine. There are also high levels of proline found in these fibers.(5)
Collagen fibers	Collagen fibers are composed of amino acids bent into a triple helix configurations known as a tropocollagen unit. These tropocollagen units form into bundles called micro-fibrils, which in turn are cross linked to eventually form collagen fibers. The tensile strength of connective tissue is derived from these collagen fibers.(5)

Specific Nutritional Support for Remodeling

The quality of ground substance, elastin, and collagen fibers are dependent on the supply of amino sugars and amino acids. Vitamins and minerals also play important roles since these substances are regulators for enzymatic reactions in the remodeling of connective tissue. The following substances are recommended as nutritional support to accelerate and enhance the remodeling process.

Vitamin C	Vitamin C besides having anti-inflammatory properties, is fundamental for tissue repair. Research has shown that vitamin C induces remodeling of the collagen pathway (14). In addition vitamin C is also a free radial quencher or antioxidant. What is even more remarkable is that Vitamin C will regenerate other antioxidants, especially vitamin E. Vitamin C supplementation should be taken to bowel tolerance for the first five day. Start at 3000 mg per day in divided doses, and increase by 1-2 thousand mg. per day until bowel tolerance is reached. If loose stool occurs, the patient should back off by one thousand mg each time until normal stool formation is achieved. This supplementation level may seem extremely high, but they are not. Noble prize laureate Linus Palling demonstrated that high dosages must be implemented to achieve the desired results. (2)
Vitamin E	Vitamin E’s main contributing effect to the repair of connective tissue destruction is in its antioxidant capabilities. Neutralizing free radical reaction is very important since these substances predominately affect the polyunsaturated fats that compromise the lipid portion of cellular membranes.(2) Consequently unchecked free radical reactions can significantly damage the cells that are responsible for tissue repair. Supplementation should be taken at 600 iu. per day for the four weeks following the injury. (7)
D-Glucoruonic Acid Supplementation:	One of the major problems with tissue destruction is the formation of free radicals. Free radical damage is typically associated with many chronic inflammatory disorders, injuries to the central nervous system and connective tissue injury. Suppression of free radical formation aids in the remodeling process. D -glucoruonic acid is a constituent of hyaluronic acid, which in turn forms the back- bone of proteoglycans. Proteoglycans act as a free radical scavenger or antioxidant. Synovial joints in particular contain high levels of D-glucoruonic acid. During the acute phase, supplementation should be taken 4 times per day for the first 5 days, then dependent on the severity of injury, reduced to 2 per day for the next two to six weeks. (6)
Glucosamine sulfate supplementation	This amino-sugar is again a fundamental component of proteoglycan formation(6). Glucosamine has shown promising results in promoting cartilage growth and inhibiting cartilage degradation. It is interesting to note that this also applies to osteoarthritis. During the acute phase, supplementation should be taken 4 times per day for the first 5 days, then dependent on the severity of injury, reduced to 2 per day for the next two to six weeks. (6)
Essential and sulfur containing Amino acids	Amino acid supplementation helps support all three major components of connective tissue; ground substance, elastin and collagen formation. The amino acids proline, lysine and cysteine also help to maintain a positive nitrogen balance. Nitrogen balance is often disrupted during tissue injury. During the acute phase, supplementation should be taken 4 times per day for the first 5 days, then dependent on the severity of injury, reduced to 2 per day for the next two to six weeks. (6)

The Chiropractic Adjustment

No matter how good the nutritional support is, it will only have limited benefits if it cannot be delivered to the affected area. Often with connective tissue injuries we are dealing with articular cartilage in an avascular tissue.

Due to the lack of blood supply, chondroyctes do not receive the steady supply of nutrients that other tissues do. Therefore articular cartilage must absorb nutrients from their surrounding environment.

This is where the Chiropractic Adjustment can facilitate the delivery of essential nutrient for the repair of injured areas. Compression and decompression of the surrounding tissues during an adjustment facilitates the delivery of the required nutrients.

References:

1. Bucci L.R. Nutrition applied to injury rehabilitation and sports medicine CRC Press: Boca Raton 1995
1. Champe Pamela C. Biochemistry: Illustrated reviews, 1987.
1. Bland JH, Cooper SM. Osteoarthritis: a review of the cell biology involved and evidence for reversibility, management rationally related to know genesis and pathophysilogy. Seminar in Arthritis and Rheumatism.
1. Alberts, Bray, Lewis, Raff, Robert, Watson, Molecular biology of the cell 1983.
1. Styyer L Biochemistry 2nd ed. San Francisco: W.H. Freeman and Co. 1975
1. Sato H. et al Antioxidant activity of synovial fluid, hyluronic acid, and two subcomponents of hyaluronic acid, Arthritis and Rheumatism 1988;31 (1):63-71.
1. Niki E. Interaction of ascorbate and alpha tocopherol. Third conference on Vitamin C. 1987; 498:187-98
1. Guyton, Textbook of medical physiology 1986, W.B. Saunders Co.

Author: Dr. Brian Abelson
Co-author and Editor: Kamali Abelson: Rowan Tree Consulting Ltd.
Kinetic Health®
Bay #10, 34 Edgedale Drive N.W.
Calgary, Alberta, T3A-2R4
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