SOFT TISSUE HEALTH # 6: ANTI-OXIDANTS AND ANTI-INFLAMMATORIES

SOFT TISSUE HEALTH #6: ANTI-OXIDANTS AND ANTI-INFLAMMATORIES

In this particular blog entry I will discuss some nutrient categories that can be very helpful for the overall management of soft tissue health and pathologies, and may be more recognizable "household names" to patients who have been keeping up with the popular literature regarding nutritional supplementation.

Some readers may wonder why we are only getting to discuss them in episode number 6 of the soft tissue health series, assuming they would be brought up much earlier. However the order in which each set of nutrients has been discussed is very intentional and reflects the hierarchy of needs and priorities when it comes to building soft tissues from the ground up. It's not so much that the anti-inflammatory and antioxidant compounds are not important for soft tissue health, but the fact that patients often try to incorporate them without 1st addressing some more basic metabolic nutrients such as oxygen and amino acids, thus putting the proverbial cart before the horses.

Our soft tissues, from muscles to ligaments to tendons, are in a constant state of turnover, the result of adaptation to our environment (both external and internal), and thus subject to episodes of stress, from such things as repetitive injuries, single traumatic injuries, or heavy training with the goal of causing some minor disruption of muscle to increase bulk. The normal repair mechanisms of the human body will best operate in a particular chemical environment with fewer free radicals and within the presence of inflammatory immune molecules that are supposed to be finally regulated to be released for short durations in controlled amounts, but will have a counterproductive effect if present in a chronic state and at higher levels. Unfortunately, most of the modern lifestyle in so-called 1st world countries predisposes people to chronic low-grade inflammation and depleted antioxidant status through the usual culprits: nutritional inadequacies, environmental toxicities, imbalanced stress rest ratio, etc. the problem with this scenario is that our soft tissues are constantly operating in a sort of chemical soup that's unfavorable to the normal repair and adaptation cycle.

Supplementing certain categories of antioxidants and nonpharmacological anti-inflammatory substances can make sense in that context, especially if the patient is experiencing more chronic or intense soft tissue demands. We have a lot of patients with heavy physical demanding jobs, 6 or more days a week for 8 months at a time, with suboptimal availability of rest for example, some patients with very chronic postural stress that is not easily altered with ergonomic modifications, or some athletes on intense training schedules. Under these types of circumstances, even when addressing the 1st 5 building blocks of soft tissue health, they still come come up short unless adding some botanical anti-inflammatory supplements for example.

Anti-inflammatory compounds fall along different categories, but primarily in the botanical family and in the fat-soluble family. Botanicals would include things such as high-grade curcumin extract, boswellia, white willow. Fat-soluble anti-inflammatories would be in the omega-3 family, vitamin A and D family. You could also make a case for categorizing CBD in the fat-soluble compounds.

Anti-inflammatory compounds also come in different families, the so-called "greens and reds" which are high concentrations of greens and berries primarily, bioflavonoids, as well as the glutathione family which is more of a direct red-ox system. The list is long and exhaustive in reality, with a lot of compounds that have both antioxidant/anti-inflammatory activity but also cross over into immune modulation and neurotransmitter/neurohormonal activity. While the basic nutrients outlined in blogs 1 through 5 are more straightforward for patients to self manage, supplementing antioxidants and anti-inflammatory compounds has a lot more nuances, and may be worth implementing with the support of a healthcare professional for maximum outcomes. It is also important to remember that the supplements will only ultimately be most effective when utilized as an additional strategy on top of a robust foundation of the previously discussed nutrients.

SOFT TISSUE HEALTH #4: HORMONES

SOFT TISSUE HEALTH #5: HORMONES

In this section we are trying to condense a very large subject into a blog size entry, meaning we will discuss general concepts without a lot of details.

In sections #1-4, we covered the nutrients needed to build high quality soft tissues, but now we to realize that nutrients are not automatically uploaded into the complex architecture of our soft tissues without some signaling to do so. Part of that signaling involves hormones.

A variety of hormones impact the growth, repair and remodeling of our soft tissues, and as such, hormone imbalances can be a source of low grade chronic poor soft tissue healing and susceptibility to chronic injuries. Below is a summary of the hormone systems that are more closely connected with soft tissue problems.

·       Gender variable hormones, including estrogens, progesterone and testosterone. These hormones are involved in improving flexibility, quality and growth of soft tissues. Women suffer the bulk of gender variable hormone problems because they experience more hormonal fluctuations throughout their lifetime. Soft tissue injuries and pain can flare up at certain times of the menstrual cycle, post partum, and especially in the first few years of menopause when estrogens can drop pretty steeply. Women may be on long acting synthetic hormones that suppress endogenous production. Both men and women can be placed on hormone blocking therapies for years at a time for hormone positive cancers. Males often will go through the equivalent of menopause, or andropause, but more gradually starting around age 50, and while the sexual impact of andropause gets a fair amount of medical attention, the soft tissue symptoms of decreasing testosterone do not.

·       Thyroid hormones: a huge driver of normal cellular metabolism, active thyroid hormones are crucial for soft tissue repair and resiliency. Ask anyone who has delt with hypothyroidism and they will tell you that every tissue in their body seems to hurt and be intolerant to normal activities. Thyroid disorders can be complex, more widespread than recognized with TSH testing alone, and in many instances, not fully balanced with straight T4 thyroid medications alone

·       Anabolic hormones: there are quite a few hormones that have anabolic ( = tissue building) activity, but for the sake of this discussion I will highlight DHEA, pregnenolone and growth hormones. The first two are more closely related to the gender variable hormones through enzyme conversion. They are part of the system often called “ adrenal” in laymen terms. Their main role is to build up tissue. Chronic stress of all forms can shunt anabolic hormone precursors into the cortisol pathway and negatively affect tissue building: mental stress of course, but other forms of stress like sleep deprivation, chronic nutritional deficiencies, chronic infections, toxic exposure, significant thermal stress, chronic fasting etc .  Medications, especially steroids which are widely used, can significantly depress normal soft tissue buildup by suppressing endogenous anabolic hormone production.

·       Insulin: insulin is often overlooked in these discussions, since most people only associate insulin with blood sugar management and diabetes. Insulin is actually a very complex hormone that regulates anabolic activity in many tissues in response to perceived energy availability ( pancreas releases insulin in response to glucose sensors primarily, but also to fatty acid and amino acids, to determine if the body has enough energy on hand to perform a task, such a building up muscle or releasing a fertile egg).  It needs to be present in a healthy normal amounts in order for other hormone systems to be active ( thyroid in particular). Soft tissue health will be affected if the body is in a state of insulin resistance and high BMI ( and can be aggravated by certain diabetic medications), or in a state of very low insulin production, such as excessive fasting, ketogenic diets etc

The bottom line: hormone imbalances can be part of chronic soft tissue disorders, but hormone imbalances are also delicate to work up and treat, and should be ideally addressed with the support of a health professional.

SOFT TISSUE HEALTH #4: AMINO ACIDS AND THE RIGHT KIND OF PROTEIN

The topic of protein adequacy should be a mainstay because it impacts every tissue in our bodies. Instead, it seems to experience episodic popularity in the area of weight loss and muscle mass building, overshadowing other important aspects of our health , such as soft tissue resilience and integrity.

All of our soft tissues are predominantly built on amino acids. What complicates matters is that collagen proteins require a higher percentage of some amino acids that are not well represented in our standard diet, even some protein rich diet: proline and glycine being the most important ones.

Proline and glycine are found in lower concentrations in vegetarian sources of protein, and in higher concentration in flesh protein. Thus vegetarian diets, even if supplemented with vegetarian protein powders like rice and peas, can be lacking the rate limiting amino acids to build strong tendons and ligaments. ( they will be usually adequate to build muscle mass however, but a bulkier muscle anchored by a weaker tendon can actually spell more soft tissue trouble). Moveover, not all animal protein is high in proline, which is not primarily found in muscle meat, but in the connective tissue of the animal you eat. Compared to even a generation ago, the standard American diet animal protein is very muscle based and contains little bone-in, skin, tendons, joints: chicken breast, steak, chops etc… All muscle meat. Contrary to their reputation for being lower quality, meat products such as sausages will often reclaim those “lower cuts” in ground form and give you a better amino acid mix for collagen building. Unless you eat your animal “nose to tail”, as humans have for most of their omnivore history, and continue to do so in many places in the world, you may need to consider a little proline/glycine and collagen support. Thankfully, collagen supplementation has been pretty readily available on the shelves and many patients have empirically found that their frame functions better when they take them, not just because collagen helps articular cartilage, but because proline ang glycine helps shore up tendons and ligaments

SOFT TISSUE HEALTH #3: HYDRATION ( WATER + ELECTROLYTES)

The topic of adequate hydration has already been debated to death, and the general public has a bit of fatigue in implementing the right hydration practices into their routine, much less listening to anything on the topic in the first place.

Getting enough water is obviously crucial yet in this part of the discussion, I want to talk about two lesser known, yet important aspects of hydration, when it comes to soft tissue health.

·       Hydration is not equal to water alone. Hydration means maintaining the right amount of fluid in the right ionic concentration in tissues. This can only be achieved if water is anchored with the right minerals that can “hold” the water and prevent it from being flushed out. I have run into many patients over the years that tell me they are constantly drinking but never feel hydrated, because they seem to urinate right away any water ingest. This phenomenon is real and is corrected by ingesting the right balance of salts and minerals along with water. This becomes a problem for many reasons that can get complicated and well beyond the scope of this blog. The two main culprits are the standard American Diet lacking high quality sources of magnesium, potassium, calcium and other trace minerals, while being overloaded with refines salts ( which unlike naturally occurring salt in food, mined salt or sea salt, contains nothing beyond plain sodium). The second is the overmedication of most of the US population, both prescription and over the counter, with many of these pharmaceuticals altering mineral balance long term. Besides improving their diet, some patients with chronic soft tissue problems may need to speed up their recovery with mineral supplementation. The most common ones we tend to use are the C-M-K ( calcium, magnesium and potassium), as well as some of the homeopathic cell salts.

·       Most patients understand that muscular function, especially cramp prevention, is affected by salt and mineral deficiency. Few seem to know that the quality and resiliency of collagen is affected by the excessively common magnesium deficiency, leading to greater susceptibility to chronic injury. Even fewer know that hydration keeps various adjacent layers of soft tissue from developing adhesions with each other during the normal friction of movement. The latter is probably one of the best kept secrets in the world of chronic myofascial dysfunction, where practitioners spend a lot of time releasing bound fascia to find it stubbornly rebounding to its original contractures and adhesions.

In summary, patients would be wise to keep adequate hydration by paying attention to the interventions mentioned above. When it comes to water alone, we should also all be wise in recognizing that the modern lifestyle is rife in stimuli that tend to suppress our natural thirst response, and that keeping a visual reminder of how much water we drink, such as pre-filling a few water bottles to be emptied out before retiring for the night, will go a long way to make up for it.

SOFT TISSUE HEALTH part 2: oxygen

The second item in the soft tissue health series is a nutrient that we often overlook, although we could not survive without it more than 3 minutes: oxygen.

Oxygen is important in many metabolic processes of our soft tissues, but I want to circle in on two specific functions: tissue flexibility and energy production. Soft tissues such as tendons can “fatigue” much more easily, manifesting as lowered endurance during activities and longer recovery time, when tissue oxygen concentration is reduced.

Perhaps the most significant manifestation of low tissue oxygen concentration however, is the inability of soft tissue to heal and repair with tissue of equal elasticity. The reason being that the type of collagen that is highly elastic can only be manufactured with a high oxygen saturation, while harder, less flexible types of collagen can be manufactured under much lower oxygen concentrations. The end result is post trauma changes in the soft tissue that feel firm, stiff, “string like”.

Oxygen is closely linked to the first topic of blood flow. While there is a lot of overlap between the two, there are still distinct situations when blood flow is adequate but oxygen concentration is not: chronic respiratory problems ( asthma, COPD), smoking, and chronic low grade anemia . Those are ongoing medical conditions that can really compound soft tissue problems from other sources.

There is a category of nutritional supplementation that helps improve oxygen delivery to peripheral tissues ( nitric oxide modulators), as well as some DME device ( PEMF), that can help make up for some of those issues, but ultimately addressing the underlying reason for low oxygen tissue concentration is the most effective way to resolve the problem.

Photo courtesy of Freepik

SOFT TISSUE HEALTH Series: #1, BLOOD

This is another overdue blog series, long overdue actually. I keep telling patients with whom we have discussions about chronic soft tissue problems throughout their bodies that I'm going to put the summary of our recommendations in writing in an easy patient reference on our website. But it's a bit of a bigger brainchild than some of my other blogs and has required a bigger bandwidth of time than I've had for a while.

This series is designed to address some key concepts about what is basic necessity to keep your soft tissues healthy, and self repairing. By soft tissues and I mean anything that's not a bony tissue, ligaments, tendons, muscles, fascia .The key nutrients that maintain soft tissue health and self repair are often a little different than what our patients understand, leading them to invest a lot of time resource and energy in the wrong solutions.

Soft tissue problems can be manifested in any part of your neuromusculoskeletal system, and can be very local and regional, related to injury, or widespread, which may have more of a metabolic component. They affect the spine and the limbs. This series of informational blogs would be especially geared towards people who have either widespread soft tissue pain and susceptibility to injury with poor repair, as well as patients who had one major soft tissue injury and do not seem to be able to recover on schedule.

The 1st nutrient we need to talk about in regards to soft tissue health is blood flow. Without adequate circulation to soft tissues, key nutrients that will be described in later blogs, such as oxygen, glucose, electrolytes cannot be delivered to the tissue. Blood flow is of clinical relevance because the mechanism of blood delivery to soft tissues can be easily impaired by trauma, both single acute trauma as well as repetitive sub traumatic forces.

Blood flow to tissues can be suboptimal under many circumstances, some of them general and metabolic and some of them more local:

– cardiovascular issues with low cardiac output, general cardiovascular deconditioning (the latter is more prevalent than people realize), medications that slow down the heart rate

– peripheral vascular disease that narrows blood vessels, especially small blood vessels called capillaries ( think diabetes and pre-diabetes)

– autonomic dysfunction affecting normal dilation of blood vessels under increased demand such as physical activity

– peripheral vascular disease such as obstructed blood vessels from atherosclerosis or calcification, especially if it affects large arteries going into the limb, for example the femoral artery

– smoking. It has a huge impact on the health of blood vessels, making them less flexible, and more easily permanently contracted under the effect of nicotine, decreasing peripheral blood flow.

– Scar tissue in the muscle from previous injuries. I find that to be the most common issue outside of the above general health and metabolic issues. Injuries, both single traumatic injuries and repetitive micro trauma such as repetitive strain injuries, can result in replacement of normal flexible connective tissue with much harder shorter and less flexible collagen, which prevents the normal extension of fine blood vessels and decreases the amount of blood flow perfusing through peripheral tissues. This cycle of decreased blood flow from scar tissue is further aggravated under certain circumstances including cold exposure, and varying degrees of additional muscle spasm, or certain compression garments.

Addressing blood flow issues for soft tissue health will obviously depends upon the nature of the blood flow interruption. In some cases, it's more easily achieved than others, as the case of some cardiovascular conditions and medications that are nonmodifiable, and will require some adjustments of soft tissue recovery expectation as a result.

Photo courtesy of Freepik

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WHAT IS WRONG WITH STOMACH SLEEPING ?

Steve and I were reflecting recently on the patient conversations we find ourselves repeating over and over again like a broken record. One such conversation pertains to sleeping position, and in particular stomach sleeping.

As a reformed stomach sleeper, I can appreciate how unpleasant of a conversation it is to have with your healthcare provider when you're told that your problem is not going to improve much or beyond a certain recovery point without changing sleeping position. But it's a necessary conversation because of what you do for 8 hours a day, or about 1/3 of your life, can have a profound impact in unraveling what we do in the office for 15 minutes much less what a patient may be doing with home exercises at home for 20 minutes a day.

In this brief video Steve and I demonstrate 3 areas of major mechanical stress associated with stomach sleeping, namely the mid to lower next, the lumbosacral spine, and the shoulder. The 4th slightly less common area of stress as the jaw, which is going to be asymmetrically chronically pushed to one side with the pressure of the mattress and pillow on the chin.

Some patients have tried to mitigate the impact of their stomach sleeping position with a few retrofits such as chest pillows with a forward face slot, and other retrofit pillows that take the rotation out of the neck, but ultimately the only long-term sustainable solution is to switch to side or back sleeping. It's a transition that will take anywhere from 3 to 4 weeks and requires some sleep interruptions. My recommendation has been for the patient to secure a fairly long pillows such as a king size pillow or a site sleeper pillow to wrap the upper arm and leg into three-quarter prone position, with a good site sleeper pillow, so that the patient may not roll all the way onto the stomach in their sleep. The patient will often wake up as they attempt to do so, and have the opportunity to reposition themselves. Over time, the body will break the automatic reflex to roll over during your sleep. It's an uncomfortable process but worthwhile in the long term.

https://www.youtube.com/watch?v=yC0Piw8vwf0

pillow stacking

Pillow conversation and questions come up frequently. At some point I would like to have an in person workshop where we have people try all sorts of different pillows since it's an incredibly individual need and there is not a one-size-fits-all answer beyond the general recommendations for site sleepers and back sleepers.

In the meantime I wanted to touch base and easy hack for side sleepers. The biggest issue for this population is having a pillow that adequately bridges the distance between the shoulder tip (minus the few inches it sinks into whatever thickness top player you have on your mattress), and the ears/head. Once you take into account pillow packing down, it's quite a bit thicker than most people realize. In that regard very often people have pillows that are too thin when their site sleepers, especially with an older pillow. After about 6 months of nightly use, a regular pillow will have packed down quite a bit from its original thickness. Sometimes you can restore life to an existing pillow by adding just enough base thickness to bring it up to correct height and cervical alignment. There are a couple simple materials to achieve that. This also can help you test out what eventual thickness of pillow you need to be looking for before you go and buy a new pillow.

https://www.youtube.com/watch?v=GEFrO45vGwM