CONNECTIVE TISSUE SOFT TISSUE

corticosteroid applications and chronic stress in the athlete? Local applications of cortisone have been used on

tendons, skin diseases and joints to great effect, and these applications are growing steadily. Given that osteoporosis is a well-known effect of long-term corticosteroid therapy, what is the long-term future of athletes who have a long history of injury and cortisone injections? And how does long-term over stimulation of the adrenal gland affect the biomechanics, connective tissue generation and tissue repair of an athlete? Studies into the application of corticosteroids by Dr

Siraya Chunekamrai (11) showed that tissue which had been treated by corticosteroids, became hypocellular and that the corticosteroids stimulated chondrocyte necrosis. The proteoglycan content of the ground substance was also shown to decrease in both content and synthesis. The ground substance as we touched on earlier is key to the support and function of the connective tissue. It surrounds all our cells. It directly influences the passage of gases, nutrients, waste products, hormones, antibodies and white blood cells; while it provides the immediate environment for every cell in the body. To damage or affect the balance of the ground substance is to change the fluidity of our entire connective tissue system. Poor nutrition and any form of trauma, places stress on the body that triggers a response from the HPA axis. This level of response leads to a decrease in ground substance which in turn allows a build up of toxins and foreign particles and compromises the functioning of all cellular activity (7). Depleted levels of ground substance are one of the main factors involved in excessive cortisol levels in the body. Cortisone in some ways stops the healing process of soft tissue and masks underlying pathology, allowing us to continue pain free without any recognition of the initial injury or damage. One study has shown that the chondrocyte cell count decreases by 25% following a cortisone injection (12). This not only has implications for the athlete who returns to sport immediately after injury but to those who are chronically over-trained, tired or who have poor dietary habits. It is very possible that this stress also has long-term health implications. The prolonged production of cortisol also leaves us

open to infection and at the high end of the scale cortisone exposure can also lead to problems like nervousness, sleep disturbance, euphoria and psychosis (8).

MASSAGE AND THE HPA AXIS As we’ve discussed above, cortisol affects the immunological, metabolic and structural function of the connective tissue. This warrants a much deeper investigation into the long-term effects of chronic stress on the HPA axis and the whole connective tissue framework, especially when we consider the recent studies exploring fibroblast activity and its role in cellular communication.

There are three strands of HPA axis management that are important to consider: n Massage - in numerous studies massage has been shown to have an effect on the levels of cortisol in the body, though the exact mechanism by which the effect is achieved is still unclear (9). It appears that the parasympathetic (unconscious) nervous system is stimulated which in turn modulates the production of cortisol. n Manual lymphatic drainage - is particularly useful in treatment of the stagnation of the lymphatic system in

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inflammatory circumstances. Interstitial fluid circulation is increased and promotes a decrease in fluid retention. n Nutrition - can have an effect on the inflammatory response of the body in the face of injury and disease. Examples of this are the pro-inflammatory cytokines that can be suppressed by dietary fish oil (10) and turmeric root, which has been shown to have anti-inflammatory and antioxidant effects.

CONCLUSION These are just a few examples of interventions that can be applied to control a disturbed HPA balance and increased inflammatory response in the body. While none of these can have a singular effective result in the immediate reduction of inflammation with sports injuries (such as occurs with cortisone injections) – together they all play a combined role in each athlete’s health and rehabilitation, without any long term damage to connective tissue health and the internal communication networks. Short-term gains it seems are all too often taken without long term health in mind, especially when so much evidence is coming to light about the multiple roles of connective tissue in our physiology and function. It may turn out to be more sensible to take a conservative approach to our treatment of injury, inflammation and HPA modulation – until the long term consequences of more direct interventions, particularly over a long period of time, become clearer.

THE AUTHOR Humphrey Bacchus CMT NMT practices naturopathic physical medicine in Oxford, UK. He has worked in neurological and orthopaedic rehabilitation and sports medicine

in the UK and USA. For more information visit http:// somahealthcare.wordpress.com

online

References 1. Langevin H, Connective Tissue: A body-wide signalling network? Medical Hypotheses 2006;66(6):1074

2. Langevin H, Cornbrooks C, Taatjes D. Fibroblasts form a body-wide cellular network. Histochemical Cell Biology 2004;122(1):7-15

3. Brook C and Marshall N. Essential Endocrinology. ISBN 0632056150. To order http://bit.ly/bj2O5R

4. Marieb, Elaine. Human Anatomy and Physiology 2009. ISBN 0321584198. To order http://bit.ly/9QJA3g

5. Mancini RE et al. The Action of ACTH, Cortisone and prednisone on the connective tissue of normal and sclerodermic human skin, Journal of Investigative Dermatology 1960;34:393-326

6. Chrousos GP. The role of stress and the hypothalamic-pituitary-adrenal axis in the pathogenesis of the metabolic syndrome: neuro-endocrine and target tissue related causes. International Journal of Obesity and Related Metabolic Disorders 2000;24(Jun):Suppl.2:S50-5

7. Juhan, D. Job’s Body – A Handbook for Bodywork. 2003 pp63-65. ISBN 1581770995. To order http://bit.ly/aUYlV5

8. “Cortisone in Football, Blessing or curse?” - www.fifa.com

9. Moraska A, Pollini R, Boulanger K, Brooks MZ, Teitlebaum L. Physiological Adjustments to Stress Measures Following Massage Therapy: A Review of Literature. Evidence Based Complementary Alternative Medicine 2008

10. Calder P. n-3 polyunsaturated fatty acids and inflammation: From Molecular Biology to the Clinic. Lipids 2003;38:343-352

11. Chunekamrai S. Changes in articular cartilage after intra-articular injections of methylprednisolone acetate in horses. American Journal of Veterinary Research 1989;50:1733-1741

12. Gogia P. Hydrocortisone and exercise effects on articular cartilage in rats. Archives of Physical Medicine and Rehabilitation 1993;74:463-467

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