The Healing Cascade: Implications of Nutrition and Tissue
With the changes in healthcare, the pursuit and pressure for quicker outcomes is at an all-time high. Healthcare costs are rising and the lockdown on reimbursement is in full force. While quicker outcomes can be a good thing, one must still respect the physiology and timetable of healing. That being said, there may be other ways in which we can enhance this process that many of us as therapists are not looking at—nutrition. Not only can proper nutrition enhance body composition, leading to less stress on our tissue, but it also plays a role throughout the healing process as our needs change depending on where in the cascade of healing our patient lies. Food choices and supplements may allow for controlling inflammation and can help with tissue regeneration following injury.
Injured tissues go through the same process of healing, called the healing cascade. Timing for how long each tissue is in each phase will change, and there are differences in the collagen and hormonal output with each different tissue, however the general principles of the cascade remain constant. The stages are as follows: Inflammation, Proliferation, Maturation and Remodeling. The following will be a multiple part series in which we take an in-depth look at each phase of healing.
Inflammation 1-6 days (2-3 weeks if bone) post injury
The inflammatory stage is crucial for healing and is extremely similar in each type of tissue. The main differences between each tissue are the amount of blood flow, the amount of cell nuclei, and the total time of inflammation. The body will respond both locally and systemically following tissue damage.
The injury itself causes damage to tissues and blood vessels, thus leading to cell death and blood flow into the extracellular matrix. Locally, blood vessels at the injured tissue vasoconstrict to decrease bleeding. A clot is formed in the gap formed by the rupture of tissue by platelets that create immune chemicals (cytokines,histamines, and oxygen radicals) and a number of growth factors. These immune chemicals act as mediators of the entire healing cascade. Necrosing factors and growth factors pour into the area to kill damaged cells and begin the process of rebuilding new cells. Within minutes prostaglandins and leukotrienes bring in neutrophils, the most abundant type of white blood cell key in fighting infection, and other macrophages to clear the area of dead and injured cells. Just upstream of the injury nitric oxide stimulates vasodilation in order to increase area for clearing of dead cells and prepare the body for the next stage of healing, proliferation.
Systemically, the sympathetic nervous system is ramped up for fight or flight. Increased sympathetic activity results in increased energy need, increased oxygen consumption, increased metabolic rate, increased temperature, and increased catabolism. An abundance of cortisol (nature’s strongest anti-inflammatory), glucagon (to enhance energy production through the mobilization of glucose), and human growth hormone (to begin rebuilding) rage into the bloodstream. Nociceptive input is sent to the brain which is interpreted as pain as the central nervous system assessed what danger the body is in and whether it needs to fight or flee. (For further information on pain check out Keaton Worland’s Stress and Pain). This process usually lasts 4-6 days post injury unless it is a bony injury, in which case the inflammatory process can last 2-3 weeks.
Important Nutritional Information During the Inflammation Stage of Healing
During the inflammation stage of healing, it is important to understand inflammation is necessary and to not immediately gobble down loads of anti-inflammatories as this will significantly slow down healing. (The same goes for workout nutrition…don’t mess with natures way of rebuilding). Most of our anti-inflammatory vitamins, minerals and herbs will be recommended in the next phase of healing, proliferation, or if inflammation is getting out of control. You will also want to avoid vitamin E as it is an anti-coagulant and will inhibit the formation of the initial clot needed for the scaffolding used to repair the damaged tissue.
Vitamins and minerals that we may need to supplement during the inflammatory phase of healing include vitamin A, vitamin C, copper, and zinc.
Vitamin A: Supplement for 1-2 weeks post injury
25,000 IU/day (Trauma/surgery) 10,000IU/day (Sports Injury)
Vitamin A is important in reversing immune suppression and enhancing the inflammatory response. It helps aid in building strong cross bridges of collagen formation.
Sources of vitamin A include red, orange, and yellow fruits and vegetables, green leafy vegetables, eggs, and dairy.
Vitamin C: Throughout injury process
1-2g/day
Judging by the amount of people guzzling down fizzy AirBorne or Emergen-C drinks during the cold and flu season, you already know vitamin C is an extremely important modulator of immune system function as it enhances neutrophil and lymphocyte activity (both white blood cells important in immunity). What you may not know, however is that vitamin C, like vitamin A, is also key in strengthening collagen cross bridging. If deficient in vitamin C or vitamin A, weaker collagen bonds are formed, leading to weaker “healed” tissue, and potentially higher risk for re-injury.
Sources of vitamin C include green leafy vegetables, broccoli, parsley, peas, potatoes, citrus, kiwi, mango, peppers, strawberries, asparagus, and cauliflower.
Copper: Supplement for 1-3 weeks post injury
2-4mg/day
Copper increases red blood cell formation and regulates gene expression. More red blood cells, means more oxygen and more nutrients to damaged tissue. It is also plays a key role in producing elastin, one of the major types of collagen that allows for spring in tissue.
Sources of copper include crab, cashews, sunflower seeds, hazelnuts, almonds, lentils, mushrooms, nut butters, chocolate, soy beans, and organ meat.
Zinc: Supplement for 3 weeks post injury
Zinc is a major player in a number of enzymatic reactions throughout the body. It also aids in cell division, DNA and protein synthesis, and collagen deposition. Essentially, everything rebuilding revolves around zinc being at adequate levels.
Sources of zinc include sesame seeds, pumpkin seeds, crab, poultry, wild game, beans, cashews, chickpeas, almonds, yogurt, mushrooms, oysters, and shrimp.
As mentioned earlier, injury is a stressful situation for the body in which energy needs increase dramatically. Energy needs during injury increase between 15 and 50 percent depending on the type of injury. It is important during this time not to increase stress to the system by being deficient in macro or micronutrients. If you are sedentary (we can talk about the need for increased activity later), you may need to increase the amount of good, nutritious food you are eating to make up for this increase in energy needs for repair. Do operate in a caloric deficit while injured as this increases stress to an already stressed out system and will prolong inflammation. For those of you that are active, though your activity levels will decrease your energy demands will not drop to the point of you being fully sedentary. You will likely have to drop your caloric intake somewhere between your active level and sedentary level.
Making sure you are not deficient in micronutrients is always important even when you are not injured. If you are worried about being deficient in your vitamins and minerals, consider taking a test from WellnessFX. They allow you to test blood levels of different substances, check those levels online, and talk with licensed health professionals about your results.
This takes us through the inflammation process, in the Part II of The Healing Cascade: Implications of Nutrition and Tissue we will discuss the next phase of healing, proliferation.
References:
Rand E, Gellhorn AC. The Healing Cascade: Facilitating and Optimizing the System. Phys Med Rehabil Clin N Am. 2016. 27: 765-781.
Berardi J, Andrews R. The Essentials of Sport and Exercise Nutrition: Certification Manual. 2nd Ed. Precision Nutrition Inc. 2013.
Jamieson J. Nutritional Strategies. http://www.8weeksout.com/module/nutrition-strategies. Accessed February 24, 2017.
