1. INTRODUCTION

There are identifiable principles of healing*.

Treatment can either support or interfere with the natural repair process. Interfering only delays healing, and research has shown this increases the risk of a chronic injury with secondary symptoms at a later stage. Supporting the natural healing tendency (principles) allows healing within the minimum time required and limits any secondary and systemic consequences. Healing completes itself when not interrupted or prolonged by uninformed strategies.

*Healing = repair, recovery, or transformation.

2. BASIC PRINCIPLES

1. The injury-recovery process occurs on multiple levels and systems, which are interconnected.
2. The central systems and vital organs heal first, only then can the healing of the peripheral systems be supported.
3. The central systems are concerned with regulation and homeostasis.
4. The function/s of the vital systems are a prerequisite for the maintenance of the peripheral
   systems. They are “the pillars” of the recovery process.
5. If a muscle won’t heal, it could be due to dysfunction in the central systems & vital organs.

2.1 PRIORITY OF THE RECOVERY PROCESS.

The Nervous System

• The Autonomic Nervous System (ANS)
• The Stress Response (“injury shock”)
• The Endocrine System (hormones)

Vital Systems + Organs

• The Cardiovascular System + Heart
• Blood Circulation + Flow
• The Digestive System

Ground Regulation (Homeostasis)

• Extracellular Matrix (ECM)
• Fascia
• Lymphatic Circulation + Flow

Soft tissue + Muscle +Joints

• Ligaments
• Tendons

The ligaments/tendons are not a priority and will only heal if the central systems are otherwise healthy and strong.

2.2 STRUCTURE OR FUNCTION?

PRINCIPLE: Function drives anatomy.

Function precedes form. Function (regulation) is causal, and structures are consequences. This means, that with a muscle, connective tissue, or joint injury – the focus of treatment must be on restoring function (regulation), not structure.

If function is supported, structure is spoken for. It heals automatically, correctly and completely. Conventional treatments (RICE) and surgery places focus on symptoms and structural integrity at the cost of function. Treating symptoms only treats “effects” and does not address causes (function).

Mechanobiology is a causal/functional principle (amongst others).

3. HEALING THE CENTRAL LEVELS FIRST

PRINCIPLE: Inclusivity

Structure AND function or, Central AND peripheral mechanisms, constitute two sides of the repair process, neither to be neglected at the cost of the other.

REST AS EXAMPLE:

If we suggest more rest, we don’t mean rest at the cost of movement, we mean more rest AND
movement is important for healing. More sleep & rest is the basis of repair, inclusive of movement – not rest at the cost of movement.

PRINCIPLE: Injury activates the stress response of the central nervous system.
Homeostasis is disturbed. The “first” priority is nervous system recovery.

PILLARS OF NERVOUS SYSTEM RECOVERY:

1. Limit stress, cortisol & inflammation.
2. General “cooling off” * or “slowing down” allows the parasympathetic nervous system to restrain injury-stress.
3. Hydration & supplements for recovery.
4. Sleep & rest – protein synthesis & tissue repair occurs with sleep & restoration.
5. *General “cooling off” is a functional strategy (supportive) – it is not the same as icing a
   structure (interference).

4. HEALING OF THE PERIPHERAL LEVELS

The stages in the injury and repair process are:

1. Mechanical or chemical impact to tissue

• Destroys the current tissue arrangements.
• Tissue is de-arranged & unstable.
• Tissue tensions are disturbed.
• Swelling occurs (fluid displacement).
• Clotting & fibrotic processes encapsulate & isolate the injury-site.

The body will always move towards homeostasis. The following steps may follow:

2. Inflammation (if required)

• Increases tissue temperature.
• Chemical & thermal destruction of old tissue.
• Returns tissue to a plastic & malleable medium.
• Source of signals to orchestrate repair.

3. Removal of old tissue

• Enzymatic destruction (denaturing proteins).
• Clearance by immune cells (macrophages).
• Removal of waste & swelling by circulation (lymphatic drainage).

4. Synthesis & formation of new tissues

• Activated stem-like cells i.e. fibroblasts secrete tissue components of the ECM.
• Progenitor cells differentiate and mature i.e. satellite cells → myofibroblasts → muscle fibres.
• Mechanical tensions & chemical gradients co- ordinate the process.

5. Integration & interconnection

• Formation of new membranes (epithelisation), cell-fascia connections (integrins), new blood vessels (angiogenesis), new lymphatic vessels (lymphangiogensis) & nerve-connections (synaptogenesis).
• Restoring circulation & innervation – to supply further growth of tissue.

6. Remodeling & maturation of tissue

• Mechanotransduction develops the tissue to attain the required & matured tissue properties with adaptations of strength, flexibility etc.
  *The steps are not exclusive & interconnect via complex switches. The signaling is enormous.

5. SUPPORTING/INTERFERING CRITICAL STEPS

PRINCIPLE: Swelling & inflammation is required.

This is a radical & heretic view in terms of the conventional treatment paradigm that treats
effects & symptoms with i.e. “icing” & NSAIDs to reduce swelling, inflammation & pain.

1. SWELLING:

-Swelling is the mechanism by which the body establishes fluid homeostasis in the context of the
injury.
-Swelling is the return of tissue to a primordial, undifferentiated, homogenous & plastic state –
that must precede differentiation & maturation.
-Swelling is a molecular-fluid matrix that attracts, conducts & anchors mechanical tension, pressure, chemical & temperature gradients across wounded tissue & injured joints.                      -Mechanochemical gradients are required to co-ordinate repair (differentiation).                             -Swelling encapsulates & embeds cells, signals and tissues in the required medium.
-It is there for a reason.

2. INFLAMMATION:

• Injury-stress is often followed by inflammation.
• Inflammation is the mechanism by which the body increases the local tissue temperature.
• Tissues transform from the de-arranged state to a new differentiated state.
• Swelling is the fluid within which temperature changes occur. Swelling AND inflammation are required.
• Increased tissue temperature attracts the repair processes i.e. increased circulation (blood flow &lymphatic drainage) & increased nerve conduction (ANS-ECM feedback & reflexes).
• Increased blood flow delivers nutrition &increased nerve conduction delivers action potentials (nerve currents).
• “Healing is born from the fire of inflammation.”
• Research shows that cooling with ice & NSAIDs may suppress swelling & inflammation, but this only delays regeneration!
• Delaying increases the risk for chronicity.

5.1 CAUTION & COMMON SENSE

PRINCIPLE: Distinguish between life-threatening trauma & other types of injuries. Restoring function is a first priority.

• With extreme pain & discomfort it is prudent to remove some swelling & inflammation with
  Icing/NSAIDs, as this restores function, which is required for structural repair & recovery.
• Icing/NSAIDs are not cures – as they do not address causes, but their application is to restore. function when needed.

5.2 RATE OF REPAIR/REGENERATION

PRINCIPLE: The repair process may be over-stimulated, hyperactive & “out-of-control” (hyper) or stagnant & dormant (hypo).*

“HYPER”:

-If hyper-activated, painful or “out-of-control”–Icing & NSAIDs restrain the process, so that a
person may cope with recovery.
-If transformative processes become destructive Icing/NSAIDs become appropriate.
-“Out-of-control” inflammation impairs healing.

“HYPO”:

-Processes may be stagnant due to inadequate mechanical & nervous stimulation or inadequate
inflammation & signals (tissue temperature).
-Methods that trigger the process are appropriate:

Mechanical loading, manual therapies, local irritation, acupuncture, heat & warm baths etc.
-Temperature gradients co-ordinate healing. COLD SLOWS & RESTRAINS, HEATING ACTIVATES!
*Diagnostic measures are lacking, use experience.

5.3 TENDONOSIS/TENDINOPATHY & TENDINITIS

Repair & recovery of tendons is a last priority; therefore, prone to stagnation & chronicity.
The repair process often does not complete – reasons are not clear, and because of this Appropriate stress/loading is needed on tendons to gain tolerance, adapt and heal.
●Ensure the recovery of central systems & function (regulation).
●Distinguish tendonosis/tendinopathy & tendinitis.

TENDONOSIS/TENDINOPATHY:

-Is “angiofibroblastic hyperplasia” – there is no inflammation, but de-arrangement of tissue
elements i.e. collagen III & fibroblasts (fibrosis).
-Tissues fail to reconstruct, mature & remodel due to absence of adequate mechanical forces,
nervous stimulation or inflammatory signals &heat (energy thresholds). Is a “maladaptation to
mechanical loading”. The repair process is unresponsive.
-It may be appropriate to induce inflammation with mechanical or chemical means at the site of
injury to trigger the response.
-Apply methods that trigger tissue-reconstruction: Mechanical loading, manual therapy & friction
with heat & warm water immersion. Friction may include “deep friction massage” & scraping of the skin to induce histamine, heat & blood flow etc.

TENDINITIS:

-Refers to chronic or “out-of-control” inflammation.
-Stress & inflammation must be restrained.
-Surgery constitutes stress that leads to hypermetabolism & inflammation.
-See treatment guidelines for nervous system recovery, icing & NSAIDs.

5.4 MECHANOTHERAPY

PRINCIPLE 1: The principles of mechanobiology can be used to stimulate tissue repair &
remodeling (#4,5&6of the repair process).

-Mechanotransduction is the conversion of mechanical forces into chemical signals via the
cell-ECM (integrins) & cytoskeletal-nucleus interconnections, culminating in gene
transcription & protein synthesis i.e., collagen I.
-Mechanical forces stimulate the differentiation of progenitor cells into mature & functional cells.
-Movement AND manual therapy can be used.

PRINCIPLE 2: Energy input or extraction from tissue alters viscoelastic properties.

-Hyperplastic de-arranged tissue lacks organization, stiffness, elasticity & rigidity.
-It is cold, dry, brittle & prone to injury.
-It cannot withstand forces or conduct signals.

Ice prevents & slows:
-Mechanical signaling,
-Nervous signaling and
-Protein synthesis (metabolism).

6. THE LYMPHATIC SYSTEM

-The lymphatic vessels are connected to the ●ECM & are also abundant at ●joints. *
-They play a role in fluid circulation, provision of ECM-substances (i.e., glycosaminoglycans)
trafficking of immune molecules & signals and drainage & removal of fluids, waste & heat.
-If swelling and/or inflammation is pathological it may be due to the restriction of lymph flow.
-Before treating swelling & inflammation (#1&2of the repair process) with Icing/NSAIDs
methods may be used that activate & assist the lymphatic system (#3of the repair process).
-Mechanical load AND manual pressure/friction can assist lymphatic functions (“lymphatic
drainage massage”).
-Mechanical loading or manual pressure/friction can restore fluid-composition (proteins/cytokines), osmotic & hydrostatic pressure AND viscoelasticity of tissue.

*Swelling in soft tissues is called edema & swelling at joints (synovial fluid) is called effusion.

PRINCIPLE: Whereas the flow dynamics between tissue &blood-vessels (which is a closed system) is linear &governed by the Starling hypothesis, the flow between tissues/ECM & lymphatic vessels (which is a non-linear & open system) can increase exponentially, when pressure or volume is-Increased flow between ECM & lymph can then aid the repair process significantly.

-Impaired flow-mechanics can alter cellular metabolic ATP-usage.

6.1 GUIDELINES

LIMITATIONS IN FLOW MAY BE DUE TO:

– Vasoconstriction (ANS tonus)
– ↑Resistance in vessels & tissues
– Passivity/rigidity of ECM/fascia
– Congestion of vessels & ECM
– Overloading of lymphatic vessels due to extent of injuries & repair.
– Stagnant ECM & lymphatic flow due to lack of adequate mechanical force and fluid-tissue pressures.

THERAPY MUST RESTORE:

– ECM/fascia compliance/viscoelasticity
– Fluid-pressure and flow-dynamics
– Osmotic balance (hydration, electrolytes, amino acids)
– ANS-tonus

ICE:

Ice cannot assist flow but slows it down further. Ice/cold below 15°C can increase swelling +
inflammation.

7. GENERAL RECCOMENDATIONS

1. Rest is initially appropriate and must continue.
2. Active movement with mechanical loading must be undertaken as soon as possible to utilize.
3. The principles of mechanotransduction in tissue repair and remodeling.
4. Manual therapy can also provide mechanical signaling i.e., deep friction massage. This decreases healing time.
5. Treatment of swelling/inflammation with cold/NSAIDs must be prudent. These delays healing time and leads to chronicity.
6. Support circulation with active movement & massage.
7. Adequate hydration & diet.
8. Application of heat or warm water immersion may lead beneficial biophysical changes in ECM & flow properties. (See #❾)

8. HEAT

Research supports “heat” not “cold”:

• Joint stiffness; ↑stretching + elongation
• Facilitates loading, preserves muscle strength
• Prevents injuries
• Circulation (blood flow, lymphatic)
• Fascia viscoelasticity
• Pain (Ca-channels)
• Metabolic rate
• Body temperature control – ↓stress (homeostasis)
• Mechanotransduction
• Nerve conduction/nerve currents (APs)
• Relaxation & ↓Stress (ANS)
• Healing, repair & recovery

9. AVOID

Research does not support:
1ICING
↓nerve conduction, proprioception & neuromuscular control
↓tissue temperature, suppresses inflammation
↓Mechanotransduction, signaling & force conduction
↓Metabolism
↑Stress
↓Swelling & circulation, but at critical thresholds (15°C), increases permeability & swelling

2NSAIDs

3 Continuous COMPRESSION GARMENTS (not Compression air systems/Boots)
Whereas compression is useful to aid flow between tissues & blood vessels (the Starling
volume-pressure hypothesis), it can impede & diminish the non-linear flow between tissue, ECM
& lymphatic vessels – which is the preferred route for the repair & recovery process.
Compression may furthermore block signaling. Although manual pressure by massage may be
beneficial to facilitate the flow between tissues, ECM & lymphatic vessels.

10. IN SUMMARY – SPORTS INJURIES

REST & SLEEP√
THERAPIES:
ACTIVE MOVEMENT √
NUTRITION/HYDRATION √
HEAT √
MANUAL WORK (MASSAGE) √
HEAT + MASSAGE √√
MOIST HEAT (SALT WATER) + MASSAGE+ Controlled Load √√√

RICE ×                                                                                                                                                    ICE/COLD  ×
COMPRESSION  ×
ELEVATION  ×
CHRONIC NSAIDs ×
*See guidelines at surgery below (#11)

11. SURGERY & RICE

For an injury that will require surgery, the following guidelines apply:

1.Acute phase – up to surgery:

-Removal of stress & rest is appropriate for the nervous system & homeostasis.
-Icing & NSAIDs are appropriate to limit inflammation, swelling & pain prior to surgery.
-Elevation is appropriate to limit swelling. (REST + ICE/COLD + NSAIDs + ELEVATION)

2. After surgery – up to 1 week:

-Rest must continue.
-Ice has no further benefits & can slow repair.
-Moderate use of NSAIDs may continue.
-Elevation may continue.
(REST, NSAIDs + ELEVATION)

3. After the first week:

-Rest must continue.
-No Ice, NSAIDs or Elevation.
-Some movement & manual therapy is required.
-If therapy leads to improvements, the conclusion is that tissue is responsive.
-There is no need for further NSAIDs.
-If there isn’t an improvement with therapy, determine if the repair process is hyper- or
hypoactive.
-If “out-of-control”, moderate use of NSAIDs may be appropriate.
-If tissue is unresponsive & inflammation hypoactive, NSAIDs has no value – methods must
be used to trigger signalling & response i.e. heat.
-Surgery-stress most likely leads to a hypermetabolic, catabolic & inflammatory state.

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