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    Nutrition as a central component of prehabilitation

    Dr. med. Tobias WürfelBy Dr. med. Tobias Würfel7 Mins Read

    Targeted nutrition in musculoskeletal pre- and rehabilitation has become increasingly important in recent years. In their current article ‘Prehabilitation Of The Anterior Cruciate Ligament’ (see pages 2 – 6), Valle / Marshall / Mengis emphasise that a patient’s nutritional status before and after surgery has a decisive influence on the healing outcome of musculoskeletal diseases. 

    According to the authors, a protein- and carbohydrate-rich diet is recommended 7 – 10 days before surgery to promote wound healing, graft healing and maintenance of muscle mass [1, 2]. Furthermore, they address the increased calorie requirement and the minimum daily intake of amino acids [3] as well as the importance of micronutrients for wound healing [2, 4 – 5] and point out the lack of large randomised controlled trials (RCTs) to date that clearly demonstrate the effectiveness of these nutritional interventions [6].

    Integration of nutraceuticals in musculoskeletal rehabilitation

    The latest research results on the rehabilitation of anterior cruciate ligament injuries (ACL) show that certain bioactive substances in food can promote the healing process through anti-inflammatory effects, support tissue regeneration and improve joint health. A recent review highlights the following active ingredients in particular [7]:

    Curcumin

    Curcumin works by inhibiting post-­traumatic inflammatory processes, activating stem cells and regulating collagen metabolism [8 – 10]. An interesting approach is the combination with nanotechnology as curcumin nanoparticles, which, for example, could improve the bioavailability in the tissue and thus achieve a higher effect, but this form of application is not yet widely used and investigated [7]. In the case of acute injuries or operations, however, the optimal timing of therapy must be discussed on the basis of the physiological inflammatory response. For further information, see [11].

    Omega-3 fatty acids

    Omega-3 fatty acids, in particular eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), help to reduce inflammatory processes and promote tissue regeneration by reducing pro-inflammatory cytokines and inducing anti-inflammatory molecules (known as resolvins) [12]. In addition, omega-3 fatty acids influence gene expression by affecting inflammatory transcription factors [13]. Clinical studies have already shown positive effects on muscular regeneration [14]; however, the optimal timing of therapy is controversial due to the physiological inflammatory response in the first few days after injury.

    Bromelain

    Bromelain is a proteolytic enzyme found in pineapples that has anti-inflammatory and decongestant properties. It also has immunomodulatory effects via the activation of macrophages, lymphocytes and natural killer cells [15]. Although the use of bromelain is relatively widespread in the context of injuries or surgery and has been relatively well researched in dentistry in particular [16], clinical data on its effects in the pre- and rehabilitation phases are lacking in the musculoskeletal field.

    Vitamin D

    Low serum levels of 25-hydroxy-vitamin D are associated with an increased incidence of injuries (e.g. muscle injuries and stress fractures; [17, 18]), increased levels of pro-inflammatory cytokines [19] and biomarkers, as well as increased postoperative loss of strength [20]. Since vitamin D metabolism is extremely complex and many of the active processes only take place in the body over the longer term, the use of vitamin D derivatives is less important in the phase of acute injury and more so as a long-term supplement.

    Vitamin C and antioxidants

    Reactive oxygen species (ROS) are formed during metabolism and play a dual role: on the one hand, they can promote muscle breakdown, but on the other hand, they are essential for trai­ning adaptations. Antioxidants such as vitamin C or polyphenols neutralise excess ROS, but an excess of antioxidants can impair recovery because positive ROS-mediated adaptation processes would be inhibited [21, 22]. Instead of long-term supplementation with isolated antioxidant preparations (e. g. high-dose vitamin C), a balanced diet with antioxidant-rich foods such as fruit and vegetables is recommended as a preventive measure to optimally support regeneration after injuries [23]. In the case of highly acute inflammation, however, antioxidant preparations can be considered to slow down the excessive inflammatory response.

    Conclusion

    The integration of nutraceuticals into musculoskeletal rehabilitation represents a forward-looking strategy. While preclinical and initial clinical studies are promising, further large-scale randomised studies are needed to validate the optimal dosage and long-term effects. Interdisciplinary collaboration between orthopaedists, nutritionists and sports scientists is crucial to integrate individual nutrition concepts into multimodal rehabilitation.

    Bibliography

    1. Hirsch, K.R., R.R. Wolfe, and A.A. Ferrando,Pre- and Post-Surgical Nutrition for Preservation of Muscle Mass, Strength, and Functionality Following Orthopedic Surgery.Nutrients, 2021. 13(5).
    2. Smith-Ryan, A.E., et al.,Nutritional Considerations and Strategies to Facilitate Injury Recovery and Rehabilitation. J Athl Train, 2020. 55(9): p. 918-930.
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    Autoren

    ist Assistenzarzt Sektion Sportorthopädie, TUM Universitätsklinikum Rechts der Isar, München. Er hat am Lehrstuhl Anatomie II der LMU über die regenerative Stammzelltherapie bei Sehnendefekten promoviert. Seine Forschungsschwerpunkte sind die Extrakorporale Stoßwellentherapie (ESWT) und physikalische Verfahren in der Orthopädie. Zuvor war er in der sportmedizinischen Praxis MedWorks Augsburg tätig.

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