Connective Tissue: The Science post!

In earlier posts I’ve said that the structure of the body is affected by Cerebral Palsy. I think it may be helpful if I explain what I mean by this. But to do so, I need to get technical and give a little context. Bear with me, I’m going to give you a lot of detail so you can see just how truly fascinating this is.

After our first ABR weekend, I returned home with new inspiration and motivation to understand structure in CP better. What I’ve learned since then has been eye-opening, especially as I’d never heard anything like this in my university lecture halls

When I talk about structure, I have to talk about connective tissue. Connective tissue is an interesting organ (yes, an organ!). As a functional organ system of the body, it was only discovered in 2007. Many people refer to it as the “Cinderella tissue” because it’s like the ugly girl in rags becoming a princess. I laugh about this, because in our anatomy courses when we dissected embalmed bodies, connective tissue was the first tissue to be cut away and thrown in the waste bucket.

Four years ago, when I started talking to doctors or therapists about connective tissue, I was met with blank stares. Now, thankfully, it’s a hot topic and many people across difference disciplines are getting to grips with this wonderful structure-giving tissue.

Connective tissue is what it says – it’s tissue that connects us (knits us) together. It’s the white sinews and glue web-like structure that you see when you pull a skin off a chicken breast. It is also liquid. Like the fluids in your joint capsules and the gel in the disks between your spinal vertebrae. It’s tendons, it’s the pale sheet-like structures that wrap every organ and tissue subtype. It is what gives us our shape. If you look at your body you will see there are areas where the skin lies loosely over the underlying muscle, then there are areas where the skin is “stitched down” tightly, like in the folds of joints and between the buttocks. The system that determines this is the connective tissue.

Our bones are not what determine our structure. Bones “float” in connective tissue. Without connective tissue, you would be a puddle on the floor. But this is old news, I’m just giving you the background.

The exciting part:

What is new is what happens at a mechanical level. It turns out that connective tissue is far more than an elegant wrapping material. It is a tensional load-bearing tissue. It has its own nerve innervation (sympathetic-involuntary nerves) and also has features that allows it to contract on its own. This important to know, because this means its cannot consciously be trained like a muscle.

In addition, it forms an endless web that connects and mechanically communicates from head to toe. So any intervention or therapy done at a specific point will translate in consequences throughout the

Connective tissue is also important when it comes to metabolic function. At its smallest level, where the cells are connected together, the connective tissue is referred to as the extracellular matrix (ECM). Important immunological, mechanical and biochemical signalling takes place here. Here I have learned that there needs to be an optimal mechanical tension for the cells of the body to work well. Just like there is an optimal range for glucose or a vitamin in the blood, there is an optimal tensional range that needs to exist in the ECM and thus throughout the whole structure for the cells and tissues to work well. When any kind of inflammation happens, the connective tissue cells adapt as a response to this injury of inflammation to protect the body until the injury is over. Things go wrong when the inflammation does not come to an end. Simply put: you need the yin and the yang to have balance in the body. If one situation dominates, this is not good for the body. The body is in a constant stable flux. We call this flux homeostasis. In cases of sustained inflammation, where the flux state is disrupted, we see problems in the connective tissue.

By “inflammation” I mean a specific mix of chemicals that is activated in the body as part of the immune system’s response to an injury. You cannot feel it or see it with the naked eye, because it is below the surface. Connective tissue reacts to such conditions by first becoming dense. When you touch the tissue it is less elastic and more dense. Like the tight bands behind the legs or under the arms, where your child has struggles to relax his/her body. The tissue cannot “give” way with tensional hold like normal tissue. When the densification and inflammation becomes chronic (over months and years) these changes in the tissue become more permanent and then we talk about fibrosis, commonly known as a type of scar tissue. In CP we talk about contractures.

The more severe the CP, the worse the scar tissue development
Healthy skeletal muscle compared with fibrotic muscle

When fibrosis happens, the effects are twofold:

Disrupted tension leads to more disrupted tension to a greater degree.
Disrupted tension leads to more sustained inflammation and a situation called oxidative stress and, in extreme cases, cell death.
What this means for a child like Emma.

So, a child that has a deteriorated structure will keep deteriorating – by this, I mean a lack of energy production, lack of growth, lack of thriving, thin and wasted muscles (atrophy), nutritional issues and mental problems. At a structural level, things end up pulling into the wrong places (and contractions). This is when you see collapsing chests, knee bones and shoulder blades that sit completely in the wrong places, the head that rests incorrectly on the first vertebrae, muscle attachments in the wrong places, hips subluxating and scoliosis. The tissue that is supposed to hold it all up, the connective tissue, is not doing its job.

These things happen because the cells have to “switch off” many of their growth and development functions in order to stay alive. This is the way we’re designed. If you are injured, the body shunts resources to vital organs and function in order to preserve life. When the injury is over, the body can start switching back to lavish functions. In the case of our kids, the disruption spirals out of control.

There have been a number of good studies that have come out in this sphere. The one that I think is the clearest – and most fascinating – is one from a study of muscle biopsies in children with varying degrees of CP. (Image above)

What these images show is that

The more severe the CP, the more distorted the tissue (especially the connective tissue)
The more severe the spasticity, the more distorted the tissue.
The more severe the balance issues, the more distorted the tissue.
Fibrosis increases with the severity of the CP

The most exciting part

I found this amazing because not even a brain scan can predict the severity of the CP, spasticity or balance issues to this degree.

The authors of the article on fibrosis in CP ( Booth et al., 2001) conclude their study with the following words: “Once severe fibrotic changes have occurred in CP, muscle function will be impaired and cannot be reversed. We therefore suggest it would be beneficial if treatment for children with CP concentrated on preventing these fibrotic alterations.”

I read these words (now 15 years old) and smile quietly to myself.

In ABR I believe I have not only found a way to prevent fibrotic change, but to reverse it! Manual therapies such as trigger point release, ABR, osteopathy etc can all reverse inflammation in the connective tissue and make it possible to restore more “normal” mechanical functions as well as attain deep tissue relaxation. The studies into this are all at a very early stage, but wouldn’t it be wonderful if specialist scientists could study this further.