Photobiomodulation does not influence maturation and mildly improves functional healing of mouse achilles tendons

Histological, Physiological and Biomechanical Effects of Low-Level Laser Therapy on Tendon Healing in Animals and Humans: A Systematic Review

Low-level Laser Therapy (LLLT) was widely used in clinical practice for tendon disorders. However, the underlying mechanisms and effectiveness of LLLT in treating tendon injury remain unclear. Therefore, the present study was conducted aiming to summarize the evidence regarding the histological, physiological, and biomechanical effects of LLLT on tendon healing in animal and human models. Four databases were searched for relevant literature. Four independent reviewers screened abstracts and full-text articles, extracted relevant data, evaluated the risk of bias, and quantified the quality of evidence. Database searches yielded 1400 non-duplicated citations. Fifty-five studies were included (50 animal and five human studies). Animal studies revealed that LT had stimulating effects on collagen organization, collagen I and collagen II formation, matrix metalloproteinase (MMP)-8, transforming growth factor β1, vascular endothelial growth factor, hydroxyproline, maximum load, maximum elongation before breaking, and tendon stiffness. However, LLLT had inhibitory effects on the number of inflammatory cells, histological scores, relative amount of collagen III, cyclooxygenase-2, prostaglandin E2 (PGE2), interleukin-6, tumor necrosis factor-α, MMP-1, and MMP-3. Although one human study found that LLLT reduced the concentration of PGE2 in peritendinous tissue of the Achilles tendon, other human studies revealed that the effects of LLLT on the physiology and biomechanics of human tendons remained uncertain. LLLT facilitates tendon healing through various histological, physiological, and biomechanical effects in animal models. Only post-LLLT anti-inflammatory effects were found in human studies.

Overload in a Rat In Vivo Model of Synergist Ablation Induces Tendon Multiscale Structural and Functional Degeneration

Tendon degeneration is typically described as an overuse injury with little distinction made between magnitude of load (overload) and number of cycles (overuse). Further, in vivo, animal models of tendon degeneration are mostly overuse models, where tendon damage is caused by a high number of load cycles. As a result, there is a lack of knowledge of how isolated overload leads to degeneration in tendons. A surgical model of synergist ablation (SynAb) overloads the target tendon, plantaris, by ablating its synergist tendon, Achilles. The objective of this study was to evaluate the structural and functional changes that occur following overload of plantaris tendon in a rat SynAb model. Tendon cross-sectional area (CSA) and shape changes were evaluated by longitudinal MR imaging up to 8 weeks postsurgery. Tissue-scale structural changes were evaluated by semiquantified histology and second harmonic generation microscopy. Fibril level changes were evaluated with serial block face scanning electron microscopy (SBF-SEM). Functional changes were evaluated using tension tests at the tissue and microscale using a custom testing system allowing both video and microscopy imaging. At 8 weeks, overloaded plantaris tendons exhibited degenerative changes including increases in CSA, cell density, collagen damage area fraction (DAF), and fibril diameter, and decreases in collagen alignment, modulus, and yield stress. To interpret the differences between overload and overuse in tendon, we introduce a new framework for tendon remodeling and degeneration that differentiates between the inputs of overload and overuse. In summary, isolated overload induces multiscale degenerative structural and functional changes in plantaris tendon.

Mechanics and differential healing outcomes of small and large defect injuries of the tendon-bone attachment in the rat rotator cuff

INTRODUCTION

Rotator cuff tear size affects clinical outcomes following rotator cuff repair and is correlated with the risk of recurrent tendon defects. This study aimed to understand if and how the initial defect size influences the structural and mechanical outcomes of the injured rotator cuff attachment in vivo.

METHODS

Full-thickness punch injuries of the infraspinatus tendon-bone attachment in Long Evans rats were created to compare differences in healing outcomes between small and large defects. Biomechanical properties, gross morphology, bone remodeling, and cell and tissue morphology were assessed at both 3- and 8-weeks of healing.

RESULTS

At the time of injury (no healing), large defects had decreased mechanical properties compared to small defects, and both defect sizes had decreased mechanical properties compared to intact attachments. However, the mechanical properties of the two defect groups were not significantly different from each other after 8-weeks of healing and significantly improved compared to no healing but failed to return to intact levels. Local bone volume at the defect site was higher in large compared to small defects on average and increased from 3- to 8-weeks. In contrast, bone quality decreased from 3- to 8-weeks of healing and these changes were not dependent on defect size. Qualitatively, large defects had increased collagen disorganization and neovascularization compared to small defects.

DISCUSSION

In this study, we showed that both large and small defects did not regenerate the mechanical and structural integrity of the intact rat rotator cuff attachment following healing in vivo after 8 weeks of healing.

Tendinopathy: sex bias starts from the preclinical development of tendon treatments. A systematic review

Tendinopathies are common overuse disorders that arise both in athletes and the general population. Available tendon treatments are used both for women and men without distinction. However, the existence of a sex-based difference in tendon biology is widely demonstrated. Since basic research represents the foundation for treatment development, an equal female–male representation should be pursued in preclinical studies. This systematic review quantified the current evidence by analyzing 150 studies on 8231 animals. Preclinical studies largely neglected the importance of sex, none analyzed sex-based differences, and only 4% of the studies reported disaggregated data suitable for the analysis of treatment results in males and females. There is an alarming female under-representation, in particular in the field of injective therapies. Despite the growing awareness on the importance of investigating treatments in both males and females, the investigated field proved resistant from properly designing studies including both sexes, and the lack of sex-representation remains critical.

Tendinopathy has sex-specific features, with sex hormones affecting tendon metabolism, structure, biomechanical properties, and injury risk.

The preclinical research on tendinopathy treatments still neglects sex-based differences, leading to translation of male data to females which may affect clinical effectiveness in women.

None of the reviewed studies looked at differences between sexes, and only 4% of the studies reported disaggregated data. Besides, female animals are under-represented.

The lack of sex-representation in tendinopathy research remains critical.

Effect of Photobiomodulation on Denervation-Induced Skeletal Muscle Atrophy and Autophagy: A Study in Mice

OBJECTIVE

The purpose of this study was to investigate whether photobiomodulation (PBM) can protect against and attenuate muscle atrophy owing to complete peripheral nerve lesion in mice by acting on autophagy.

METHODS

C57BL/10 mice underwent right sciatic nerve transection to induce tibialis anterior muscle atrophy. After 6 hours of denervation, the mice received PBM (wavelength, 830 nm) daily, transcutaneously over the tibialis anterior muscle region for 5 or 14 days. Some mice with sciatic nerve lesion did not receive PBM. Mice that did not have sciatic nerve lesion and PBM were used as controls. After 5 and 14 days, the right tibialis anterior muscle was examined using histomorphometric (cross-sectional area of muscle fibers), Western blot (levels of the autophagy marker LC3), and immunofluorescence analyses (number of LC3 puncta in the muscle fibers).

RESULTS

The cross-sectional area of the tibialis anterior muscle fibers decreased after 5 and 14 days of denervation. PBM protected against muscle fiber atrophy after 5 days of denervation and attenuated muscle fiber atrophy after 14 days of denervation. After 5 days of muscle denervation, autophagy did not change, as demonstrated by the comparable levels of LC3-I/II ratio and LC3 puncta between the controls and the mice with atrophic muscle; PBM did not change this profile. After 14 days of denervation, an increased LC3-I/II ratio suggested an ongoing autophagy, which was not affected by PBM.

CONCLUSION

PBM attenuated the tibialis anterior muscle atrophy induced by sciatic nerve transection in the mice after at least 5 and 14 days of muscle denervation, without affecting autophagy. The transient protective effect of PBM was observed as early as 5 days after the of complete nerve lesion.

Evaluation of Gender Differences in Response to Photobiomodulation Therapy, Including Laser Acupuncture: A Narrative Review and Implication to Precision Medicine

Background: The influence of gender is significant in the manifestation and response to many diseases and in the treatment strategy. Photobiomodulation (PBM) therapy, including laser acupuncture, is an evidence-based treatment and disease prevention modality that has shown promising efficacy for a myriad of chronic and acute diseases. Anecdotal experience and limited clinical trials suggest gender differences exist in treatment outcomes to PBM therapy. There is preliminary evidence that gender may be as important as skin color in the individual response to PBM therapy. Purpose: To conduct a literature search of publications addressing the effects of gender differences in PBM therapy, including laser acupuncture, to provide a narrative review of the findings, and to explore potential mechanisms for the influence of gender. Methods: A narrative review of the literature on gender differences in PBM applications was conducted using key words relating to PBM therapy and gender. Results: A total of 13 articles were identified. Of these articles, 11 have direct experimental investigations into the response difference in gender for PBM, including laser acupuncture. A variety of cadaver, human, and experimental studies demonstrated results that gender effects were significant in PBM outcome responses, including differences in tendon structural and mechanical outcomes, and mitochondrial gene expression. One cadaver experiment showed that gender was more important than skin tone. The physiologic mechanisms directing gender differences are explored and postulated. Conclusions: The review suggests that to address the requirements of a proficient precision medicine-based strategy, it is important for PBM therapy to consider gender in its treatment plan and dosing prescription. Further research is warranted to determine the correct dose for optimal gender treatment, including gender-specific treatment plans to improve outcomes, taking into account wavelength, energy exposure, intensity, and parameters related to the deliverance of treatment to each anatomical location.

The dispersion of viscoelastic properties of fascicle bundles within the tendon results from the presence of interfascicular matrix and flow of body fluids

In this work, we investigate differences in the mechanical and structural properties of tendon fascicle bundles dissected from different areas of bovine tendons. The properties of tendon fascicle bundles were investigated by means of uniaxial tests with relaxation periods and hysteresis, dynamic mechanical analysis (DMA), as well as magnetic resonance imaging (MRI). Uniaxial tests with relaxation periods revealed greater elastic modulus, hysteresis, as well as stress drop during the relaxation of samples dissected from the posterior side of the tendon. However, the normalized stress relaxation curves did not show a statistically significant difference in the stress drop between specimens cut from different zones or between different strain levels. Using dynamic mechanical analysis, we found that fascicle bundles dissected from the anterior side of the tendon had lower storage and loss moduli, which could result from altered fluid flow within the interfascicular matrix (IFM). The lower water content, diffusivity, and higher fractional anisotropy of the posterior part of the tendon, as observed using MRI, indicates a different structure of the IFM, which controls the flow of fluids within the tendon. Our results show that the viscoelastic response to dynamic loading is correlated with fluid flow within the IFM, which was confirmed during analysis of the MRI results. In contrast to this, the long-term relaxation of tendon fascicle bundles is controlled by viscoplasticity of the IFM and depends on the spatial distribution of the matrix within the tendon. Comparison of results from tensile tests, DMA, and MRI gives new insight into tendon mechanics and the role of the IFM. These findings may be useful in improving the diagnosis of tendon injury and effectiveness of medical treatments for tendinopathies.

The effect of low-level red and near-infrared photobiomodulation on pain and function in tendinopathy: a systematic review and meta-analysis of randomized control trials

Background

Tendinopathy is a common clinical condition that can significantly affect a person’s physical function and quality of life. Despite exercise therapy being the mainstay of tendinopathy management, there are many potential adjunct therapies that remain under investigated, one of which is photobiomodulation (PBM). PBM uses varied wavelengths of light to create a biological effect. While PBM is used frequently in the management of tendinopathy, high quality evidence supporting its utility is lacking.

Methods

A systematic search of the Pubmed, CINAHL, SCOPUS, Cochrane Database, Web of Science and SPORTSDICUS databases was performed for eligible articles in August 2020. Randomized Control Trials that used red or near-infrared PBM to treat tendinopathy disorders that made comparisons with a sham or ‘other’ intervention were included. Pain and function data were extracted from the included studies. The data were synthesized using a random effects model. The meta-analysis was performed using the mean difference (MD) and standardized mean difference (SMD) statistics.

Results

A total of 17 trials were included (n = 835). When compared solely to other interventions PBM resulted in similar decreases in pain (MD -0.09; 95% CI − 0.79 to 0.61) and a smaller improvement in function (SMD -0.52; 95% CI − 0.81 to − 0.23). When PBM plus exercise was compared to sham treatment plus exercise, PBM demonstrated greater decreases in pain (MD 1.06; 95% CI 0.57 to 1.55) and improved function (MD 5.65; 95% CI 0.25 to 11.04). When PBM plus exercise was compared to other interventions plus exercise, no differences were noted in pain levels (MD 0.31; 95% CI − 0.07 to 0.70). Most studies were judged as low-risk of bias. The outcome measures were classified as very low to moderate evidence quality according to the Grading of Recommendation, Development and Evaluation tool.

Conclusion

There is very-low-to-moderate quality evidence demonstrating that PBM has utility as a standalone and/or adjunctive therapy for tendinopathy disorders.

Trial registration

PROPERO registration number: CRD42020202508.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00306-z.

Metabolic Regulation of Tendon Inflammation and Healing Following Injury

PURPOSE OF REVIEW

This review seeks to provide an overview of the role of inflammation and metabolism in tendon cell function, tendinopathy, and tendon healing. We have summarized the state of knowledge in both tendon and enthesis.

RECENT FINDINGS

Recent advances in the field include a substantial improvement in our understanding of tendon cell biology, including the heterogeneity of the tenocyte environment during homeostasis, the diversity of the cellular milieu during in vivo tendon healing, and the effects of inflammation and altered metabolism on tendon cell function in vitro. In addition, the mechanisms by which altered systemic metabolism, such as diabetes, disrupts tendon homeostasis continue to be better understood. A central conclusion of this review is the critical need to better define fundamental cellular and signaling mechanisms of inflammation and metabolism during tendon homeostasis, tendinopathy, and tendon healing in order to identify therapies to enhance or maintain tendon function.