Timing of the administration of suramin treatment after muscle injury

Electroacupuncture regulates inflammation, collagen deposition and macrophage function in skeletal muscle through the TGF-β1/Smad3/p38/ERK1/2 pathway

Skeletal muscle injury is one of the most common sports injury, which accounts for ~40% of all sports-related injuries among the elderly. In addition, cases of full recovery from treatment are rare. Although electroacupuncture (EA) is an integral aspect of traditional Chinese medicine, the effects of EA on skeletal muscle fibrosis and the possible underlying mechanism remain unclear. To investigate the effect and potential mechanism of EA on skeletal inflammation, collagen deposition and macrophage function, a skeletal muscle injury model was established by injecting 100 µl cardiotoxin into the anterior tibial muscle of Sprague Dawley rats. The animals were randomly divided into the following three groups: Control, model and EA. The expression of inflammation-related factors (IL-6, IL-4, IL-33, IL-10 and TNF-α) were measured using ELISA. H&E staining, Masson's staining and immunohistochemistry (collagen II, Axin2 and β-catenin) were performed to assess collagen deposition and fibrosis in the muscle tissues. Additionally, immunofluorescence was performed to measure the ratio of M₁ to M₂ macrophages. Western blotting was performed to examine the activity of the TGF-β1/Smad3/p38/ERK1/2 pathway. Compared with that in the control rats, the mental state, such as the degree of activity and excitement, of the model rats deteriorated, with clear activity limitations. Compared with those in the model rats, EA-treated rats exhibited improved mental status and activity, reduced levels of IL-6, IL-4 and TNF-α, reduced collagen deposition and fibrosis, in addition to increased expression of IL-33 and IL-10. This improvement became increasingly evident with prolonged intervention time. EA also promoted the transformation of macrophages from the M₁ into the M₂ sub-type, where the M₁/M₂ ratio on day 7 was lower compared with that on day 14. Western blotting results showed that compared with that in the model rats, the expression of TGF-β1, MMP-2, MMP-7 and the activation of Smad3 and p38 was decreased in EA-treated rats, whilst the activation of ERK1/2 was significantly elevated. In conclusion, EA can inhibit inflammation and collagen deposition whilst promoting the transformation of macrophages from the M₁ into the M₂ sub-type. The underlying mechanism was found to be associated with TGF-β1/Smad3/p38/ERK1/2 signaling.

Stem Cells from a Female Rat Model of Type 2 Diabetes/Obesity and Stress Urinary Incontinence Are Damaged by In Vitro Exposure to its Dyslipidemic Serum, Predicting Inadequate Repair Capacity In Vivo

Female stress urinary incontinence (FSUI) is prevalent in women with type 2 diabetes/obesity (T2D/O), and treatment is not optimal. Autograph stem cell therapy surprisingly has poor efficacy. In the male rat model of T2D/O, it was demonstrated that epigenetic changes, triggered by long-term exposure to the dyslipidemic milieu, led to abnormal global transcriptional signatures (GTS) of genes and microRNAs (miR), and impaired the repair capacity of muscle-derived stem cells (MDSC). This was mimicked in vitro by treatment of MDSC with dyslipidemic serum or lipid factors. The current study aimed to predict whether these changes also occur in stem cells from female 12 weeks old T2D/O rats, a model of FSUI. MDSCs from T2D/O (ZF4-SC) and normal female rats (ZL4-SC) were treated in vitro with either dyslipidemic serum (ZFS) from late T2D/O 24 weeks old female Zucker fatty (ZF) rats, or normal serum (ZLS) from 24 weeks old female Zucker lean (ZL) rats, for 4 days and subjected to assays for fat deposition, apoptosis, scratch closing, myostatin, interleukin-6, and miR-GTS. The dyslipidemic ZFS affected both female stem cells more severely than in the male MDSC, with some gender-specific differences in miR-GTS. The changes in miR-GTS and myostatin/interleukin-6 balance may predict in vivo noxious effects of the T2D/O milieu that might impair autograft stem cell (SC) therapy for FSUI, but this requires future studies.

Role of transforming growth factor-β in muscle damage and regeneration: focused on eccentric muscle contraction

High-intensity eccentric muscle contraction induces muscle damage. Damaged muscles recover through different processes, including degeneration, inflammation, regeneration, and fibrosis; some of these processes are mediated through the actions of cytokines. The transforming growth factor-beta (TGF-β) is one such cytokine involved in muscle recovery and repair. In this regard, TGF-β regulates the skeletal muscle inflammatory response, inhibits muscle regeneration, regulates extracellular matrix remodeling, and promotes fibrosis. Although some studies have suggested that inhibition of TGF-β after muscle damage promotes muscle regeneration and recovery, other studies have noted that TGF-β inhibition actually reduces muscle strength because it leads to incomplete muscle regeneration. Despite the importance of TGF-β in the repair of damaged muscles, most studies have focused on examining its role in muscle diseases such as chronic inflammatory diseases or Duchenne’s muscular dystrophy. Here, we have reviewed the existing literature for examining the role of TGF-β in muscle damage and regeneration after eccentric muscle contraction.

The Use of Platelet-Rich and Platelet-Poor Plasma to Enhance Differentiation of Skeletal Myoblasts: Implications for the Use of Autologous Blood Products for Muscle Regeneration

BACKGROUND

Platelet-rich plasma (PRP) has been used to augment tissue repair and regeneration after musculoskeletal injury. However, there is increasing clinical evidence that PRP does not show a consistent clinical effect. Purpose/Hypothesis: This study aimed to compare the effects of the following non-neutrophil-containing (leukocyte-poor) plasma fractions on human skeletal muscle myoblast (HSMM) differentiation: (1) PRP, (2) modified PRP (Mod-PRP), in which transforming growth factor β1 (TGF-β1) and myostatin (MSTN) were depleted, and (3) platelet-poor plasma (PPP). The hypothesis was that leukocyte-poor PRP would lead to myoblast proliferation (not differentiation), whereas certain modifications of PRP preparations would increase myoblast differentiation, which is necessary for skeletal muscle regeneration.

STUDY DESIGN

Controlled laboratory study.

METHODS

Blood from 7 human donors was individually processed to simultaneously create leukocyte-poor fractions: PRP, Mod-PRP, PPP, and secondarily spun PRP and Mod-PRP (PRP_ss and Mod-PRP_ss, respectively). Mod-PRP was produced by removing TGF-β1 and MSTN from PRP using antibodies attached to sterile beads, while a second-stage centrifugal spin of PRP was performed to remove platelets. The biologics were individually added to cell culture groups. Analysis for induction into myoblast differentiation pathways included Western blot analysis, reverse-transcription polymerase chain reaction, and immunohistochemistry, as well as confocal microscopy to assess polynucleated myotubule formation.

RESULTS

HSMMs cultured with PRP showed an increase in proliferation but no evidence of differentiation. Western blot analysis confirmed that MSTN and TGF-β1 could be decreased in Mod-PRP using antibody-coated beads, but this modification mildly improved myoblast differentiation. However, cell culture with PPP, PRP_ss, and Mod-PRP_ss led to a decreased proliferation rate but a significant induction of myoblast differentiation verified by increased multinucleated myotubule formation and myosin heavy chain expression (mean 8-fold change in mRNA level; P < .05), which was comparable with 2% horse serum, the positive control.

CONCLUSION

PPP and leukocyte-poor PRP preparations subjected to a second spin to remove the platelets led to induction of myoblast cells into the muscle differentiation pathway, whereas unmodified leukocyte-poor PRP led to myoblast proliferation.

CLINICAL RELEVANCE

These results indicate that traditionally formulated PRP may not be appropriate to induce muscle regeneration. Laboratory evidence suggests that PPP or non-neutrophil-containing PRP_ss, subjected to an additional spin to remove platelets, should be used to stimulate myoblast differentiation, which is necessary for skeletal muscle regeneration. Clinical studies will be required to confirm the effect of these biologics on muscle regeneration.

Platelet-Rich Plasma in a Murine Model: Leukocytes, Growth Factors, Flt-1, and Muscle Healing

BACKGROUND

It is well known that platelet-rich plasma (PRP) preparations are not the same and that not all preparations include white blood cells, but the part that leukocytes play on the healing role of PRP is still unknown.

PURPOSE

The primary aim of this study was to evaluate the influence of leukocytes in different PRP preparations with a special emphasis on growth factor concentrations. The secondary aim was to evaluate the influence of PRP on muscle healing.

STUDY DESIGN

Controlled laboratory study.

METHODS

Two PRP preparation procedures were evaluated. Blood fractions were stained with Rapid Panoptic, and growth factors (transforming growth factor beta 1 [TGF-β1], vascular endothelial growth factor [VEGF], insulin-like growth factor [IGF], epidermal growth factor [EGF], hepatocyte growth factor [HGF], and platelet-derived growth factor [PDGF]) were quantified by enzyme-linked immunosorbent assay. Western blotting analysis was performed for Fms-related tyrosine kinase 1 (Flt-1). A muscle contusion injury was created and treated with PRP at different time points.

RESULTS

Leukocytes were the main source of VEGF, and all other growth factors measured had a higher concentration in the preparations that included the buffy coat and consequently had a higher concentration of white blood cells. Flt-1 was also found in platelet-poor plasma (PPP). There were higher concentrations of PDGF and HGF in the preparations that encompassed the buffy coat. A PRP injection 7 days after the injury provided significantly increased exercise performance and decreased the fibrotic area when compared with other PRP-treated groups.

CONCLUSION

VEGF is only present in PRP's buffy coat, while Flt-1 is present in PPP. A PRP injection 7 days after an injury resulted in improved exercise performance.

CLINICAL RELEVANCE

The presence of Flt-1 in PRP provides yet another explanation for results described in the literature after a PRP injection. This information is relevant for selecting the best PRP for each type of injury.

Therapeutic strategies for preventing skeletal muscle fibrosis after injury

Skeletal muscle repair after injury includes a complex and well-coordinated regenerative response. However, fibrosis often manifests, leading to aberrant regeneration and incomplete functional recovery. Research efforts have focused on the use of anti-fibrotic agents aimed at reducing the fibrotic response and improving functional recovery. While there are a number of mediators involved in the development of post-injury fibrosis, TGF-β1 is the primary pro-fibrogenic growth factor and several agents that inactivate TGF-β1 signaling cascade have emerged as promising anti-fibrotic therapies. A number of these agents are FDA approved for other conditions, clearing the way for rapid translation into clinical treatment. In this article, we provide an overview of muscle's host response to injury with special emphasis on the cellular and non-cellular mediators involved in the development of fibrosis. This article also reviews the findings of several pre-clinical studies that have utilized anti-fibrotic agents to improve muscle healing following most common forms of muscle injuries. Although some studies have shown positive results with anti-fibrotic treatment, others have indicated adverse outcomes. Some concerns and questions regarding the clinical potential of these anti-fibrotic agents have also been presented.

Effects of low-level laser therapy on skeletal muscle repair: a systematic review

A review of the literature was performed to demonstrate the most current applicability of low-level laser therapy (LLLT) for the treatment of skeletal muscle injuries, addressing different lasers, irradiation parameters, and treatment results in animal models. Searches were performed in the PubMed/MEDLINE, SCOPUS, and SPIE Digital Library databases for studies published from January 2006 to August 2013 on the use of LLLT for the repair of skeletal muscle in any animal model. All selected articles were critically appraised by two independent raters. Seventeen of the 36 original articles on LLLT and muscle injuries met the inclusion criteria and were critically evaluated. The main effects of LLLT were a reduction in the inflammatory process, the modulation of growth factors and myogenic regulatory factors, and increased angiogenesis. The studies analyzed demonstrate the positive effects of LLLT on the muscle repair process, which are dependent on irradiation and treatment parameters. The findings suggest that LLLT is an excellent therapeutic resource for the treatment of skeletal muscle injuries in the short-term.

Bone marrow mesenchymal cells improve muscle function in a skeletal muscle re-injury model

Skeletal muscle injury is the most common problem in orthopedic and sports medicine, and severe injury leads to fibrosis and muscle dysfunction. Conventional treatment for successive muscle injury is currently controversial, although new therapies, like cell therapy, seem to be promise. We developed a model of successive injuries in rat to evaluate the therapeutic potential of bone marrow mesenchymal cells (BMMC) injected directly into the injured muscle. Functional and histological assays were performed 14 and 28 days after the injury protocol by isometric tension recording and picrosirius/Hematoxilin & Eosin staining, respectively. We also evaluated the presence and the fate of BMMC on treated muscles; and muscle fiber regeneration. BMMC treatment increased maximal skeletal muscle contraction 14 and 28 days after muscle injury compared to non-treated group (4.5 ± 1.7 vs 2.5 ± 0.98 N/cm2, p<0.05 and 8.4 ± 2.3 vs. 5.7 ± 1.3 N/cm2, p<0.05 respectively). Furthermore, BMMC treatment increased muscle fiber cross-sectional area and the presence of mature muscle fiber 28 days after muscle injury. However, there was no difference in collagen deposition between groups. Immunoassays for cytoskeleton markers of skeletal and smooth muscle cells revealed an apparent integration of the BMMC within the muscle. These data suggest that BMMC transplantation accelerates and improves muscle function recovery in our extensive muscle re-injury model.

Upregulation of transforming growth factor-β signaling in a rat model of rotator cuff tears

BACKGROUND

Muscle atrophy, fatty infiltration, and fibrosis of the muscle have been described as important factors governing outcome after rotator cuff injury and repair. Muscle fibrosis is also thought to have a role in determining muscle compliance at the time of surgery. The transforming growth factor-β (TGF-β) pathways are highly conserved pathways that exert a potent level of control over muscle gene expression and are critical regulators of fibrosis in multiple organ systems. It has been shown that TGF-β can regulate important pathways of muscle atrophy, including the Akt/mammalian target of rapamycin pathway. The purpose of this study was to evaluate the expression of TGF-β and its downstream effectors of fibrosis after a massive rotator cuff tear (RCT) in a previously established rat model.

METHODS

To simulate a massive RCT, infraspinatus and supraspinatus tenotomy and suprascapular nerve transection were performed on Sprague-Dawley rats with use of a validated model. Two and 6 weeks after surgery, supraspinatus muscles were harvested to study alterations in TGF-β signaling by Western blotting, quantitative polymerase chain reaction, and histologic analysis.

RESULTS

There was a significant increase in fibrosis in the rotator cuff muscle after RCT in our animal model. There was a concomitant increase in TGF-β gene and protein expression at both 2 and 6 weeks after RCT. Evaluation of the TGF-β signaling pathway revealed an increase in SMAD2 activation but not in SMAD3. There was an increase in profibrotic markers collagen I, collagen III, and α-smooth muscle actin.

CONCLUSIONS

TGF-β signaling is significantly upregulated in rat supraspinatus muscles after RCTs.

Therapeutic approaches to skeletal muscle repair and healing

Context:

Skeletal muscle is comprised of a highly organized network of cells, neurovascular structures, and connective tissue. Muscle injury is typically followed by a well-orchestrated healing response that consists of the following phases: inflammation, regeneration, and fibrosis. This review presents the mechanisms of action and evidence supporting the effectiveness of various traditional and novel therapies at each phase of the skeletal muscle healing process.

Evidence Acquisition:

Relevant published articles were identified using MEDLINE (1978-2013).

Study Design:

Clinical review.

Level of Evidence:

Level 3.

Results:

To facilitate muscle healing, surgical techniques involving direct suture repair, as well as the implantation of innovative biologic scaffolds, have been developed. Nonsteroidal anti-inflammatory drugs may be potentially supplanted by nitric oxide and curcumin in modulating the inflammatory pathway. Studies in muscle regeneration have identified stem cells, myogenic factors, and β-agonists capable of enhancing the regenerative capabilities of injured tissue. Furthermore, transforming growth factor-β1 (TGF-β1) and, more recently, myostatin and the rennin-angiotensin system have been implicated in fibrous tissue formation; several antifibrotic agents have demonstrated the ability to disrupt these systems.

Conclusion:

Effective repair of skeletal muscle after severe injury is unlikely to be achieved with a single intervention. For full functional recovery of muscle there is a need to control inflammation, stimulate regeneration, and limit fibrosis.

Strength-of-Recommendation Taxonomy (SORT):

B

Pro-inflammatory mediation of myoblast proliferation

Skeletal muscle satellite cell function is largely dictated by the surrounding environment following injury. Immune cell infiltration dominates the extracellular space in the injured area, resulting in increased cytokine concentrations. While increased pro-inflammatory cytokine expression has been previously established in the first 3 days following injury, less is known about the time course of cytokine expression and the specific mechanisms of cytokine induced myoblast function. Therefore, the expression of IL-1β and IL-6 at several time points following injury, and their effects on myoblast proliferation, were examined. In order to do this, skeletal muscle was injured using barium chloride in mice and tissue was collected 1, 5, 10, and 28 days following injury. Mechanisms of cytokine induced proliferation were determined in cell culture using both primary and C2C12 myoblasts. It was found that there is a ∼20-fold increase in IL-1β (p≤0.05) and IL-6 (p = 0.06) expression 5 days following injury. IL-1β increased proliferation of both primary and C2C12 cells ∼25%. IL-1β stimulation also resulted in increased NF-κB activity, likely contributing to the increased proliferation. These data demonstrate for the first time that IL-1β alone can increase the mitogenic activity of primary skeletal muscle satellite cells and offer insight into the mechanisms dictating satellite cell function following injury.

Targeted inhibition of TGF-β results in an initial improvement but long-term deficit in force production after contraction-induced skeletal muscle injury

Transforming growth factor-β (TGF-β) is a proinflammatory cytokine that regulates the response of many tissues following injury. Previous studies in our lab have shown that treating muscles with TGF-β results in a dramatic accumulation of type I collagen, substantial fiber atrophy, and a marked decrease in force production. Because TGF-β promotes atrophy and fibrosis, our objective was to investigate whether the inhibition of TGF-β after injury would enhance the recovery of muscle following injury. We hypothesized that inhibiting TGF-β after contraction-induced injury would improve the functional recovery of muscles by preventing muscle fiber atrophy and weakness, and by limiting the accumulation of fibrotic scar tissue. To test this hypothesis, we induced an injury using a series of in situ lengthening contractions to extensor digitorum longus muscles of mice treated with either a bioneutralizing antibody against TGF-β or a sham antibody. Compared with controls, muscles from mice receiving TGF-β inhibitor showed a greater recovery in force 3 days and 7 days after injury but had a decrease in force compared with controls at the 21-day time point. The early enhancement in force in the TGF-β inhibitor group was associated with an initial improvement in tissue morphology, but, at 21 days, while the control group was fully recovered, the TGF-β inhibitor group displayed an irregular extracellular matrix and an increase in atrogin-1 gene expression. These results indicate that the inhibition of TGF-β promotes the early recovery of muscle function but is detrimental overall to full muscle recovery following moderate to severe muscle injuries.

Combination therapy of human adipose-derived stem cells and basic fibroblast growth factor hydrogel in muscle regeneration

Skeletal muscle regeneration after sport injury is inconsistent, and complete healing without fibrosis is very important. In this study, we determined whether the combination therapy using human adipose-derived stem cells (h-ADSCs) and basic fibroblast growth factor (bFGF) incorporated into hydrogel could enhance muscle regeneration in a muscle laceration animal model. The h-ADSCs and/or bFGF hydrogels were applied to the lacerated gastrocnemius muscle. Fast twitch muscle contraction improved significantly and fibrosis decreased significantly in combined h-ADSC and bFGF-hydrogel group compared to other experimental groups. Skeletal muscle differentiation of h-ADSCs was determined by immunohistochemistry (PKH-26/MyHC co-staining) and Western blot. Our data suggested that combination therapy of h-ADSCs and bFGF hydrogel resulted in functional recovery, revascularization and reinnervation with minimal fibrosis in lacerated muscle. A combination of h-ADSCs and bFGF hydrogel can be used as a promising therapy for skeletal muscle regeneration.