Low-level laser and adipose-derived stem cells altered remodelling genes expression and improved collagen reorganization during tendon repair

The effects of combined and independent low-level laser and mesenchymal stem cell therapy on induced knee osteoarthritis: An animal study

BACKGROUND

Mesenchymal stem cell (MSC) injection has emerged as a novel treatment for knee osteoarthritis (OA). In addition, low-level laser therapy (LLLT) has been reported to delay the progression of OA. Thus, the current study on animal models of OA investigated the effectiveness of these methods when administered independently and combined.

METHODS

Twenty-five guinea pig models of OA were randomly sorted into five study groups. The test groups received intra-articular MSC, LLLT, and a combination of these therapeutics for 8 weeks. Radiological and histopathologic evaluations were carried out for the test groups and the control after the completion of treatments.

RESULTS

The MSC-treated groups showed better outcomes in terms of all radiological and histological indexes compared with the control, apart from subchondral bone (P < 0.05). Similarly, but to a different extent, the LLLT-treated group showed better results than the controls (P < 0.05). The combination of MSC therapy and LLLT improved the cartilage, surface, matrix, space width, osteophytes, and radiologic OA scores more effectively than each of these methods alone (P < 0.05).

CONCLUSIONS

According to our results, the combination of intra-articular MSC and LLLT can effectively improve OA in animal models. Further preclinical and clinical studies are recommended to assess the effectiveness of these therapeutics alone and in combination.

Experimental study on the mechanical properties and thermal damage of laser welding the ruptured flexor digitorum longus tendons

To investigate the influence of laser parameters on the performance of tendon tissue, experiments were conducted and the process of laser-assisted tendon welding was studied. Several conclusions were drawn by analyzing the effects of laser parameters on the tensile strength, microstructure, and collagen content of tendon tissue incisions. The optimal parameters for laser welding tendon tissue were found to be a laser power of 5 W, a scanning speed of 150 mm/s, and a defocus amount of 0 mm, resulting in a laser energy density of 32.164 J/cm2 . At these parameters, the percentage of inactivated cells due to thermal damage was only 23.78%, and the tensile strength of the tendon tissue incisions reached 0.61 MPa. Additionally, the collagen content around the incision was measured to be 33.679%, composed of type I and type III collagens, with the latter accounting for 50.714% of the total collagen content.

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.

Regenerative Medicine and Rehabilitation Therapy in the Canine

Regenerative medicine is used in the canine to optimize tissue healing and treat osteoarthritis and soft tissue injuries. Rehabilitation therapy is also often implemented in the treatment and management of musculoskeletal conditions in the canine. Initial experimental studies have shown that regenerative medicine and rehabilitation therapy may work safely and synergistically to enhance tissue healing. Although additional study is required to define optional rehabilitation therapy protocols after regenerative medicine therapy in the canine, certain fundamental principles of rehabilitation therapy still apply to patients treated with regenerative medicine.

High-Performance Polarization Microscopy Reveals Structural Remodeling in Rat Calcaneal Tendons Cultivated In Vitro

Collagenous tissues exhibit anisotropic optical properties such as birefringence and linear dichroism (LD) as a result of their structurally oriented supraorganization from the nanometer level to the collagen bundle scale. Changes in macromolecular order and in aggregational states can be evaluated in tendon collagen bundles using polarization microscopy. Because there are no reports on the status of the macromolecular organization in tendon explants, the objective of this work was to evaluate the birefringence and LD characteristics of collagen bundles in rat calcaneal tendons cultivated in vitro on substrates that differ in their mechanical stiffness (plastic vs. glass) while accompanying the expected occurrence of cell migration from these structures. Tendon explants from adult male Wistar rats were cultivated for 8 and 12 days on borosilicate glass coverslips (n = 3) and on nonpyrogenic polystyrene plastic dishes (n = 4) and were compared with tendons not cultivated in vitro (n = 3). Birefringence was investigated in unstained tendon sections using high-performance polarization microscopy and image analysis. LD was studied under polarized light in tendon sections stained with the dichroic dyes Ponceau SS and toluidine blue at pH 4.0 to evaluate the orientation of proteins and acid glycosaminoglycans (GAG) macromolecules, respectively. Structural remodeling characterized by the reduction in the macromolecular orientation, aggregation and alignment of collagen bundles, based on decreased average gray values concerned with birefringence intensity, LD and morphological changes, was detected especially in the tendon explants cultivated on the plastic substrate. These changes may have facilitated cell migration from the lateral regions of the explants to the substrates, an event that was observed earlier and more intensely upon tissue cultivation on the plastic substrate. The axial alignment of the migrating cells relative to the explant, which occurred with increased cultivation times, may be due to the mechanosensitive nature of the tenocytes. Collagen fibers possibly played a role as a signal source to cells, a hypothesis that requires further investigation, including studies on the dynamics of cell membrane receptors and cytoskeletal organization, and collagen shearing electrical properties.

Efficacy of autologous mesenchymal stromal cell treatment for chronic degenerative musculoskeletal conditions in dogs: A retrospective study

Introduction

The objective of this study was to retrospectively analyze clinical data from a referral regenerative medicine practice, to investigate the efficacy of autologous mesenchymal stromal cells (MSC) in 245 dogs deemed unresponsive to conventional treatment by their referring vet.

Methods

Diagnostic imaging [radiology and musculoskeletal ultrasound (MSK-US)] identified musculoskeletal pathology holistically. MSCs, produced according to current guidelines, were initially administered with PRP by targeted injection to joints and/or tendons, with a second MSC monotherapy administered 12 weeks later to dogs with severe pathology and/or previous elbow arthroscopic interventions. Dogs with lumbosacral disease received epidural MSCs with additional intravenous MSCs administered to dogs with spondylosis of the cervical, thoracic and lumbar spine. All dogs received laser therapy at 10 J/cm² at the time of treatment and for 5 sessions thereafter. Objective outcome measures (stance analysis, range of joint motion, pressure algometry) and validated subjective outcome measures (owner reported VetMetrica HRQL™ and veterinary pain and quality of life impact scores) were used to investigate short and long-term (6-104 weeks) efficacy. Outcome data were collected at predetermined time windows (0-6, 7-12, 13-18, 19-24, 25-48, 49-78, 79-104) weeks after initial treatment.

Results

There were statistically significant improvements in post compared with pre-treatment measures at all time windows in stance analysis, shoulder and hip range of motion, lumbosacral pressure algometry, and to 49-78 weeks in carpus and elbow range of motion. Improvements in 4 domains of quality of life as measured by VetMetricaTM were statistically significant, as were scores in vet-assessed pain and quality of life impact. In dogs receiving one initial treatment the mean time before a second treatment was required to maintain improvements in objective measures was 451 days. Diagnostic imaging confirmed the regenerative effects of MSCs in tendinopathies by demonstrating resolution of abnormal mineralization and restoration of normal fiber patterns.

Discussion

This represents the first study using "real-world" data to show that cell-based therapies, injected into multiple areas of musculoskeletal pathology in a targeted holistic approach, resulted in rapid and profound positive effects on the patient's pain state and quality of life which was maintained with repeat treatment for up to 2 years.

The Influence of Different Modes of Exercise on Healthy and Injured Tendons

Tendons are essential components of the musculoskeletal system that links the skeletal muscle to the skeleton. This dense connective tissue exhibits great plasticity. Therefore, research on the influence of types of exercise, including acute and long-term training, on the structural and mechanical properties of tendons in athletic and sedentary populations is of critical importance in the design of scientific-based exercise plans and effective tendinopathy treatment. Here, we review recent studies on the relationship between exercise and tendon health and tendinopathy repair to provide a general understanding of how exercise may reshape tendons.

Rehabilitation of the Canine Forelimb

The goal of rehabilitation is to restore function and mobility and reduce pain associated with chronic disease. In human medicine, physical therapy is standard of care for acute and chronic injuries and an integral component of postoperative recovery. Although there is a dearth of evidence-based veterinary medical studies in rehabilitation therapy and modalities for forelimb injuries in dogs, some extrapolation from human medicine can be made and applied. When developing a rehabilitation and therapeutic plan, the biomechanics of the affected limb and timeline of tissue healing of the target tissue and/or joint are important to consider.

Biological Responses of Stem Cells to Photobiomodulation Therapy

BACKGROUND

Stem cells have attracted the researchers interest, due to their applications in regenerative medicine. Their self-renewal capacity for multipotent differentiation, and immunomodulatory properties make them unique to significantly contribute to tissue repair and regeneration applications. Recently, stem cells have shown increased proliferation when irradiated with low-level laser therapy or Photobiomodulation Therapy (PBMT), which induces the activation of intracellular and extracellular chromophores and the initiation of cellular signaling. The purpose of this study was to evaluate this phenomenon in the literature.

METHODS

The literature investigated the articles written in English in four electronic databases of PubMed, Scopus, Google Scholar and Cochrane up to April 2019. Stem cell was searched by combining the search keyword of "low-level laser therapy" OR "low power laser therapy" OR "low-intensity laser therapy" OR "photobiomodulation therapy" OR "photo biostimulation therapy" OR "LED". In total, 46 articles were eligible for evaluation.

RESULTS

Studies demonstrated that red to near-infrared light is absorbed by the mitochondrial respiratory chain. Mitochondria are significant sources of reactive oxygen species (ROS). Mitochondria play an important role in metabolism, energy generation, and are also involved in mediating the effects induced by PBMT. PBMT may result in the increased production of (ROS), nitric oxide (NO), adenosine triphosphate (ATP), and cyclic adenosine monophosphate (cAMP). These changes, in turn, initiate cell proliferation and induce the signal cascade effect.

CONCLUSION

The findings of this review suggest that PBMT-based regenerative medicine could be a useful tool for future advances in tissue engineering and cell therapy.

Acmella oleracea extract increases collagen content and organization in partially transected tendons

Acmella oleracea contains spilanthol as the main active compound, which possesses analgesic and anti-inflammatory effects that can favor tendon reorganization. To analyze the effect of A. oleracea on the content and organization of collagen in injured tendons, the calcaneal tendon of male Lewis rats was partially transected and treated at the site of injury with a topical application of 20% A. oleracea ointment (AO group) or with the ointment base without the plant extract (B group). The animals were euthanized 21 days after partial transection. Higher collagen concentration was observed in the AO group than in the B group, and morphological analysis using polarization microscopy showed higher birefringence in the AO group than in the B group, indicating higher collagen organization. No difference was observed in the number of fibroblasts, blood vessels, proteoglycan distribution, and maximum load between the B and AO groups. In conclusion, topical application of 20% A. oleracea ointment increased the molecular organization and content of collagen, thus indicating a potential application in tendon repair. Studies on the later phases of the tendon healing process are necessary to demonstrate the possible biomechanical changes after the application of A. oleracea ointment.

Evaluation of Efficacy of Low-Level Laser Therapy

Introduction: Given the inconsistencies in the literature regarding laser performance in non-surgical treatments, this study investigated the available literature to determine the advantages and disadvantages of low-power lasers in treating non-surgical complications and diseases. Methods: Authentic information from articles was extracted and evaluated to assess low-power laser performance for non-surgical treatments. A systematic search of studies on low-level laser therapy (LLLT) for non-surgical treatments was conducted mainly in PubMed and google scholar articles. Results: Four categories of diseases, including brain-related diseases, skin-related diseases, cancers, and bone-related disorders, which were treated by LLLT were identified and introduced. The various types of LLLT regarding the studied diseases were discussed. Conclusion: Positive aspects of LLLT versus a few disadvantages of its application imply more investigation to find better and efficient new methods.

Microcurrent and adipose-derived stem cells modulate genes expression involved in the structural recovery of transected tendon of rats

Tendon injuries are common and have a high incidence of re-rupture that can cause loss of functionality. Therapies with adipose-derived stem cells (ASC) and the microcurrent (low-intensity electrical stimulation) application present promising effects on the tissue repair. We analyzed the expression of genes and the participation of some molecules potentially involved in the structural recovery of the Achilles tendon of rats, in response to the application of both therapies, isolated and combined. The tendons were distributed in five groups: normal (N), transected (T), transected and ASC (C) or microcurrent (M) or with ASC, and microcurrent (MC). Microcurrent therapy was beneficial for tendon repair, as it was observed a statistically significant increase in the organization of the collagen fibers, with involvement of the TNC, CTGF, FN, FMDO, and COL3A1 genes as well as PCNA, IL-10, and TNF-α. ASC therapy significantly increased the TNC and FMDO genes expression with no changes in the molecular organization of collagen. With the association of therapies, a significant greater collagen fibers organization was observed with involvement of the FMOD gene. The therapies did not affect the expression of COL1A1, SMAD2, SMAD3, MKX, and EGR1 genes, nor did they influence the amount of collagen I and III, caspase-3, tenomodulin (Tnmd), and hydroxyproline. In conclusion, the application of the microcurrent isolated or associated with ASC increased the organization of the collagen fibers, which can result in a greater biomechanical resistance in relation to the tendons treated only with ASC. Future studies will be needed to demonstrate the biological effects of these therapies on the functional recovery of injured tendons.

Growth and Stem Cell Characteristics of Tendon-Derived Cells with Different Initial Seeding Densities: An In Vitro Study in Mouse Flexor Tendon Cells

Tendon stem/progenitor cells (TSPCs) are considered promising seed cells for tendon regeneration. Previous studies reported that a low seeding density favors TSPC growth, whereas a high seeding density favors tenocyte growth. We aimed to distinguish TSPCs from tenocytes by seeding tendon-derived cells at a density gradient. In this study, tendon-derived cells were isolated from flexor digitorum profundus tendons of mice and seeded at the initial densities of 50, 500, 5,000, and 50,000/cm². We found that distinct cell colonies were formed from cells with initial seeding densities of 50 and 500/cm², but colonies were not discernible for cells seeded at 5,000 and 50,000/cm². There was a positive correlation between cell proliferation rate and seeding density, but a negative correlation between cell senescence and seeding density. The cell proliferation rate decreased gradually during serial passages. All cells exhibited restricted differentiation potentials, and expressed stem cell markers and relatively high levels of tenogenic markers without notable differences among cells seeded at different densities. We concluded that a pure population of TSPCs could not be isolated from mouse digital flexor tendons through culturing cells at a density gradient. Cells seeded at low densities had very limited proliferative ability and did not show more prominent stem cell characteristics when compared with cells seeded at high densities.

Inhibitory effect of red LED irradiation on fibroblasts and co-culture of adipose-derived mesenchymal stem cells

The objective of this study was to evaluate the effects of red Light Emiting Diode (red LED) irradiation on fibroblasts in adipose-derived mesenchymal stem cells (ASC) co-culture on the scratch assay. We hypothesized that red LED irradiation could stimulate paracrine secretion of ASC, contributing to the activation of genes and molecules involved in cell migration and tissue repair. ASC were co-cultured with NIH/3T3 fibroblasts through direct contact and subjected to red LED irradiation (1.45 J/cm²/5min6s) after the scratch assay, during 4 days. Four groups were established: fibroblasts (F), fibroblasts + LED (FL), fibroblasts + ASC (FC) and fibroblasts + LED + ASC (FLC). The analyzes were based on Ctgf and Reck expression, quantification of collagen types I and III, tenomodulin, VEGF, TGF-β1, MMP-2 and MMP-9, as well as viability analysis and cell migration. Higher Ctgf expression was observed in FC compared to F. Group FC presented higher amount of tenomodulin and VEGF in relation to the other groups. In the cell migration analysis, a higher number of cells was observed in the scratched area of the FC group on the 4^th day. There were no differences between groups considering cell viability, Reck expression, amount of collagen types I and III, MMP-2 and TGF-β1, whereas TGF-β1 was not detected in the FC group and the MMP-9 in none of the groups. Our hypothesis was not supported by the results because the red LED irradiation decreased the healing response of ASC. An inhibitory effect of the LED irradiation associated with ASC co-culture was observed with reduction of the amount of TGF-β1, VEGF and tenomodulin, possibly involved in the reduced cell migration. In turn, the ASC alone seem to have modulated fibroblast behavior by increasing Ctgf, VEGF and tenomodulin, leading to greater cell migration. In conclusion, red LED and ASC therapy can have independent effects on fibroblast wound healing, but the combination of both does not have a synergistic effect. Therefore, future studies with other parameters of red LED associated with ASC should be tested aiming clinical application for tissue repair.

Systematic Review of Photobiomodulation Therapy (PBMT) on the Experimental Calcaneal Tendon Injury in Rats

This systematic review analyzed the light parameters and the effects of photobiomodulation therapy (PBMT) through low-level laser therapy (LLLT) and/or LED (light-emitting diode) on tendon repair of rats submitted to calcaneal injury. This study was conducted in accordance with the guidelines of the Preferred Reporting Items for Meta-Analysis, and PubMed and MEDLINE databases were accessed to search eligible studies published in English. The search terms were as follows: "Achilles tendon" or "Calcaneal tendon" or "tendon injuries" or "soft tissue injuries" and "tendinopathy" or "tendinitis" and "low-level light therapy" or "low-level laser therapy" or "low intensity power therapy" or "light-emitting diode" or photobiomodulation." The SYRCLE (SYstematic Review Center for Laboratory animal Experimentation) risks of bias was used to assess the risk of bias for selected studies. A total of 225 studies were found based on the descriptors used, and only 33 studies were eligible. Light parameters identified per point of irradiation were approximately 60 mW (continuous mode at infrared spectra), 2 W cm^-2 , 2 J and 45 J cm^-2 . Light parameters at red spectra, continuous versus pulsed mode, and PBMT combined or compared with other therapies such as ultrasound, and studies using unhealthy rats (ovariectomized and/or diabetic models) were also identified and grouped according to these similarities. The main effects found were decreased inflammatory markers and signs of inflammatory process. PBMT (laser/LED) has positive effects in reducing the inflammatory and time for tissue repair in animal models of tendon injury and/or tendinitis using parameters identified.

Tendon and Ligament Healing and Current Approaches to Tendon and Ligament Regeneration

Ligament and tendon injuries are common problems in orthopedics. There is a need for treatments that can expedite nonoperative healing or improve the efficacy of surgical repair or reconstruction of ligaments and tendons. Successful biologically-based attempts at repair and reconstruction would require a thorough understanding of normal tendon and ligament healing. The inflammatory, proliferative, and remodeling phases, and the cells involved in tendon and ligament healing will be reviewed. Then, current research efforts focusing on biologically-based treatments of ligament and tendon injuries will be summarized, with a focus on stem cells endogenous to tendons and ligaments. Statement of clinical significance: This paper details mechanisms of ligament and tendon healing, as well as attempts to apply stem cells to ligament and tendon healing. Understanding of these topics could lead to more efficacious therapies to treat ligament and tendon injuries. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:7-12, 2020.

The Effect of Photobiomodulation Therapy on the Differentiation, Proliferation, and Migration of the Mesenchymal Stem Cell: A Review

Introduction: The purpose of this study is to investigate the effect of a low-power laser on the proliferation, migration, differentiation of different types of mesenchymal stem cells (MSCs) in different studies. Methods: The relevant articles that were published from 2004 to 2019 were collected from the sources of PubMed, Scopus, and only the articles specifically examining the effect of a lowpower laser on the proliferation, differentiation, and migration of the MSCs were investigated. Results: After reviewing the literature, only 42 articles were found relevant. Generally, most of the studies demonstrated that different laser parameters increased the proliferation, migration, and differentiation of the MSCs, except the results of two studies which were contradictory. In fact, changing the parameters of a low-power laser would affect the results. On the other hand, the source of the stem cells was reported as a key factor. In addition, the combination of lasers with other therapeutic approaches was found to be more effective. Conclusion: The different parameters of lasers has been found to be effective in the proliferation, differentiation, and migration of the MSCs and in general, a low-power laser has a positive effect on the MSCs, helping to improve different disease models.

Fate of systemically and locally administered adipose-derived mesenchymal stromal cells and their effect on wound healing

There is increasing interest in the use of adipose‐derived mesenchymal stromal cells (ASCs) for wound repair. As the fate of administered cells is still poorly defined, we aimed to establish the location, survival, and effect of ASCs when administered either systemically or locally during wound repair under physiological conditions. To determine the behavior of ASCs, a rat model with wounds on the dorsal aspect of the hind paws was used and two treatment modes were assessed: ASCs administered systemically into the tail vein or locally around the wound. ASCs were transduced to express both firefly luciferase (Fluc) and green fluorescent protein to enable tracking by bioluminescence imaging and immunohistological analysis. Systemically administered ASCs were detected in the lungs 3 hours after injection with a decrease in luminescent signal at 48 hours and signal disappearance from 72 hours. No ASCs were detected in the wound. Locally administered ASCs remained strongly detectable for 7 days at the injection site and became distributed within the wound bed as early as 24 hours post injection with a significant increase observed at 72 hours. Systemically administered ASCs were filtered out in the lungs, whereas ASCs administered locally remained and survived not only at the injection site but were also detected within the wound bed. Both treatments led to enhanced wound closure. It appears that systemically administered ASCs have the potential to enhance wound repair distally from their site of entrapment in the lungs whereas locally administered ASCs enhanced wound repair as they became redistributed within the wound bed.

Overview on the Evolution of Laser Welding of Vascular and Nervous Tissues

Laser welding presents a core position in the health sector. This process has had an outstanding impact on the surgical procedures from many medical areas, such as on vascular and nervous surgeries. The aim of the present research is to present an overview on the evolution of laser welding of vascular and nervous tissues. These surgeries present many advantages, such as an absence of foreign-body reactions and aneurysms and good tensile strengths. However, despite the sutureless nature of the process, complementary sutures have been applied to support the procedure success. An important concern in vascular and nervous laser welding is the thermal damage. The development of temperature-controlled feedback systems has reduced this concern with a very precise control of the laser parameters. The bonding strength of vascular and nerve laser welds can be enhanced with the application of solder solutions, bonding materials, and laser-activated dyes. Alternative techniques to laser welding, such as photochemical tissue bonding and electrosurgical high-frequency technologies, have also been tested for vascular and nervous repairs.

Low-level laser and adipose-derived stem cells altered remodelling genes expression and improved collagen reorganization during tendon repair

Objectives

The cellular therapy using adipose‐derived mesenchymal stem cells (ASCs) aims to improve tendon healing, considering that repaired tendons often result in a less resistant tissue. Our objective was to evaluate the effects of the ASCs combination with a low‐level laser (LLL), an effective photobiostimulation for the healing processes.

Materials and methods

Rats calcaneal tendons were divided into five groups: normal (NT), transected (T), transected and ASCs (SC) or LLL (L), or with ASCs and LLL (SCL).

Results

All treated groups presented higher expression of Dcn and greater organization of collagen fibres. In comparison with T, LLL also up‐regulated Gdf5 gene expression, ASCs up‐regulated the expression of Tnmd, and the association of LLL and ASCs down‐regulated the expression of Scx. No differences were observed for the expression of Il1b, Timp2, Tgfb1, Lox, Mmp2, Mmp8 and Mmp9, neither in the quantification of hydroxyproline, TNF‐α, PCNA and in the protein level of Tnmd. A higher amount of IL‐10 was detected in SC, L and SCL compared to T, and higher amount of collagen I and III was observed in SC compared to SCL.

Conclusions

Transplanted ASCs migrated to the transected region, and all treatments altered the remodelling genes expression. The LLL was the most effective in the collagen reorganization, followed by its combination with ASCs. Further investigations are needed to elucidate the molecular mechanisms involved in the LLL and ASCs combination during initial phases of tendon repair.