Low-level stretching accelerates cell migration into a gap

The complex interplay between mechanical forces, tissue response and individual susceptibility to pressure ulcers

OBJECTIVE

The most recent edition of the International Clinical Practice Guideline for the Prevention and Treatment of Pressure Ulcers/Injuries was released in 2019. Shortly after, in 2020, the first edition of the SECURE Prevention expert panel report, focusing on device-related pressure ulcers/injuries, was published as a special issue in the Journal of Wound Care. A second edition followed in 2022. This article presents a comprehensive summary of the current understanding of the causes of pressure ulcers/injuries (PU/Is) as detailed in these globally recognised consensus documents.

METHOD

The literature reviewed in this summary specifically addresses the impact of prolonged soft tissue deformations on the viability of cells and tissues in the context of PU/Is related to bodyweight or medical devices.

RESULTS

Prolonged soft tissue deformations initially result in cell death and tissue damage on a microscopic scale, potentially leading to development of clinical PU/Is over time. That is, localised high tissue deformations or mechanical stress concentrations can cause microscopic damage within minutes, but it may take several hours of continued mechanical loading for this initial cell and tissue damage to become visible and clinically noticeable. Superficial tissue damage primarily stems from excessive shear loading on fragile or vulnerable skin. In contrast, deeper PU/Is, known as deep tissue injuries, typically arise from stress concentrations in soft tissues at body regions over sharp or curved bony prominences, or under stiff medical devices in prolonged contact with the skin.

CONCLUSION

This review promotes deeper understanding of the pathophysiology of PU/Is, indicating that their primary prevention should focus on alleviating the exposure of cells and tissues to stress concentrations. This goal can be achieved either by reducing the intensity of stress concentrations in soft tissues, or by decreasing the exposure time of soft tissues to such stress concentrations.

Negative-Pressure Wound Therapy: What We Know and What We Need to Know

Negative-pressure wound therapy (NPWT) promotes wound healing by applying negative pressure to the wound surface. A quarter of a century after its introduction, NPWT has been used in various clinical conditions, although molecular biological evidence is insufficient due to delay in basic research. Here, we have summarized the history of NPWT, its mechanism of action, what is currently known about it, and what is expected to be known in the future. Particularly, attention has shifted from the four main mechanisms of NPWT to the accompanying secondary effects, such as effects on various cells, bacteria, and surgical wounds. This chapter will help the reader to understand the current status and shortcomings of NPWT-related research, which could aid in the development of basic research and, eventually, clinical use with stronger scientific evidence.

Probing Local Force Propagation in Tensed Fibrous Gels

Fibrous hydrogels are a key component of soft animal tissues. They support cellular functions and facilitate efficient mechanical communication between cells. Due to their nonlinear mechanical properties, fibrous materials display non-trivial force propagation at the microscale, that is enhanced compared to that of linear-elastic materials. In the body, tissues are constantly subjected to external loads that tense or compress them, modifying their micro-mechanical properties into an anisotropic state. However, it is unknown how force propagation is modified by this isotropic-to-anisotropic transition. Here, force propagation in tensed fibrin hydrogels is directly measured. Local perturbations are induced by oscillating microspheres using optical tweezers. 1-point and 2-point microrheology are combined to simultaneously measure the shear modulus and force propagation. A mathematical framework to quantify anisotropic force propagation trends is suggested. Results show that force propagation becomes anisotropic in tensed gels, with, surprisingly, stronger response to perturbations perpendicular to the axis of tension. Importantly, external tension can also increase the range of force transmission. Possible implications and future directions for research are discussed. These results suggest a mechanism for favored directions of mechanical communication between cells in a tissue under external loads.

Expansion of fibroblast cell sheets using a modified MEEK micrografting technique for wound healing applications

Cell sheet engineering, a scaffold-free approach to fabricate functional tissue constructs from several cell monolayers, has shown promise in tissue regeneration and wound healing. Unfortunately, these cell sheets are often too small to provide sufficient wound area coverage. In this study, we describe a process to enlarge cell sheets using MEEK micrografting, a technique extensively used to expand skin autografts for large burn treatments. Human dermal fibroblast cell sheets were placed on MEEK's prefolded gauze without any use of adhesive, cut along the premarked lines and stretched out at various expansion ratios (1:3, 1:6 and 1:9), resulting in regular distribution of many square islands of fibroblasts at a much larger surface area. The cellular processes essential for wound healing, including reattachment, proliferation, and migration, of the fibroblasts on expanded MEEK gauze were superior to those on nylon dressing which served as a control. The optimal expansion ratio with the highest migration rate was 1:6, possibly due to the activation of chemical signals caused by mechanical stretching and an effective intercellular communication distance. Therefore, the combination of cell sheet engineering with the MEEK micrografting technique could provide high quality cells with a large coverage area, which would be particularly beneficial in wound care applications.

The influence zone: a critical performance measure for negative pressure wound therapy systems

This article provides an introduction to the theory of, what is termed, the 'influence zone' in the context of negative pressure wound therapy (NPWT). It is a quantitative bioengineering performance measure for NPWT systems, to indicate their effectiveness, namely, how far from the wound bed edges a specific system is able to deliver effective mechano-stimulation into the periwound, and at which intensity. The influence zone therefore provides objective and standardised metrics of one of the fundamental modes of action of NPWT systems: the ability to effectively and optimally deform both the wound and periwound macroscopically and microscopically. Most important is the mechanical deformation of the periwound area to activate cells responsible for tissue repair, particularly (myo)fibroblasts. Notably, the influence zone must extend sufficiently into the periwound to stimulate (myo)fibroblasts in order that they migrate and progress the wound healing process, facilitating the formation of scar tissue, without overstretching the periwound tissues so as not cause or escalate further cell and tissue damage. The inclusion of the influence zone theory within research to investigate the efficacy of NPWT systems facilitates systematic comparisons of commercially available and potentially new systems. This approach has the capacity to guide not only research and development work, but also clinical decision-making. Recently published research found that inducing an effective influence zone first and foremost requires continuous delivery of the intended pressure to the wound bed.

Effective negative pressure wound therapy for open wounds: The importance of consistent pressure delivery

Two distinct design concepts exist for single-use negative pressure wound therapy systems: Canister-based versus canisterless. The canister-based technology provides intrinsic stable delivery of the intended negative pressure, because exudate is constantly transferred from the wound into a canister, thereby preventing dressing saturation. In contrast, with a canisterless system, where delivery of the negative pressure depends on continuous evaporation of wound fluids from its dressing, loss of the intended wound-bed pressure may occur due to dressing saturation. To investigate whether these two designs differ in their mechanobiological effect with respect to magnitudes and distributions of tissue strain fields under the absorptive dressing, termed the influence zone, we integrated computational modelling with an animal study. This influence zone must be of biologically influential strain levels and extend sufficiently into the peri-wound for stimulating fibroblasts to migrate and progress the healing. We found that an effective influence zone requires continuous delivery of the intended pressure to the wound-bed. Loss of negative pressure at the wound-bed below 40 mmHg adversely lowered the peri-wound stimulation around a 120 × 70 mm sized wound to less than one-third of the baseline stimulation, and further pressure decreases to 20 mmHg or lower resulted in complete lack of peri-wound mechano-stimulation.

Current Development in Interdigital Transducer (IDT) Surface Acoustic Wave Devices for Live Cell In Vitro Studies: A Review

Acoustics have a wide range of uses, from noise-cancelling to ultrasonic imaging. There has been a surge in interest in developing acoustic-based approaches for biological and biomedical applications in the last decade. This review focused on the application of surface acoustic waves (SAW) based on interdigital transducers (IDT) for live-cell investigations, such as cell manipulation, cell separation, cell seeding, cell migration, cell characteristics, and cell behaviours. The approach is also known as acoustofluidic, because the SAW device is coupled with a microfluidic system that contains live cells. This article provides an overview of several forms of IDT of SAW devices on recently used cells. Conclusively, a brief viewpoint and overview of the future application of SAW techniques in live-cell investigations were presented.

Our contemporary understanding of the aetiology of pressure ulcers/pressure injuries

In 2019, the third and updated edition of the Clinical Practice Guideline (CPG) on Prevention and Treatment of Pressure Ulcers/Injuries has been published. In addition to this most up‐to‐date evidence‐based guidance for clinicians, related topics such as pressure ulcers (PUs)/pressure injuries (PIs) aetiology, classification, and future research needs were considered by the teams of experts. To elaborate on these topics, this is the third paper of a series of the CPG articles, which summarises the latest understanding of the aetiology of PUs/PIs with a special focus on the effects of soft tissue deformation. Sustained deformations of soft tissues cause initial cell death and tissue damage that ultimately may result in the formation of PUs/PIs. High tissue deformations result in cell damage on a microscopic level within just a few minutes, although it may take hours of sustained loading for the damage to become clinically visible. Superficial skin damage seems to be primarily caused by excessive shear strain/stress exposures, deeper PUs/PIs predominantly result from high pressures in combination with shear at the surface over bony prominences, or under stiff medical devices. Therefore, primary PU/PI prevention should aim for minimising deformations by either reducing the peak strain/stress values in tissues or decreasing the exposure time.

Progress in the mechanical modulation of cell functions in tissue engineering

In mammals, mechanics at multiple stages-nucleus to cell to ECM-underlie multiple physiological and pathological functions from its development to reproduction to death. Under this inspiration, substantial research has established the role of multiple aspects of mechanics in regulating fundamental cellular processes, including spreading, migration, growth, proliferation, and differentiation. However, our understanding of how these mechanical mechanisms are orchestrated or tuned at different stages to maintain or restore the healthy environment at the tissue or organ level remains largely a mystery. Over the past few decades, research in the mechanical manipulation of the surrounding environment-known as substrate or matrix or scaffold on which, or within which, cells are seeded-has been exceptionally enriched in the field of tissue engineering and regenerative medicine. To do so, traditional tissue engineering aims at recapitulating key mechanical milestones of native ECM into a substrate for guiding the cell fate and functions towards specific tissue regeneration. Despite tremendous progress, a big puzzle that remains is how the cells compute a host of mechanical cues, such as stiffness (elasticity), viscoelasticity, plasticity, non-linear elasticity, anisotropy, mechanical forces, and mechanical memory, into many biological functions in a cooperative, controlled, and safe manner. High throughput understanding of key cellular decisions as well as associated mechanosensitive downstream signaling pathway(s) for executing these decisions in response to mechanical cues, solo or combined, is essential to address this issue. While many reports have been made towards the progress and understanding of mechanical cues-particularly, substrate bulk stiffness and viscoelasticity-in regulating the cellular responses, a complete picture of mechanical cues is lacking. This review highlights a comprehensive view on the mechanical cues that are linked to modulate many cellular functions and consequent tissue functionality. For a very basic understanding, a brief discussion of the key mechanical players of ECM and the principle of mechanotransduction process is outlined. In addition, this review gathers together the most important data on the stiffness of various cells and ECM components as well as various tissues/organs and proposes an associated link from the mechanical perspective that is not yet reported. Finally, beyond addressing the challenges involved in tuning the interplaying mechanical cues in an independent manner, emerging advances in designing biomaterials for tissue engineering are also explored.

A novel system for dynamic stretching of cell cultures reveals the mechanobiology for delivering better negative pressure wound therapy

Serious wounds, both chronic and acute (e.g., surgical), are among the most common, expensive and difficult-to-treat health problems. Negative pressure wound therapy (NPWT) is considered a mainstream procedure for treating both wound types. Soft tissue deformation stimuli are the crux of NPWT, enhancing cell proliferation and migration from peri-wound tissues which contributes to healing. We developed a dynamic stretching device (DSD) contained in a miniature incubator for applying controlled deformations to fibroblast wound assays. Prior to the stretching experiments, fibroblasts were seeded in 6-well culture plates with elastic substrata and let to reach confluency. Squashing damage was then induced at the culture centers, and the DSD was activated to deliver stretching regimes that represented common clinical NPWT protocols at two peak strain levels, 0.5% and 3%. Analyses of the normalized maximal migration rate (MMR) data for the collective cell movement revealed that for the 3% strain level, the normalized MMR of cultures subjected to a 0.1 Hz stretch frequency regime was ~ 1.4 times and statistically significantly greater (p < 0.05) than that of the cultures subjected to no-stretch (control) or to static stretch (2nd control). Correspondingly, analysis of the time to gap closure data indicated that the closure time of the wound assays subjected to the 0.1 Hz regime was ~ 30% shorter than that of the cultures subjected to the control regimes (p < 0.05). Other simulated NPWT protocols did not emerge as superior to the controls. The present method and system are a powerful platform for further revealing the mechanobiology of NPWT and for improving this technology.

High body mass index is a strong predictor of intraoperative acquired pressure injury in spinal surgery patients when prophylactic film dressings are applied: A retrospective analysis prior to the BOSS Trial

We reported the efficacy of soft silicone multilayered foam dressings in preventing intraoperatively acquired pressure injuries (IAPIs) in the prone position using a Relton-Hall frame (BOSS trial). The aim of this study was to clarify the incidence and extract the risk factors for IAPIs in cases in which polyurethane film dressing was used against IAPIs before the BOSS trial period. This study conducted as a retrospective dual-center cohort study between August 2014 and Jun 2015 using the medical records in the operating room. The incidence of IAPIs that developed within 24 hours after surgery was 7.1% (7/99). The multivariate logistic regression analysis revealed that body mass index (BMI) (P = .0016, odds ratio [OR]: 1.22, 95% confidence interval (CI) 1.08-1.4) and length of surgery (P < .0001, OR 2.47, 95% CI 1.86-3.51) were independently associated with the development of IAPIs. Since high BMI was not extracted in BOSS trial, we conclude that the application of soft silicone multilayer foam dressings is important for preventing the development of IAPIs in patients with high BMI values.

Finite element analysis reveals an important role for cell morphology in response to mechanical compression

Mechanical loading naturally controls cell phenotype, development, motility and various other biological functions; however, prolonged or substantial loading can cause cell damage and eventual death. Loading-induced mechanobiological and mechanostructural responses of different cell types affect their morphology and the internal architecture and the mechanics of the cellular components. Using single, mesenchymal stem cells, we have developed a cell-specific three-dimensional finite-element model; cell models were developed from phase-contrast microscopy images. This allowed us to evaluate the mechanostructural response of the naturally occurring variety of cell morphologies to increase sustained compressive loading. We focus on the morphology of the cytoplasm and the nucleus, as the main mechanically responsive elements, and evaluate formation of tensional strains and area changes in cells undergoing increasing uniaxial compressions. Here, we study mesenchymal stem cells as a model, due to their important role in tissue engineering and regenerative medicine; the method and findings are, however, applicable to any cell type. We observe variability in the cell responses to compression, which correlate directly with the morphology of the cells. Specifically, in cells with or without elongated protrusions (i.e., lamellipodia) tensional strains were, respectively, distributed mostly in the thin extensions or concentrated around the stiff nucleus. Thus, through cell-specific computational modeling of mechanical loading we have identified an underlying cause for stiffening (by actin recruitment) along the length of lamellipodia as well as a role for cell morphology in inducing cell-to-cell variability in mechanostructural response to loading.

Biological Effects of Shikonin in Human Gingival Fibroblasts via ERK 1/2 Signaling Pathway

Shikonin, an active ingredient of Lithospermum erythrorhizon, exerts anti-inflammatory and antibacterial effects, and promotes wound healing. We investigated whether shikonin stimulated gingival tissue wound healing in human gingival fibroblasts (hGF). In addition, we evaluated the effects of shikonin on the mitogen-activated protein kinase (MAPK) signaling pathway, which has an important role in wound healing. hGF were subjected to primary culture using gingiva collected from patients. The cells were exposed to/treated with Shikonin at concentrations ranging from 0.01 to 100 μM. The optimal concentration was determined by cell proliferation and migration assays. Type I collagen and fibronectin synthesis, the gene expression of vascular endothelial growth factor (VEGF) and FN, and the phosphorylation of Extracellular signal-regulated kinase (ERK) 1/2 were investigated. Identical experiments were performed in the presence of PD98059 our data suggest, a specific ERK 1/2 inhibitor. Shikonin significantly promoted hGF proliferation and migration. Shikonin (1 µM) was chosen as the optimal concentration. Shikonin promoted type I collagen and FN synthesis, increased VEGF and FN expression, and induced ERK 1/2 phosphorylation. These changes were partially suppressed by PD98059. In conclusion, Shikonin promoted the proliferation, migration, type I collagen and FN synthesis, and expression of VEGF and FN via ERK 1/2 signaling pathway in hGFs. Therefore, shikonin may promote periodontal tissue wound healing.

Sodium pyruvate pre-treatment prevents cell death due to localised, damaging mechanical strains in the context of pressure ulcers

We demonstrate sodium pyruvate (NaPy) pre-treatment as a successful approach for pressure ulcer (PU) prevention by averting their aetiological origin-cell-level damage and death by large, sustained mechanical loads. We evaluated the NaPy pre-treatment effect on permeability changes in the cell's plasma membrane (PM) following application of in vitro damaging-level strains. Fibroblasts or myoblasts, respectively, models for superficial or deep-tissue damage were grown in 0 or 1 mM NaPy, emulating typical physiological or cell culture conditions. Cells were pre-treated for 4 hours with 0 to 5 mM NaPy prior to 3-hour sustained, damaging-level loads (12% strain). PM permeability was quantified by the cell uptake of small (4 kDa), fluorescent dextran compared with unstrained control using fluorescence-activated cell sorting (FACS). Pre-treatment with 1 mM, and especially 5 mM, NaPy significantly reduces damage to PM integrity. Long-term NaPy pre-exposure can improve protective treatment, affecting fibroblasts and myoblasts differently. Pre-treating with NaPy, a natural cell metabolite, allows cells under damaging-level mechanical loads to maintain their PM integrity, that is, to avoid loss of homeostasis and inevitable, eventual cell death, by preventing initial, microscale stages of PU formation. This pre-treatment may be applied prior to planned periods of immobility, for example, planned surgery or transport, to prolong safe time in a position by preventing initial cell damage that can cascade and lead to PU formation.

Non-damaging stretching combined with sodium pyruvate supplement accelerate migration of fibroblasts and myoblasts during gap closure

BACKGROUND

Sustained, low- and mid-level (3-6%), radial stretching combined with varying concentrations of sodium pyruvate (NaPy) supplement increase the migration rate during microscale gap closure following an in vitro injury; NaPy is a physiological supplement often used in cell-culture media. Recently we showed that low-level tensile strains accelerate in vitro kinematics during en masse cell migration; topically applied mechanical deformations also accelerate in vivo healing in larger wounds. The constituents and nutrients at injury sites change. Thus, we combine a supplement with stretching conditions to effectively accelerate wound healing.

METHODS

Monolayers of murine fibroblasts (NIH3T3) or myoblasts (C2C12) were cultured in 1 mM NaPy on stretchable, linear-elastic substrates. Monolayers were subjected to 0, 3, or 6% stretching using a custom three-dimensionally printed stretching apparatus, micro-damage was immediately induced, media was replaced with fresh media containing 0, 1, or 5 mM NaPy, and cell migration kinematics during gap-closure were quantitatively evaluated.

FINDINGS

In myoblasts, the smallest evaluated strain (3%, minimal risk of damage) combined with preinjury (1 mM) and post-injury exogenous NaPy supplements accelerated gap closure in a statistically significant manner; response was NaPy concentration dependent. In both fibroblasts and myoblasts, when cells were pre-exposed to NaPy, yet no supplement was provided post-injury, mid-level stretches (6%) compensated for post-injury deficiency in exogenous NaPy and accelerated gap-closure in a statistically significant manner.

INTERPRETATION

Small deformations combined with NaPy supplement prior-to and following cell-damage accelerate en masse cell migration and can be applied in wound healing, e.g. to preventatively accelerate closure of microscale gaps.

Mechanical stress as a regulator of cell motility

The motility of a cell can be triggered or inhibited not only by an applied force but also by a mechanically neutral force couple. This type of loading, represented by an applied stress and commonly interpreted as either squeezing or stretching, can originate from extrinsic interaction of a cell with its neighbors. To quantify the effect of applied stresses on cell motility we use an analytically transparent one-dimensional model accounting for active myosin contraction and induced actin turnover. We show that stretching can polarize static cells and initiate cell motility while squeezing can symmetrize and arrest moving cells. We show further that sufficiently strong squeezing can lead to the loss of cell integrity. The overall behavior of the system depends on the two dimensionless parameters characterizing internal driving (chemical activity) and external loading (applied stress). We construct a phase diagram in this parameter space distinguishing between static, motile, and collapsed states. The obtained results are relevant for the mechanical understanding of contact inhibition and the epithelial-to-mesenchymal transition.