Date Published: February 4, 2019
Publisher: Public Library of Science
Author(s): Anderson Rodrigues de Oliveira, Flávio Santos da Silva, Raul Hernandes Bortolin, Dáfiny Emanuele da Silva Marques, Gracielle Vieira Ramos, Rita C. Marqueti, Naisandra Bezerra da Silva, Karina Carla de Paula Medeiros, Márcio Assolin Corrêa, João Paulo Matos Santos Lima, Adriana Augusto de Rezende, Paul W. Ackermann, Bento J. Abreu, Wouber Hérickson de Brito Vieira, Michael R. Hamblin.
The aim of this study was to compare the treatment effects of laser photobiomodulation (LPBM) therapy and aerobic exercise on the biomechanical properties, tissue morphology and the expression of tendon matrix molecules during early remodeling of Achilles tendon (AT) injury in diabetic rats. Animals were randomly assigned to five groups: injured non diabetic (I, n = 15), injured diabetic (ID, n = 15), injured diabetic plus LPBM (IDL, n = 16), injured diabetic plus aerobic exercise (IDE, n = 16) and injured diabetic plus aerobic exercise and LPBM (IDEAL, n = 17). Type 1 diabetes was induced via a single intravenous injection of Streptozotocin at a dose of 40 mg/kg. A partial tenotomy was performed in the right AT. LPBM was performed with an indium-gallium-aluminum-phosphide 660 nm 10 mW laser device (spot size 0.04 cm2, power density 250 mW/cm2, irradiation duration 16 s, energy 0.16 J, energy density 4 J/cm2) on alternate days for a total of 9 sessions over 3 weeks (total energy 1.44 J), using a stationary contact technique to a single point over the dorsal aspect of the AT. Moderate aerobic exercise was performed on a motorized treadmill (velocity 9 m/min for 60 minutes). At 3 weeks post-injury, biomechanical analyzes as well as assessment of fibroblast number and orientation were performed. Collagen 1 (Col1) and 3 (Col3) and matrix metalloproteinases (MMPs) -3 and 13 protein distributions were studied by immunohistochemistry; while Col1 and Col3 and MMP-2 and 9 gene expression were assessed by quantitative RT-PCR (qRT-PCR). IDEAL exhibited significant increases in several biomechanical parameters in comparison to the other groups. Moreover, IDEAL presented stronger Col1 immunoreactivity when compared to ID, and weaker Col3 immunoreactivity than IDE. Both IDL and IDEAL demonstrated weaker expression of MMP-3 in comparison to I, while IDL presented no expression of MMP-13 when compared to ID. ID, IDL and IDE showed an increased number of fibroblasts in comparison to I, while IDEAL decreased the number of these cells in comparison to ID and IDE. IDL and IDEAL groups exhibited decreased angular dispersion among the fibroblasts when compared to I. The gene expression results showed that IDE demonstrated a downregulation in Col1 mRNA expression in comparison to I and ID. IDEAL demonstrated upregulation of Col1 mRNA expression when compared to IDL or IDE alone and increased MMP-2 expression when compared to IDL and IDE. MMP-9 expression was upregulated in IDEAL when compared to I, IDL and IDE. Our results suggest a beneficial interaction of combining both treatment strategies i.e., aerobic exercise and LPBM, on the biomechanical properties, tissue morphology and the expression of matrix molecules in diabetic tendons.
Diabetes Mellitus (DM) is a complex metabolic disease characterized by chronic hyperglycemia which is responsible for several long term systemic complications . In the last years, a growing body of evidence has demonstrated the association between DM and tendinopathy [2,3]. Indeed, this painful connective tissue disorder can affect up to 60% of diabetic patients  and cause considerable disability, possibly due to compromised regenerative and healing capability .
Recent literature advocates that DM exhibits an essential role in tendon metabolism and healing. In fact, diabetes has been shown to cause non-enzymatic cross-linking  and disorganization of collagen fibers , promote inflammatory cell invasion and delayed angiogenesis , disrupt neurotrophic and angiotrophic factors  as well as matrix protein synthesis and degradation , and lead to poor biomechanical properties [9,34,35]. Thus, different strategies have been placed to enhance rehabilitation of tendon disorders in patients with DM .