Manufacturing and use of human placenta-derived mesenchymal stromal cells for phase I clinical trials: Establishment and evaluation of a protocol

Background/Aim. Mesenchymal stromal cells (MSCs) have been utilised in many clinical trials as an experimental treatment in numerous clinical settings. Bone marrow remains the traditional source tissue for MSCs but is relatively hard to access in large volumes. Alternatively, MSCs may be derived from other tissues including the placenta and adipose tissue. In an initial study no obvious differences in parameters such as cell surface phenotype, chemokine receptor display, mesodermal differentiation capacity or immunosuppressive ability, were detected when we compared human marrow derived- MSCs to human placenta-derived MSCs. The aim of this study was to establish and evaluate a protocol and related processes for preparation placenta-derived MSCs for early phase clinical trials. Methods. A full-term placenta was taken after delivery of the baby as a source of MSCs. Isolation, seeding, incubation, cryopreservation of human placentaderived MSCs and used production release criteria were in accordance with the complex regulatory requirements applicable to Code of Good Manufacturing Practice manufacturing of ex vivo expanded cells. Results. We established and evaluated instructions for MSCs preparation protocol and gave an overview of the three clinical areas application. In the first trial, MSCs were co-transplanted iv to patient receiving an allogeneic cord blood transplant as therapy for treatmentrefractory acute myeloid leukemia. In the second trial, MSCs were administered iv in the treatment of idiopathic pulmonary fibrosis and without serious adverse effects. In the third trial, MSCs were injected directly into the site of tendon damage using ultrasound guidance in the treatment of chronic refractory tendinopathy. Conclusion. Clinical trials using both allogeneic and autologous cells demonstrated MSCs to be safe. A described protocol for human placenta-derived MSCs is appropriate for use in a clinical setting, relatively inexpensive and can be relatively easily adjusted to a different set of regulatory requirements, as applicable to early phase clinical trials.

L'effet de la réadaptation physique post-opératoire sur la guérison tendineuse : étude chez le lapin en tant que modèle animal

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Fiabilité et changement minimal détectable de mesures obtenues à partir d'images enregistrées par ultrasonographie afin de caractériser l'intégrité du tendon d'Achille

Problématique : La quantification de l’intégrité du tendon d’Achille (TA) représente un défi en réadaptation. L’adoption de mesures quantitatives du TA, extraites à partir d’une image ultrasonographique (QUS), pourrait remédier à cette lacune. Objectifs : 1) Évaluer la fiabilité test-retest et la précision de mesures QUS du TA; 2) Déterminer le meilleur protocole de collecte de mesures QUS à employer en pratique clinique. Méthodologie : Un total de 23 TAs présentant des symptômes d’une tendinopathie achilléenne et 63 TAs asymptomatiques ont été évalués. Pour chaque TA, 8 images ont été enregistrées (2 visites * 2 évaluatrices * 2 images). Différents types de mesures QUS ont été prises : géométriques (épaisseur, largeur, aire), dérivées d’un histogramme des niveaux de gris et dérivées d’une matrice de co-occurrence. Une étude de généralisabilité a quantifié la fiabilité et la précision de chaque mesure QUS et une étude de décision a fait ressortir les meilleurs protocoles de prise de mesures. Résultats : Les mesures géométriques ont démontré une excellente fiabilité et précision. Les mesures dérivées de l’histogramme des niveaux de gris ont démontré une fiabilité et précision médiocres. Les mesures dérivées d’une matrice de co-occurrence ont démontré une fiabilité modérée à excellente et une précision variable. En pratique clinique, il est recommandé de moyenner les résultats de trois images collectées par un évaluateur lors d’une visite. Conclusion : L’utilisation des mesures QUS géométriques permet de quantifier l’intégrité du TA (clinique et recherche). Davantage d’études sur les mesures QUS dérivées d’une matrice de co-occurrence s’avèrent nécessaires.

Anthropometry, physical performance, and ultrasound patellar tendon abnormality in elite junior basketball players: a cross-sectional study

Objective: Patellar tendinopathy has been reported to be associated with many intrinsic risk factors. Few have been fully investigated. This cross-sectional study examined the anthropometric and physical performance results of elite junior basketball players with normal or abnormal patellar tendons to see if any measures were associated with changes in tendon morphology.

Methods: Agility, leg strength, endurance, and flexibility were measured in 71 male and 64 female players. A blinded radiologist ultrasonographically examined their patellar tendons and athletes were grouped as having normal or abnormal tendons. One-way ANOVA was used to test for differences in anthropometric and physical performance data for athletes whose tendons were normal or abnormal (unilateral or bilateral tendinopathy) on ultrasound.

Results: Results show that females with abnormalities in their tendons had a significantly better vertical jump (50.9±6.8 cm) than those with normal tendons (46.1±5.4 cm) (p = 0.02). This was not found in males. In males, the mean sit and reach in those with normal tendons (13.2±6.7 cm) was greater (p<0.03) than in unilateral tendinopathy (10.3±6.2 cm) or in bilateral tendinopathy (7.8±8.3 cm). In females, those with normal tendons (13.3±4.8 cm) and bilateral tendinopathy (15.8±6.2 cm) were distinctly different from those with unilateral tendinopathy (7.9±6.6 cm).

Conclusion: Flexibility and vertical jump ability are associated with patellar tendinopathy and the findings warrant consideration when managing young, jumping athletes.

Vascularity and pain in the patellar tendon of adult jumping athletes : a 5 month longitudinal study

Background: This study investigated changes in tendon vascularity in 102 (67 men and 35 women) volleyball players over a 6 month competitive season.

Methods: Athletes were examined with both grey scale ultrasound and standardised colour Doppler settings. Vessel length and pain were measured each month on five separate occasions. Vascular tendons were divided into (i) those that were vascular on all occasions (persistent vascularity) and (ii) those that were vascular on more than two but less than five occasions (intermittent vascularity).

Results: A total of 41 of the 133 abnormal tendons were vascular on two or more occasions. Of these, 16 had persistent vascularity and 25 had intermittent vascularity. There was no significant difference in the prevalence of vascularity between men and women. None of the tendons had a pattern of vascularity over the season that could be clearly interpreted as the onset or resolution of vascularity. Subjects with changes in both tendons were more likely to have persistent vascularity (p = 0.045). Vessels were longer in tendons with persistent vascularity (p<0.000) and pain was significantly greater (p = 0.043) than in tendons with intermittent vascularity. Tendons with intermittent vascularity had similar pain scores on all days, whether or not they had detectable blood flow.

Asymptomatic hypoechoic regions on patellar tendon ultrasound : a 4-year clinical and ultrasound followup of 46 tendons

Patellar tendon ultrasound appearance is commonly used in clinical practice to diagnose patellar tendinopathy and guide management. Using a longitudinal study design we examined whether or not the presence of a hypoechoic ultrasonographic lesion in an asymptomatic patellar tendon conferred a risk for developing jumper's knee compared with a tendon that was ultrasonographically normal. Ultrasonographic, symptomatic and anthropometric assessment was completed at baseline and followup. Magnetic resonance imaging was performed on four tendons that resolved ultrasonographically in the study period. Forty-six patellar tendons were followed over 47±11.8 months. Eighteen tendons were hypoechoic at baseline and 28 were ultrasonographically normal. Five tendons resolved ultrasonographically in the study period. Magnetic resonance imaging in four of these tendons was normal. Seven normal patellar tendons at baseline developed a hypoechoic area but only two became symptomatic. Analysis of ultrasonography at baseline and clinical outcome with Fisher's exact test shows there is no association between baseline ultrasound changes and symptoms at followup. In this study there is no statistically significant relationship between ultrasonographic patellar tendon abnormalities and clinical outcome in elite male athletes. Management of jumper's knee should not be solely based on ultrasonographic appearance; clinical assessment remains the cornerstone of appropriate management.

The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinoplasty

Background: There is no disease specific, reliable, and valid clinical measure of Achilles tendinopathy. Objective: To develop and test a questionnaire based instrument that would serve as an index of severity of Achilles tendinopathy. Methods: Item generation, item reduction, item scaling, and pretesting were used to develop a questionnaire to assess the severity of Achilles tendinopathy. The final version consisted of eight  questions that measured the domains of pain, function in daily living, and sporting activity. Results range from 0 to 100, where 100 represents the perfect score. Its validity and reliability were then tested in a population of non-surgical patients with Achilles tendinopathy (n = 45), presurgical patients with Achilles tendinopathy (n = 14), and two normal control populations (total n = 87). Results: The VISA-A questionnaire had good test-retest (r = 0.93), intrarater (three tests, r = 0.90), and interrater (r = 0.90) reliability as well as good stability when compared one week apart (r = 0.81). The mean (95% confidence interval) VISA-A score in the non-surgical patients was 64 (59–69), in presurgical patients 44 (28–60), and in control subjects it exceeded 96 (94–99). Thus the VISA-A score was higher in non-surgical than presurgical patients (p = 0.02) and higher in control subjects than in both patient populations (p<0.001). Conclusions: The VISA-A questionnaire is reliable and displayed construct validity when means were compared in patients with a range of severity of Achilles tendinopathy and control subjects. The continuous numerical result of the VISA-A questionnaire has the potential to provide utility in both the clinical setting and research. The test is not designed to be diagnostic. Further studies are needed to determine whether the VISA-A score predicts prognosis.

Increased versican content is associated with tendinosis pathology in the patellar tendon of athletes with jumper

Expansion of the extracellular matrix is a prominent but poorly characterized feature of tendinosis. The present study aimed to characterize the extent and distribution of the large aggregating proteoglycan versican in patients with patellar tendinosis. We obtained tendon from tendinopathy patients undergoing debridement of the patellar tendon and from controls undergoing intramedullary tibial nailing. Versican content was investigated by Western blotting and immunohistochemistry. Microvessel thickness and density were determined using computer-assisted image analysis. Markers for smooth muscle actin, endothelial cells (CD31) and proliferating cells (Ki67) were examined immunohistochemically. Western blot analysis and immunohistochemical staining revealed elevated versican content in the proximal patellar tendon of tendinosis patients (P=0.042). Versican content was enriched in regions of fibrocartilage metaplasia and fibroblast proliferation, as well as in the perivascular matrix of proliferating microvessels and within the media and intima of arterioles. Microvessel density was higher in tendinosis tissue compared with control tissue. Versican deposition is a prominent feature of patellar tendinosis. Because this molecule is not only a component of normal fibrocartilagenous matrices but also implicated in a variety of soft tissue pathologies, future studies should further detail both pathological and adaptive roles of versican in tendons.

Rehabilitation of Achilles and patellar tendinopathies

Achilles and patellar tendinopathies affect a broad range of the population and are difficult conditions to manage clinically. The pathology is persistent in the chronic tendon and can be considered to be failed healing. The exact cause of tendinopathy pain is unclear but may be related to changes in neurovascular structures.

Rehabilitation for Achilles and patellar tendinopathies is based on an exercise programme that aims to improve muscle–tendon function and normalise the pelvic/lower limb kinetic chain. This incorporates a programme for restoring and improving muscle strength, endurance and power and retraining sport-specific function.

Rehabilitation may take a prolonged period of time, both the athlete and clinician must be patient and persistent to maximise results from an exercise-based treatment.

No effect of eccentric training on jumper's knee in volleyball plays. During the competitive season : a randomized clinical trial

Background: The effect of surgery on patellar tendinopathy (jumper's knee) is questionable, and conservative treatment protocols have not been properly documented.

Purpose: The aim of this study was to investigate the effect of a newly developed eccentric training program for patellar tendinopathy in volleyball players during the competitive season.

Study Design: Randomized clinical trial.

Methods: Patients were recruited from male and female elite volleyball teams in Norway, and the diagnosis was based on clinical examination alone. Of 51 players diagnosed with patellar tendinopathy, 29 could be included in the study. The training group (n = 13) performed squats on a 25° decline board as a home exercise program (3 × 15 repetitions twice daily) for a 12-week intervention period during the final half of the competitive season. The eccentric (downward) component was done on the affected leg. The control group (n = 16) trained as usual. The primary outcome was a symptom-based questionnaire developed specifically for patellar tendinopathy (Victorian Institute of Sport Assessment score), and patients were followed up before and after the intervention period, as well as after 6 and 30 weeks. All subjects self-recorded training to document their activity level (eccentric training, volleyball training, matches, other training).

Results: There was no change in Victorian Institute of Sport Assessment score during the intervention period in the training (pre, 71.1 ± 11.3; post, 70.2 ± 15.4) or control group (pre, 76.4 ± 12.1; post, 75.4 ± 16.7), nor was there any change during the follow-up period at 6 weeks or 6 months. The training group completed 8.2 ± 4.6 weekly sessions of eccentric training during the intervention period (59% of the recommended volume), and there was no difference between groups in training or competition load.

Conclusion: There was no effect on knee function from a 12-week program with eccentric training among a group of volleyball players with patellar tendinopathy who continued to train and compete during the treatment period. Whether the training would be effective if the patients did not participate in sports activity is not known.

Pathology of chronic achilles-tendon injuries in athletes

Overuse tendon conditions have traditionally been considered to result from an inflammatory process and were treated as such. Microscopic examination of abnormal Achilles-tendon tissues, however, reveals a non-inflammatory degenerative process. The histopathology found in surgical specimens in patients with chronic overuse Achilles tendinopathy and those with Achilles-tendon rupture are reviewed. Seminal studies suggest that so-called tendinitis is a rare condition that might occur occasionally in the Achilles tendon in association with a primary tendinosis. These data have clinical implications and require a review of the traditional classification of pathologies seen in tendon conditions, The authors recommend that nomenclature be based on histopathological findings rather than traditional hypothesis.

Reduced ankle dorsiflexion range may increase the risk of patellar tendon injury among volleyball players

Patellar tendon injury, a chronic overuse injury characterised by pain during tendon loading, is common in volleyball players and may profoundly restrict their ability to compete. This cross-sectional study investigated the association between performance factors and the presence of patellar tendon injury. These performance factors (sit and reach flexibility, ankle dorsiflexion range, jump height, ankle plantarflexor strength, years of volleyball competition and activity level) were measured in 113 male and female volleyball players. Patellar tendon health was determined by measures of pain and ultrasound imaging. The association between these performance factors and patellar tendon health (normal tendon, abnormal imaging without pain, abnormal imaging with pain) was investigated using analysis of variance. Only reduced ankle dorsiflexion range was associated with patellar tendinopathy (p < 0.05). As coupling between ankle dorsiflexion and eccentric contraction of the calf muscle is important in absorbing lower limb force when landing from a jump, reduced ankle dorsiflexion range may increase the risk of patellar tendinopathy.

Discriminative ability of functional loading tests for adolescent jumper

Objective: To investigate the reliability and validity of five squat-based loading tests that are clinically appropriate for jumper's knee. The loading tests were step up, double leg squat, double leg squat on a 25-degree decline (decline squat), single leg decline squat, and decline hop. Design: Cross-sectional controlled cohort. Subjects without knee pain comprised controls, those with extensor tendon pain comprised the jumper's knee group. Setting: Institutional athlete study group in Australia. Participants: Fifty-six elite adolescent basketball players participated in this study, thirteen comprised the jumper's knee group, fifteen athletes formed a control group. Intervention: Each subject performed each loading test for baseline and reliability data on the first testing day. Subjects then performed three days of intensive (6 h daily) basketball training, after which each loading test was reexamined. Main outcome measures: Eleven point interval scale for pain. Results: The tests that best detected a change in pain due to intensive workload were the single leg decline squat and single leg decline hop. This study found that decline tests have better discriminative ability than the standard squat to detect change in jumper's knee pain due to intensive training. The typical error for these tests ranged from 0.3 to 0.5, however, caution should be exercised in the interpretation of these reliability figures due to relatively low scores. Conclusions: The single leg decline squat is recommended in the physical assessment of adolescent jumper's knee. The decline squat was selected as the best clinical test over the decline hop because it was easier to standardise performance.

In search of the tendon holy grail : predictable clinical outcomes

What is your first reaction when you find out your next patient has a long-term tendinopathy? I suspect you want to hide or get an urgent phone call that drags you away from the practice. You know that the person will have tried multiple interventions, probably had several injections, read all the literature about treatments for tendinopathy on the internet and want an immediate and lifelong cure. You also know that your assessment will take well into your next patient’s time allotment and even then it will remain difficult to prioritise treatments and to explain the rationale behind your plan to the patient. Even as a tendon researcher and part-time clinician whose practice consists solely of tendinopathy patients, my reactions to chronic tendinopathy patients are similar.