ECM-Targeted and cell-based therapies in musculoskeletal and aging-related disorders: A review

BackgroundExtracellular matrix (ECM) stiffness is increasingly recognized as a key pathological factor in musculoskeletal and aging-related disorders. Although cell-based therapies-particularly mesenchymal stem cells (MSCs)-hold regenerative potential, their effectiveness is significantly reduced in fibrotic and mechanically rigid environments.ObjectiveThis review compares ECM-targeted and cell-based therapies, with a focus on their mechanistic basis, limitations, and potential for integration in regenerative strategies.SummaryPathological ECM stiffening, driven by lysyl oxidase (LOX)-mediated collagen crosslinking, chronic inflammation, and Piezo channel activation, alters cell-matrix interactions and promotes tissue degeneration. Therapeutic interventions such as LOX inhibitors, low-intensity pulsed ultrasound (LIPUS), and antifibrotic agents show promise in reversing matrix rigidity and restoring tissue biomechanics. In contrast, the success of MSC therapies is often hindered by impaired viability, reduced paracrine activity, and disrupted immunomodulation in stiffened ECM. Mechanosensitive pathways-including YAP/TAZ, integrins, and Piezo1/2-play critical roles in mediating this dysfunction.ConclusionEffective tissue regeneration requires a permissive mechanical and biochemical microenvironment. Rather than treating ECM remodeling as ancillary, it should be prioritized as a foundational therapeutic target. Preconditioning the ECM enhances the efficacy of cell-based therapies, suggesting that matrix normalization is essential for long-term regenerative success. Targeting ECM stiffness may therefore represent the most decisive step in overcoming barriers to musculoskeletal and aging-related tissue repair.