Training-induced skeletal muscle adaptations are independent of systemic adaptations

MR Imaging of the Musculoskeletal System Using Ultrahigh Field (7T) MR Imaging

MR imaging is an indispensable instrument for the diagnosis of musculoskeletal diseases. In vivo MR imaging at 7T offers many advantages, including increased signal-to-noise ratio, higher spatial resolution, improved spectral resolution for spectroscopy, improved sensitivity for X-nucleus imaging, and decreased image acquisition times. There are also however technical challenges of imaging at a higher field strength compared with 1.5 and 3T MR imaging systems. We discuss the many potential opportunities as well as the challenges presented by 7T MR imaging systems and highlight recent developments in in vivo research imaging of musculoskeletal applications in general and cartilage, skeletal muscle, and bone in particular.

Impaired cardiac and skeletal muscle bioenergetics in children, adolescents, and young adults with Barth syndrome

Barth syndrome (BTHS) is an X‐linked condition characterized by altered cardiolipin metabolism and cardioskeletal myopathy. We sought to compare cardiac and skeletal muscle bioenergetics in children, adolescents, and young adults with BTHS and unaffected controls and examine their relationships with cardiac function and exercise capacity. Children/adolescents and young adults with BTHS (n = 20) and children/adolescent and young adult control participants (n = 23, total n = 43) underwent ³¹P magnetic resonance spectroscopy (³¹P‐MRS) of the lower extremity (calf) and heart for estimation of skeletal muscle and cardiac bioenergetics. Peak exercise testing (VO_2peak) and resting echocardiography were also performed on all participants. Cardiac PCr/ATP ratio was significantly lower in children/adolescents (BTHS: 1.5 ± 0.2 vs. Control: 2.0 ± 0.3, P < 0.01) and adults (BTHS: 1.9 ± 0.2 vs. Control: 2.3 ± 0.2, P < 0.01) with BTHS compared to Control groups. Adults (BTHS: 76.4 ± 31.6 vs. Control: 35.0 ± 7.4 sec, P < 0.01) and children/adolescents (BTHS: 71.5 ± 21.3 vs. Control: 31.4 ± 7.4 sec, P < 0.01) with BTHS had significantly longer calf PCr recovery (τPCr) postexercise compared to controls. Maximal calf ATP production through oxidative phosphorylation (Qmax‐lin) was significantly lower in children/adolescents (BTHS: 0.5 ± 0.1 vs. Control: 1.1 ± 0.3 mmol/L per sec, P < 0.01) and adults (BTHS: 0.5 ± 0.2 vs. Control: 1.0 ± 0.2 mmol/L sec, P < 0.01) with BTHS compared to controls. Blunted cardiac and skeletal muscle bioenergetics were associated with lower VO_2peak but not resting cardiac function. Cardiac and skeletal muscle bioenergetics are impaired and appear to contribute to exercise intolerance in BTHS.

Fatigue in healthy and diseased individuals

OBJECTIVES

Although fatigue is experienced by everyone, its definition and classification remains under debate.

METHODS

A review of the previously published data on fatigue.

RESULTS

Fatigue is influenced by age, gender, physical condition, type of food, latency to last meal, mental status, psychological conditions, personality type, life experience, and the health status of an individual. Fatigue may not only be a symptom but also a measurable and quantifiable dimension, also known as fatigability. Additionally, it may be classified as a condition occurring at rest or under exercise or stress, as physiologic reaction or pathologic condition, as spontaneous phenomenon or triggerable state, as resistant or irresistant to preconditioning, training, or attitude, as prominent or collateral experience, and as accessible or inaccessible to any type of treatment or intervention. Fatigue may be the sole symptom of a disease or one among others. It may be also classified as acute or chronic. Quantification of fatigability is achievable by fatigue scores, force measurement, electromyography, or other means. Fatigue and fatigability need to be delineated from conditions such as sleepiness, apathy, exhaustion, exercise intolerance, lack of vigor, weakness, inertia, or tiredness. Among neurological disorders, the prevalence of fatigue is particularly increased in multiple sclerosis, amyotrophic lateral sclerosis, Parkinson disease, traumatic brain injury, stroke, and bleeding and also in neuromuscular disorders. Fatigue may be influenced by training, mental preconditioning, or drugs.

CONCLUSIONS

Fatigue needs to be recognized as an important condition that is not only a symptom but may also be quantified and can be modified by various measures depending on the underlying cause.

Effect of resistance training on physical disability in chronic heart failure

PURPOSE

Patients with chronic heart failure (CHF) report difficulty performing activities of daily living. To our knowledge, however, no study has directly measured performance in activities of daily living in these patients to systematically assess their level of physical disability. Moreover, the contribution of skeletal muscle weakness to physical disability in CHF remains unclear. Thus, we measured performance in activities of daily living in CHF patients and controls, its relationship to aerobic capacity and muscle strength, and the effect of resistance exercise training to improve muscle strength and physical disability.

METHODS

Patients and controls were assessed for performance in activities of daily living, self-reported physical function, peak aerobic capacity, body composition, and muscle strength before and after an 18-wk resistance training program. To remove the confounding effects of several disease-related factors (muscle disuse, hospitalization, acute illness), we recruited controls with similar activity levels as CHF patients and tested patients >6 months after any disease exacerbation/hospitalization.

RESULTS

Performance in activities of daily living was 30% lower (P < 0.05) in CHF patients versus controls and was related to both reduced aerobic capacity (P < 0.001) and muscle strength (P < 0.01). Moreover, resistance training improved (P < 0.05 to P < 0.001) physical function and muscle strength in patients and controls similarly, without altering aerobic capacity.

CONCLUSIONS

CHF patients are characterized by marked physical disability compared with age- and physical activity-matched controls, which is related to reduced aerobic capacity and muscle strength. CHF patients respond to resistance training with normal strength/functional adaptations. Our results support muscle weakness as a determinant of physical disability in CHF and show that interventions that increase muscle strength (resistance training) reduce physical disability.

Muscle energetics changes throughout maturation: a quantitative 31P-MRS analysis

We quantified energy production in 7 prepubescent boys (11.7 ± 0.6 yr) and 10 men (35.6 ± 7.8 yr) using (31)P-magnetic resonance spectroscopy to investigate whether development affects muscle energetics, given that resistance to fatigue has been reported to be larger before puberty. Each subject performed a finger flexions exercise at 0.7 Hz against a weight adjusted to 15% of their maximal voluntary strength for 3 min, followed by a 15-min recovery period. The total energy cost was similar in both groups throughout the exercise bout, whereas the interplay of the different metabolic pathways was different. At the onset of exercise, children exhibited a higher oxidative contribution (50 ± 15% in boys and 25 ± 8% in men, P < 0.05) to ATP production, whereas the phosphocreatine breakdown contribution was reduced (40 ± 10% in boys and 53 ± 12% in men, P < 0.05), likely as a compensatory mechanism. The anaerobic glycolysis activity was unaffected by maturation. The recovery phase also disclosed differences regarding the rates of proton efflux (6.2 ± 2.5 vs. 3.8 ± 1.9 mM · pH unit(-1) · min(-1), in boys and men, respectively, P < 0.05), and phosphocreatine recovery, which was significantly faster in boys than in men (rate constant of phosphocreatine recovery: 1.3 ± 0.5 vs. 0.7 ± 0.4 min(-1); V(max): 37.5 ± 14.5 vs. 21.1 ± 12.2 mM/min, in boys and men, respectively, P < 0.05). Our results obtained in vivo clearly showed that maturation affects muscle energetics. Children relied more on oxidative metabolism and less on creatine kinase reaction to meet energy demand during exercise. This phenomenon can be explained by a greater oxidative capacity, probably linked to a higher relative content in slow-twitch fibers before puberty.

Biochemical and physiological MR imaging of skeletal muscle at 7 tesla and above

Ultra-high field (UHF; >or=7 T) magnetic resonance imaging (MRI), with its greater signal-to-noise ratio, offers the potential for increased spatial resolution, faster scanning, and, above all, improved biochemical and physiological imaging of skeletal muscle. The increased spectral resolution and greater sensitivity to low-gamma nuclei available at UHF should allow techniques such as (1)H MR spectroscopy (MRS), (31)P MRS, and (23)Na MRI to be more easily implemented. Numerous technical challenges exist in the performance of UHF MRI, including changes in relaxation values, increased chemical shift and susceptibility artifact, radiofrequency (RF) coil design/B (1)(+) field inhomogeneity, and greater RF energy deposition. Nevertheless, the possibility of improved functional and metabolic imaging at UHF will likely drive research efforts in the near future to overcome these challenges and allow studies of human skeletal muscle physiology and pathophysiology to be possible at >or=7 T.

Does oxidative capacity affect energy cost? An in vivo MR investigation of skeletal muscle energetics

Investigations of training effects on exercise energy cost have yielded conflicting results. The purpose of the present study was to compare quadriceps energy cost and oxidative capacity between endurance-trained and sedentary subjects during a heavy dynamic knee extension exercise. We quantified the rates of ATP turnover from oxidative and anaerobic pathways with (31)P-MRS, and we measured simultaneously pulmonary oxygen uptake in order to assess both total ATP production [i.e., energy cost (EC)] and O(2) consumption (O(2) cost) scaled to power output. Seven sedentary (SED) and seven endurance-trained (TRA) subjects performed a dynamic standardized rest-exercise-recovery protocol at an exercise intensity corresponding to 35% of maximal voluntary contraction. We showed that during a dynamic heavy exercise, the O(2) cost and EC were similar in the SED and endurance-trained groups. For a given EC, endurance-trained subjects exhibited a higher relative mitochondrial contribution to ATP production at the muscle level (84 +/- 12% in TRA and 57 +/- 12% in SED; P < 0.01) whereas the anaerobic contribution was reduced (18 +/- 12% in TRA and 44 +/- 11% in SED; P < 0.01). Our results obtained in vivo illustrate that on the one hand the beneficial effects of endurance training are not related to any reduction in EC or O(2) cost and on the other hand that this similar EC was linked to a change regarding the contribution of anaerobic and oxidative processes to energy production, i.e., a greater aerobic energy contribution associated with a concomitant reduction of the anaerobic energy supply.

Comparative analysis of skeletal muscle oxidative capacity in children and adults: a 31P-MRS study

The aim of the present study was to compare the oxidative capacity of the forearm flexor muscles in vivo between children and adults using 31-phosphorus magnetic resonance spectroscopy. Seven boys (11.7 +/- 0.6 y) and 10 men (35.6 +/- 7.8 year) volunteered to perform a 3 min dynamic finger flexions exercise against a standardized weight (15% of the maximal voluntary contraction). Muscle oxidative capacity was quantified on the basis of phosphocreatine (PCr) post-exercise recovery kinetics analysis. End-of-exercise pH was not significantly different between children and adults (6.6 +/- 0.2 vs. 6.5 +/- 0.2), indicating that indices of PCr recovery kinetics can be reliably compared. The rate constant of PCr recovery (kPCr) and the maximum rate of aerobic ATP production were about 2-fold higher in young boys than in men (kPCr: 1.7 +/- 1.2 vs. 0.7 +/- 0.2 min(-1); Vmax: 49.7 +/- 24.6 vs. 29.4 +/- 7.9 mmol.L(-1).min(-1), p < 0.05). Our results clearly illustrate a greater mitochondrial oxidative capacity in the forearm flexor muscles of young children. This larger ATP regeneration capacity through aerobic mechanisms in children could be one of the factors accounting for their greater resistance to fatigue during high-intensity intermittent exercise.

Influence of endurance training on muscle [PCr] kinetics during high-intensity exercise

We hypothesized that a period of endurance training would result in a speeding of muscle phosphocreatine concentration ([PCr]) kinetics over the fundamental phase of the response and a reduction in the amplitude of the [PCr] slow component during high-intensity exercise. Six male subjects (age 26 +/- 5 yr) completed 5 wk of single-legged knee-extension exercise training with the alternate leg serving as a control. Before and after the intervention period, the subjects completed incremental and high-intensity step exercise tests of 6-min duration with both legs separately inside the bore of a whole-body magnetic resonance spectrometer. The time-to-exhaustion during incremental exercise was not changed in the control leg [preintervention group (PRE): 19.4 +/- 2.3 min vs. postintervention group (POST): 19.4 +/- 1.9 min] but was significantly increased in the trained leg (PRE: 19.6 +/- 1.6 min vs. POST: 22.0 +/- 2.2 min; P < 0.05). During step exercise, there were no significant changes in the control leg, but end-exercise pH and [PCr] were higher after vs. before training. The time constant for the [PCr] kinetics over the fundamental exponential region of the response was not significantly altered in either the control leg (PRE: 40 +/- 13 s vs. POST: 43 +/- 10 s) or the trained leg (PRE: 38 +/- 8 s vs. POST: 40 +/- 12 s). However, the amplitude of the [PCr] slow component was significantly reduced in the trained leg (PRE: 15 +/- 7 vs. POST: 7 +/- 7% change in [PCr]; P < 0.05) with there being no change in the control leg (PRE: 13 +/- 8 vs. POST: 12 +/- 10% change in [PCr]). The attenuation of the [PCr] slow component might be mechanistically linked with enhanced exercise tolerance following endurance training.

Musculoskeletal spectroscopy

Magnetic resonance spectroscopy (MRS) of skeletal muscle has been successfully applied by physiologists over several decades, particularly for studies of high-energy phosphates (by (31)P-MRS) and glycogen (by (13)C-MRS). Unfortunately, the observation of these heteronuclei requires equipment that is typically not available on clinical MR scanners, such as broadband capability and a second channel for decoupling and nuclear Overhauser enhancement (NOE). On the other hand, (1)H-MR spectra of skeletal muscle can be acquired on many routine MR systems and also provide a wealth of physiological information. In particular, studies of intramyocellular lipids (IMCL) attract physiologists and endocrinologists because IMCL levels are related to insulin resistance and thus can lead to a better understanding of major health problems in industrial countries. The combination of (1)H-, (13)C-, and (31)P-MRS gives access to the major long- and short-term energy sources of skeletal muscle. This review summarizes the technical aspects and unique MR-methodological features of the different nuclei. It reviews clinical studies that employed MRS of one or more nuclei, or combinations of MRS with other MR modalities. It also illustrates that MR spectra contain additional physiological information that is not yet used in routine clinical applications.

Recovery kinetics throughout successive bouts of various exercises in elite cyclists

PURPOSE

In the present study we investigated whether a high volume of cycling training would influence the metabolic changes associated with a succession of three exhaustive cycling exercises.

METHODS

Seven professional road cyclists (VO2max: 74.3 +/- 3.7 mL.min.kg; maximal power tolerated: 475 +/- 18 W; training: 22 +/- 3 h.wk) and seven sport sciences students (VO2max: 54.2 +/- 5.3 mL.min.kg; maximal power tolerated: 341 +/- 26 W; training: 6 +/- 2 h.wk) performed three different exhaustive cycling exercise bouts (progressive, constant load, and sprint) on an electrically braked cycloergometer positioned near the magnetic resonance scanner. Less than 45 s after the completion of each exercise bout, recovery kinetics of high-energy phosphorylated compounds and pH were measured using P-MR spectroscopy.

RESULTS

Resting values for phosphomonoesters (PME) and phosphodiesters (PDE) were significantly elevated in the cyclist group (PME/ATP: 0.82 +/- 0.11 vs 0.58 +/- 0.19; PDE/ATP: 0.27 +/- 0.03 vs 0.21 +/- 0.05). Phosphocreatine (PCr) consumption and inorganic phosphate (Pi) accumulation measured at end of exercise bouts 1 (PCr: 6.5 +/- 3.2 vs 10.4 +/- 1.6 mM; Pi: 1.6 +/- 0.7 vs 6.8 +/- 3.4 mM) and 3 (PCr: 5.6 +/- 2.4 vs 9.3 +/- 3.9 mM; Pi: 1.5 +/- 0.5 vs 7.7 +/- 3.3 mM) were reduced in cyclists compared with controls. During the recovery period after each exercise bout, the pH-recovery rate was larger in professional road cyclists, whereas the PCr-recovery kinetics were significantly faster for cyclists only for bout 3.

DISCUSSION

Whereas the PDE and PME elevation at rest in professional cyclists may indicate fiber-type changes and an imbalance between glycogenolytic and glycolytic activity, the lower PCr consumption during exercise and the faster pH-recovery kinetic clearly suggest an improved mitochondrial function.

Skeletal muscle energetics with PNMR: personal views and historic perspectives

This article reviews historical and current NMR approaches to describing in vivo bioenergetics of skeletal muscles in normal and diseased populations. It draws upon the first author's more than 70 years of personal experience in enzyme kinetics and the last author's physiological approaches. The development of in vivo PNMR jointly with researchers around the world is described. It is explained how non-invasive PNMR has advanced human exercise biochemistry, physiology and pathology. Further, after a brief explanation of bioenergetics with PNMR on creatine kinase, anerobic glycolysis and mitochondrial oxidative phosphorylation, some basic and controversial subjects are focused upon, and the authors' view of the subjects are offered, with questions and answers. Some of the research has been introduced in exercise physiology. Future directions of NMR on bioenergetics, as a part of system biological approaches, are indicated.

New aspects for the role of physical training in the management of patients with chronic heart failure

Recent experimental and clinical data have shown that physical training is an important therapeutic intervention in the management of patients with chronic heart failure (CHF), improving central hemodynamics and attenuating peripheral abnormalities (endothelial dysfunction and skeletal myopathy) characterizing the progression of the syndrome. Additionally, physical training seems to beneficially modulate peripheral immune responses of CHF expressed by elevated circulating proinflammatory cytokines, soluble cellular adhesion molecules and soluble apoptosis signaling molecules, resulting in improvement in exercise capacity of CHF patients. This article summarizes current knowledge about the beneficial role of physical training in CHF, as well as about traditional and novel mechanisms contributing to the physical training-induced improvement in clinical performance of CHF patients.

Muscle metabolism assessed by phosphorus-31 nuclear magnetic resonance spectroscopy after myocardial infarction in rehabilitated patients: a 1-year follow-up

BACKGROUND

The most common effect of postmyocardial infarction (post MI) rehabilitation is an increase of peak maximal oxygen consumption correlated with changes in calf muscle metabolism, but there are few data on follow-up after rehabilitation on skeletal muscle and maximal oxygen consumption. The purpose of this study was to investigate the respective modifications in skeletal muscle metabolism and peak oxygen consumption (VO2) occurring during a supervised rehabilitation program and 1 year after MI in patients free of heart failure.

METHODS

Fifteen outpatients were studied prospectively after the acute phase of the MI, at the end of the rehabilitation program (2 months after the MI), and 1 year after. The rehabilitation comprised 20 sessions with three sessions per week. The program consisted of exercise training with bicycle, arm ergometer, and treadmill. The program also included respiratory exercises, psychological support, and counseling for secondary prevention of cardiovascular diseases. At each visit, a stress test on a bicycle ergometer was performed and the peak VO2 was measured. Phosphorus magnetic resonance spectroscopy of the gastrocnemius muscle was performed at rest and during a plantar flexion-type exercise against an adjustable load. Data were analyzed using analysis of variance and post-hoc test when appropriate.

RESULTS

The mechanical power output measured during the bicycle exercise increased from 111 +/- 28 watts at the post MI test to 136 +/- 40 watts after rehabilitation (post rehab) and decreased to 125 +/- 36 watts at 1 year. The peak VO2 increased significantly (P < 0.05) from 22 +/- 7 ml/kg-1/min-1 (post MI) to 27 +/- 9 ml/kg-1/min-1 (post rehab), and decreased significantly to 24 +/- 8 ml/kg-1/min-1 (1 year). The mechanical power output measured in the magnet during the stress test increased from 2.22 +/- 0.13 watts (post MI) to 2.85 +/- 1.24 (post rehab), and stabilized at 2.78 +/- 1.10 watts at 1 year. At the highest workload attained in the three successive tests, the phosphocreatine/(phosphocreatine + inorganic phosphate) ratio rose significantly (P < 0.05) from 0.46 +/- 0.13 (post MI) to 0.51 +/- 0.13 (post rehab) and remained at 0.51 +/- 0.13 at 1 year.

CONCLUSION

The improvement of the peak VO2 after training post MI is not maintained 1 year later. This decline is not accompanied by muscular metabolic abnormalities. This suggests that the muscle metabolism after MI remains normal, and that the long-term decrease of the peak VO2 reflects a global deconditioning that should be avoided by maintaining a long-term phase III rehabilitation program.

Effect of intensive therapy for heart failure on the vasodilator response to exercise

OBJECTIVES

The purpose of the study was to evaluate the lower extremity vascular responsiveness to metabolic stimuli in patients with heart failure and to determine whether these responses improve acutely after intensive medical therapy.

BACKGROUND

Metabolic regulation of vascular tone is an important determinant of blood flow, and may be abnormal in heart failure.

METHODS

The leg blood flow responses were measured in 11 patients with nonedematous class III-IV heart failure before and after inpatient medical therapy and in 10 normal subjects. Venous occlusion plethysmography was used to measure peak blood flow and total hyperemia in the calf after arterial occlusion and also after isotonic ankle exercise. Measurements were repeated following short-term inpatient treatment with vasodilators and diuretics administered to decrease right atrial pressure (18+/-2 to 7+/-1 mm Hg), pulmonary wedge pressure (32+/-3 to 15+/-2 mm Hg), and systemic vascular resistance (1581+/-200 to 938+/-63 dynes.s.cm(-5), all p < 0.02).

RESULTS

Leg blood flow at rest, after exercise, and during reactive hyperemia was less in heart failure patients than in control subjects. Resting leg blood flow did not increase significantly after medical therapy, but peak flow after the high level of exercise increased by 59% (p = 0.009). Total hyperemic volume in the recovery period increased by 73% (p = 0.03). Similarly, the peak leg blood flow response to ischemia increased by 88% (p = 0.04), whereas hyperemic volume rose by 98% (p = 0.1).

CONCLUSIONS

The calf blood flow responses to metabolic stimuli are blunted in patients with severe heart failure, and improve rapidly with intensive medical therapy.

Skeletal muscle metabolism limits exercise capacity in patients with chronic heart failure

BACKGROUND

Several studies have indicated that skeletal muscle is important in determining the exercise capacity of patients with chronic heart failure (CHF). However, this theory has been investigated only in experiments based on local exercise involving a small muscle mass. We investigated skeletal muscle metabolism during maximal systemic exercise to determine whether muscle metabolism limits exercise capacity in patients with CHF. We also studied the relationship between muscle metabolic abnormalities during local and systemic exercise.

METHODS AND RESULTS

Skeletal muscle metabolism was measured during maximal systemic exercise on a bicycle ergometer by a combination of the metabolic freeze method and 31P magnetic resonance spectroscopy in 12 patients with CHF and 7 age- and size-matched normal subjects. We also evaluated skeletal muscle metabolism during local exercise while subjects performed unilateral plantar flexion. Muscle phosphocreatine (PCr) was nearly depleted during maximal systemic exercise in patients with CHF and normal subjects (12.5+/-0.04% and 12.3+/-0.07%, respectively, of initial level). PCr depletion occurred at a significantly lower peak oxygen uptake (peak VO2) in patients with CHF than in normal subjects (CHF, 20.2+/-3.0 versus normal, 31.8+/-3.7 mL . min-1 . kg-1, P<0. 0001). Muscle metabolic capacity, evaluated as the slope of PCr decrease in relation to increasing workload, was correlated with peak VO2 during maximal systemic exercise in patients with CHF (r=0.83, P<0.001). Muscle metabolic capacity during local exercise was impaired in patients with CHF and was correlated with capacity during systemic exercise (r=0.76, P<0.01) and with peak VO2 (r=0. 83, P<0.001).

CONCLUSIONS

These results suggest that impaired muscle metabolism associated with early metabolic limitation determines exercise capacity during maximal systemic exercise in patients with CHF. There was a significant correlation between muscle metabolic capacity during systemic and local exercise in patients with CHF.

Improved exercise tolerance after losartan and enalapril in heart failure: correlation with changes in skeletal muscle myosin heavy chain composition

BACKGROUND

In congestive heart failure, fatigue-resistant, oxidative, slow type I fibers are decreased in leg skeletal muscle, contributing to exercise capacity (EC) limitation. The mechanisms by which ACE inhibitors and AII antagonists improve EC is still unclear. We tested the hypothesis that improvement in EC is related to changes in skeletal muscle composition toward type I fibers.

METHODS AND RESULTS

Eight patients with congestive heart failure, NYHA classes I through IV, were treated for 6 months with enalapril (E) 20 mg/d, and another 8 with losartan (L) 50 mg/d. EC was assessed with maximal cardiopulmonary exercise testing at baseline and after treatment. Myosin heavy chain (MHC) composition of the gastrocnemius was studied after electrophoretic separation of slow MHC1, fast oxidative MHC2a, and fast glycolytic MHC2b isoforms from needle microbiopsies obtained at baseline and after 6 months. EC improved in both groups. Peak V(O2) increased from 21.0+/-4.7 to 27.6+/-4.3 mL . kg-1 . min -1 (P=0.011) in the L group and from 17.5+/-5.0 to 25.0+/-5.5 mL . kg-1 . min -1 (P=0.014) in the E group. Similarly, ventilatory threshold changed from 15.0+/-4.0 to 19.9+/-4.9 mL (P=0. 049) with L and from 12.0+/-1.9 to 15.4+/-3.5 mL (P=0.039) with E. MCH1 increased from 61.2+/-11.2% to 75.4+/-7.6% with L (P=0.012) and from 60.6+/-13.1% to 80.1+/-10.9% (P=0.006) with E. Similarly, MHC2a decreased from 21.20+/-9.5% to 12.9+/-4.4% (P=0.05) with L and from 19.9+/-7.8% to 11.8+/-7.9% (P=0.06) with E. MHC2b changed from 17. 5+/-6.5% to 11.7+/-5.2% (P=0.07) with L and from 19.5+/-6.4% to 8. 1+/-4.6% (P=0.0015) with E. There was a significant correlation between net changes in MHC1 and absolute changes in peak V(O2) (r2=0.29, P=0.029) and a trend to significance for MHC2a and 2b.

CONCLUSIONS

Six months' treatment with L and with E produces an improvement in EC of similar magnitude. These changes are accompanied by a reshift of MHCs of leg skeletal muscle toward the slow, more fatigue-resistant isoforms. Magnitude of MHC1 changes correlates with the net peak V(O2) gain, which suggests that improved EC may be caused by favorable biochemical changes occurring in the skeletal muscle.

Exercise training in patients with CHF and heart transplant recipients

The number of chronic heart failure (CHF) patients and heart transplantation (HT) recipients enrolled in rehabilitation and maintenance exercise programs continues to expand. There is growing clinical consensus that stable patients with CHF respond favorably to exercise training and convincing evidence that exercise training should be an essential adjunct therapy in postoperative management of HT recipients. This review examines the following specific advances in exercise physiology for heart failure and heart transplantation patients: 1) the mechanisms of exercise intolerance in CHF and the results of exercise rehabilitation studies in these patients; 2) the exercise challenges conferred by glucocorticoid therapy and chronic cardiac denervation in HT recipients; and 3) a summary of current recommendations and guidelines for exercise prescription in each patient population.

Exercise limitation in chronic heart failure: central role of the periphery

The symptoms of chronic heart failure (CHF) are predominantly shortness of breath and fatigue during exercise and reduced exercise capacity. Disturbances of central hemodynamic function are no longer considered to be the major determinants of exercise capacity. The two symptoms of fatigue and breathlessness are often considered in isolation. A pulmonary abnormality is usually considered to be the cause of abnormal ventilation, and increased dead space ventilation has come to be accepted as a major cause of the increased ventilation relative to carbon dioxide production seen in CHF. Rather than decreased skeletal muscle perfusion, an intrinsic muscle abnormality is considered to be responsible for fatigue. Another abnormality seen in CHF is persistent sympathetic nervous system activation, which is difficult to explain on the basis of baroreflex activation. There is increasing evidence for the importance of skeletal muscle ergoreceptors or metaboreceptors in CHF. These receptors are sensitive to work performed, and activation results in increased ventilation and sympathetic activation. The ergoreflex appears to be greatly enhanced in CHF. We put forward the "muscle hypothesis" as an explanation for many of the pathophysiologic events in CHF. Impaired skeletal muscle function results in ergoreflex activation. In turn, this causes increased ventilation, thus linking the symptoms of breathlessness and fatigue. Furthermore, ergoreflex stimulation may be responsible for persistent sympathetic activation.

Relationship between increased peak oxygen uptake and modifications in skeletal muscle metabolism following rehabilitation after myocardial infarction

PURPOSE

Rehabilitation after myocardial infarction produces an increased peak oxygen uptake (VO2peak). This study investigates the relationship between the modifications in skeletal muscle metabolism and the modification in VO2peak induced by a standard program of physical training following a myocardial infarction.

METHODS

Seventeen patients (14 male, 3 female) were studied by phosphorus 31(31P) magnetic resonance spectroscopy after the acute phase of a myocardial infarction and after 2 months of rehabilitation. Changes in calf muscle pH, phosphocreatine, and inorganic phosphates were measured at rest and during a plantar flexion-type incremental workload protocol. Calf muscle pH, phosphocreatine/(phosphocreatine + inorganic phosphates), and inorganic phosphates/phosphocreatine ratios were compared at the highest identical workload attained in both studies. The VO2peak (mL/kg/min) was determined during a cycle stress test.

RESULTS

At the highest identical workload attained in both tests, the ratio phosphocreatine/(phosphocreatine + inorganic phosphates) was significantly higher (0.48 +/- 0.15 to 0.57 +/- 0.18: P < .001), and the ratio inorganic phosphates/phosphocreatine was lower (1.38 +/- 1.14 to 0.99 +/- 0.87: P < .01). After rehabilitation, no difference was observed for the pH at stress (6.83 +/- 0.16 to 6.91 +/- 0.14: not significant [NS]). The increase in the VO2peak was significant after rehabilitation (24 +/- 9 to 29 +/- 11 mL/kg/min: P < .001). The VO2peak improvement induced by the physical training was correlated with the increase in the phosphocreatine/(phosphocreatine + inorganic phosphates) (r = 0.818, P < .001).

CONCLUSIONS

The reduction in phosphocreatine depletion indicated that the oxidative capacity of the skeletal muscle was improved during the rehabilitation. The good correlation between the indexes of skeletal muscle metabolism and VO2peak suggests the peripheral effect of training.

Physical deconditioning may be a mechanism for the skeletal muscle energy phosphate metabolism abnormalities in chronic heart failure

The aim of our study was to investigate the contribution of physical deconditioning in skeletal muscle metabolic abnormalities in patients with chronic heart failure (CHF). Phosphate metabolism was studied in the leg muscle at rest and during exercise by using phosphate 31 nuclear magnetic resonance spectroscopy in a group of 14 patients with New York Heart Association class II and III CHF and left ventricular ejection fraction <40% and in two groups of age-matched healthy volunteers: one group of 7 sedentary and another of 7 trained subjects. Phosphocreatine depletion rate, intracellular pH, and adenosine diphosphate levels in the muscle during exercise were not statistically different in the CHF patients and in the sedentary healthy subjects, but both groups were statistically different from the trained healthy subjects, who had slower phosphocreatine depletion rates, as well as less intracellular acidosis and lower adenosine diphosphate levels during exercise (p = 0.02; analysis of variance). Our results suggest that metabolic changes occurring in the skeletal muscle of patients with CHF may contribute to the limitation of exercise capacity and are most likely to be a consequence of physical deconditioning because they are very similar to what is observed in sedentary and otherwise healthy subjects as compared with trained subjects.

Low intensity exercise training in patients with chronic heart failure

OBJECTIVES

The present study was designed to evaluate whether a specific program of low intensity exercise training may be sufficient to improve the exercise tolerance of patients with chronic heart failure.

BACKGROUND

Recent studies have shown that exercise training can improve exercise tolerance in patients with stable chronic heart failure, mainly through peripheral adaptations. These changes have been observed with exercise regimens at intensities of 70% to 80% of peak oxygen uptake and > 8 weeks.

METHODS

We studied 27 patients (23 men, 4 women; mean [+/- SD] age 57 +/- 6 years) with mild chronic heart failure. We classified patients into two groups: trained group and untrained group. The trained group underwent a low intensity (40% of peak oxygen uptake) training program three times/week for 8 weeks. The untrained group performed no exercise.

RESULTS

An increase in peak oxygen uptake (17%, p < 0.0001), lactic acidosis threshold (20%, p < 0.0002) and peak work load (21%, p < 0.0002) were obtained in the trained group only. Cardiac output and stroke volume were unchanged. A high correlation was found between the increases in peak oxygen uptake and volume density of mitochondria of vastus lateralis muscle (r = 0.77, p < 0.0002).

CONCLUSIONS

Patients with stable chronic heart failure can achieve significant improvement in functional capacity from a low intensity exercise training regimen. The mechanism responsible for this favorable effect involves an increase in mitochondrial density, which reflects an improvement in oxidative capacity of trained skeletal muscles.

Factors which influence alterations of phosphates and pH in exercising human skeletal muscle: measurement error, reproducibility, and effects of fasting, carbohydrate loading, and metabolic acidosis

Previous studies have shown considerable variability in the metabolic response of human skeletal muscle during a standardized exercise protocol. The goal of these studies was to investigate the factors responsible for the broad range of metabolic changes produced by fatiguing exercise. Experiments were performed to quantitate the measurement error of 31P nuclear magnetic resonance spectroscopy of human muscle, the reproducibility of changes within a single subject, and the effects of fasting, carbohydrate loading, and metabolic acidosis. The results show that none of these factors appear to be responsible for the wide variation between subjects. However, the effects of training and genetic factors were not investigated and are likely to be responsible for the substantial variability between subjects.

Metabolic adaptations to endurance training in older individuals

The purpose of this study was to describe the effects of moderate intensity exercise training on the muscle energy utilization, blood flow, and exercise performance of four sedentary older individuals (58 +/- 4 yrs). Subjects trained the dominant forearm each day for 12 weeks. The nondominant arm was not trained and served as a within-subject control. 31P nuclear magnetic resonance spectroscopy (31P NMRS) was used to identify the power output in watts (W) at the onset, or threshold, of intracellular acidosis (IT) in the exercising muscle during progressive exercise tests to fatigue. After 6 weeks of training, power output at the IT increased by 14% (p < 0.05) in the dominant arm; however, an additional 6 weeks of the same exercise program failed to produce a further increase in IT power. IT power of the nondominant forearm was not changed. In the dominant forearm, endurance time for a submaximal wrist flexion test was increased 34% and 58% at 6 and 12 weeks, respectively. Maximal voluntary strength was not affected by training, nor was resting or exercising blood flow. The training program delayed the onset of intracellular acidosis during progressive exercise and increased the capacity for submaximal work. These effects did not appear to depend on an increase in muscle blood flow.

Muscular metabolism during oxygen supplementation in patients with chronic hypoxemia

The effects of supplemental oxygen (O2) versus air on working calf muscle metabolism were studied in seven patients with stable chronic obstructive pulmonary disease (COPD) and chronic hypoxemia (PaO2 = 57 +/- 3 SE mm Hg) and seven age-matched control subjects. Oxygen and air were randomly administrated at 24-h intervals, and O2 flow rate was adjusted to correct hypoxemia (PaO2 = 87 +/- 4 mm Hg) in the COPD group. The relative concentrations of ATP, phosphocreatine (PCr), inorganic phosphate (Pi), phosphomonoesters (PME), and the intracellular pH (pHi) were determined with 31P magnetic resonance spectroscopy at rest, during a graded standardized and localized exercise protocol (360 active plantar flexions), and during recovery. In resting muscle no significant effect of added O2 was demonstrable in each group with regard to pHi, Pi/PCr, and ATP/(PCr+Pi+PME) ratios. Mechanical data were similar between the two groups and between the two tests during the whole exercise. The indices of muscular oxidative metabolism (Pi/PCr and pHi at the end of exercise and recovering PCr resynthesis rate) were impaired in the COPD group compared with that in the control group during air (all p < 0.05). All these parameters were significantly improved with added O2 in the COPD group (p < 0.05), whereas no similar effects were observed in the control group. However, these beneficial effects were incomplete since the exercising Pi/PCr ratio remained higher in the COPD group than in the control group during added O2. This energetic muscular impairment could correspond to tissular damage related to chronic hypoxemia.

Noninvasive measurements of activity-induced changes in muscle metabolism

Two noninvasive measurement techniques were used to monitor activity-induced changes in skeletal muscle in humans. Phosphorus magnetic resonance spectroscopy (P-MRS) was used to measure changes in energy metabolism by measuring the ratio of inorganic phosphate to phosphocreatine (Pi/PCr) during steady level work in the wrist flexor muscles in a 30 cm bore, 1.9 Telsa magnet, and the rate of PCr recovery from exercise in the calf muscles in a 76 cm bore, 1.8 Tesla magnet. Near red spectroscopy (NRS) was used to measure changes in oxygen saturation of hemoglobin and myoglobin during and after exercise. Fourteen days of wrist flexion exercise resulted in significant improvement in muscle metabolism as measured by MRS. This improvement disappeared after 35 days of inactivity. Indications of muscle stress during training such as muscle soreness and decreased maximum strength were associated with increases in resting Pi/PCr. A similar training protocol using plantar flexion exercise resulted in an improved rate of PCr resynthesis, which returned to control values 42 days after training stopped. NRS measurements of the wrist flexor muscles during a ramp exercise protocol demonstrated a decrease in the oxygen saturation of hemoglobin-myoglobin from 60% at rest to 15% at the highest work levels. The half time of recovery of oxygen saturation was faster than that of PCr in both young and old subjects, supporting the hypothesis that oxygen delivery is not rate limiting in submaximal exercise in healthy individuals.

Skeletal muscle response to exercise training in congestive heart failure

To examine the ability of the skeletal muscle of congestive heart failure (CHF) patients to adapt to chronic exercise, five patients performed localized nondominant wrist flexor training for 28 d. Inorganic phosphate (Pi) and phosphocreatine (PCr) were monitored by magnetic resonance spectroscopy in both forearms at rest and during submaximal wrist flexion exercise at 6, 12, 24, and 36 J.min-1 before and after exercise training. Simultaneous measurements of limb blood flow were made by plethysmography at 12, 24, and 36 J.min-1. Forearm muscle mass and endurance were measured by magnetic resonance imaging and wrist flexion exercise before and after training. The Pi/PCr ratio and pH were calculated from the measured Pi and PCr. Exercise cardiac output, heart rate, plasma norepinephrine, and lactate measured during training were not elevated above resting values, confirming that training was localized to the forearm flexor muscles. After training, muscle bioenergetics, as assessed by the slope of the regression line relating Pi/PCr to submaximal workloads, were improved in the trained forearm of each patient, although muscle mass, limb blood flow, and pH were unchanged. Forearm endurance increased by greater than 260% after training. In the dominant untrained forearm, none of the measured indices were affected. We conclude that localized forearm exercise training in CHF patients improves muscle energetics at submaximal workloads in the trained muscle, an effect which is independent of muscle mass, limb blood flow, or a central cardiovascular response during training. These findings indicate that peripheral muscle metabolic and functional abnormalities in CHF can be improved without altering cardiac performance.