Non-local Muscle Fatigue Effects on Muscle Strength, Power, and Endurance in Healthy Individuals: A Systematic Review with Meta-analysis

The impact of task (un)certainty on repeated grip force production

Many studies found that in physical tasks, reducing certainty regarding their endpoints hinders performance. However, the impact of reducing certainty regarding other aspects of physical tasks is unknown. Here we manipulated the certainty of the required effort on an unrelated, parallel task (i.e., off-task uncertainty) and examined how it impacts force production in two within-subject experiments (N = 79). In two sessions, subjects completed 20 repetitions composed of maximal forces using a gripper with their dominant hand. Between repetitions, participants applied either submaximal constant or varied grip forces, with their non-dominant arm, matched for total forces across repetitions. While we observed trivial differences in total forces between conditions, under the varied condition, participants produced a steeper decrease in forces, suggesting that off-task uncertainty impacted their effort allocation strategy. We speculate that this pattern can be attributed to cognitive overload and/or changes in motivation stemming from the imposed uncertainty.

Assessment of Self-report, Palpation, and Surface Electromyography Dataset During Isometric Muscle Contraction

Measuring muscle fatigue involves assessing various components within the motor system. While subjective and sensor-based measures have been proposed, a comprehensive comparison of these assessment measures is currently lacking. This study aims to bridge this gap by utilizing three commonly used measures: participant self-reported perceived muscle fatigue scores, a sports physiotherapist's manual palpation-based muscle tightness scores, and surface electromyography sensors. Compensatory muscle fatigue occurs when one muscle group becomes fatigued, leading to the involvement and subsequent fatigue of other muscles as they compensate for the workload. The evaluation of compensatory muscle fatigue focuses on nine different upper body muscles selected by the sports physiotherapist. With a cohort of 30 male subjects, this study provides a valuable dataset for researchers and healthcare practitioners in sports science, rehabilitation, and human performance. It enables the exploration and comparison of diverse methods for evaluating different muscles in isometric contraction.

Immediate crossover fatigue after unilateral submaximal eccentric contractions of the knee flexors involves peripheral alterations and increased global perceived fatigue

After a unilateral muscle exercise, the performance of the non-exercised contralateral limb muscle can be also impaired. This crossover fatigue phenomenon is still debated in the literature and very few studies have investigated the influence of eccentric contractions. This study was designed to assess neuromuscular adaptations involved in the crossover fatigue of the non-exercised contralateral knee flexor muscles. Seventeen healthy young men performed a unilateral submaximal eccentric exercise of the right knee flexors until a 20% reduction in maximal voluntary isometric contraction torque was attained in the exercised limb. Before (PRE), immediately after exercise cessation (POST) and 24 hours later (POST24), neuromuscular function and perceived muscle soreness were measured in both the exercised limb and non-exercised limb. In addition, global perceived fatigue was assessed at each measurement time. At POST, significant reductions in maximal voluntary isometric contraction were observed in the exercised limb (-28.1%, p < 0.001) and in the non-exercised limb (-8.5%, p < 0.05), evidencing crossover fatigue. At POST, voluntary activation decreased in the exercised limb only (-6.0%, p < 0.001), while electrically evoked potentiated doublet torque was impaired in both the exercised limb and the non-exercised limb (-11.6%, p = 0.001). In addition, global perceived fatigue significantly increased at POST (p < 0.001). At POST24, all measured variables returned to PRE values, except for perceived muscle soreness scores exhibiting greater values than PRE (p < 0.05). A possible cumulative interaction between peripheral alterations and global perceived fatigue may account for the immediate crossover fatigue observed in the non-exercised limb.

Non-Local Muscle Fatigue Impairs Mean Propulsive Velocity During Strength Loading in Strength-Trained Men

Purpose: This study examined the acute influence of a bench press (BP) loading on the explosive squat (SQ) performance and vice versa. Methods: Nineteen strength-trained men completed 2 experimental sessions consisting of either a SQ+BP loading or a BP+SQ loading with 3 × 5 + 3 × 3 repetitions at 80% of the 1-repetition maximum in a randomized order. SQ and BP mean propulsive velocity (MPV) were assessed during both loadings, at baseline (T0) as well as immediately after the first (T1) and second strength loading (T2). Results: Both BP and SQ MPV decreased between T0 and T1 in SQ+BP (-6.13 ± 6.13%, p = .014, g = 0.485 and -9.11 ± 7.23%, p < .001, g = 0.905, respectively) and BP+SQ (-15.15 ± 7.69%, p < .001, g = 1.316 and -7.18 ± 6.16%, p < .001, g = 0.724, respectively). Mean BP MPV was lower in set 2 to set 6 in SQ+BP when compared to BP+SQ (-7.90% - 9.88%, all p < .05, g = 0.523-0.808). Mean SQ MPV was lower in set 1 and set 4 in BP+SQ when compared to SQ+BP (-4.94% - 5.22%, all p < .001, g = 0.329-0.362). Conclusions: These results demonstrate that the presence of non-local muscle fatigue affects the movement velocity. Therefore, if a training program aims to perform strength training exercises with maximal movement velocity, it is essential to carefully evaluate whether upper and lower body exercises should be carried out within close proximity.

The Effects of Core Stabilization Trunk Muscle Fatigue on Lower Limb Stiffness of Basketball Players

Core stability is the ability to control the position and motion of the trunk over the pelvis and legs to allow the optimum production and transfer of force to the terminal segment in sporting activities. The effect of fatigue, especially core muscle fatigue, on stiffness as a performance index requires more study. This research aimed to investigate the effect of the core stabilization muscles' fatigue on lower limb stiffness during hopping. Thirty active basketball players participated in this study (age: 20.90 ± 1.49 years; weight: 60.30 ± 3.10 kg; height: 163.2 ± 5.04 cm). The hopping test (15 jumps) was performed before and after the fatigue protocol in three states including at a preferred (no frequency control), maximum, and 2.2 Hz frequency on the force plate. The stiffness of the lower extremities was measured before and after the fatigue protocol. The results of the dependent t-test showed core muscle fatigue led to reduced lower extremity stiffness under all three hopping-test conditions by 15.3-15.9% (p ≤ 0.005). It seems that core muscle function affects lower extremity stiffness, and can function as a performance index in athletes. Although performed in healthy volunteers, this study may have implications for injury prevention, highlighting the necessity to perform interspersed endurance training using the different body parts of the kinetic chain.

Acute effects of foam roller or stick massage on indirect markers from exercise-induced muscle damage in healthy individuals: A systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis examined the effects of foam roller or stick massage performed after exercise-induced muscle damage protocols on indirect markers of muscle damage compared to a non-intervention control group in healthy individuals.

METHODS

PubMed, Biblioteca Virtual em Saúde, Scopus, Google Scholar, and Cochrane Library database were searched in August 2, 2020, with last update on February 21, 2021. Were included clinical trials involving healthy adult individuals who received foam roller/stick massage versus a non-intervention group and evaluated indirect markers of muscle damage. Risk of bias was assessed by the Cochrane Risk of Bias tools. Standardized mean differences with 95% confidence intervals were used to measure the foam roller/stick massage effect on muscle soreness.

RESULTS

The five included studies investigated 151 participants (136 men). Overall, the studies presented a moderate/high risk of bias. A between-groups meta-analysis showed no significant difference between massage and non-intervention control groups on muscle soreness immediately after (0.26 [95%CI: 0.14; 0.65], p = 0.20), 24 h (-0.64 [95%CI: 1.34; 0.07], p = 0.08), 48 h (-0.35 [95%CI: 0.85; 0.15], p = 0.17), 72 h (-0.40 [95%CI: 0.92; 0.12], p = 0.13), and 96 h (0.05 [95%CI: 0.40; 0.50], p = 0.82) after an exercise-induced muscle damage protocol. Moreover, the qualitative synthesis showed that foam roller or stick massage had no significant effect on range of motion, muscle swelling, and maximal voluntary isometric contraction recovery.

CONCLUSION

In conclusion, the current literature appears to not support the advantage of foam roller or stick massage to improve recovery of muscle damage indirect markers (muscle soreness, range of motion, muscle swelling, and maximal voluntary isometric contraction) compared to a non-intervention control group in healthy individuals. Furthermore, due to the heterogeneity of the methodological designs among the included studies, making it difficult to compare the results. In addition, there are not enough high-quality and well-designed studies on foam roller or stick massage to draw any definite conclusions.

REVIEW PROTOCOL NUMBER

The study was pre-registered in the International Prospective Register of Systematic Review (PROSPERO) on August 2, 2020, with last update on February 21, 2021. Protocol number: CRD2017058559.

Unilaterally Induced Quadriceps Fatigue during Sustained Submaximal Isometric Exercise Does Not Alter Contralateral Leg Extensor Performance

This study investigated the effects of fatiguing unilateral exercise on the ipsilateral, exercised, and contralateral, non-exercised limb's post-exercise performance in males and females. Ten males and ten females performed a fatiguing, unilateral isometric leg extension at 50% maximal voluntary isometric contraction (MVIC) force. Prior to and immediately after the fatiguing tasks, MVICs were performed for the exercised and non-exercised limb, with surface electromyographic (sEMG) and mechanomyography (sMMG) amplitude (AMP) and mean power frequency (MPF) recorded from each limb's vastus lateralis. There were no fatigue-induced, sex-dependent, differences in time to task failure (p = 0.265) or ipsilateral performance fatigability (p = 0.437). However, there was a limb by time interaction (p < 0.001) which indicated decreases in MVIC force of the ipsilateral, exercised (p < 0.001), but not the contralateral, non-exercised limb (p = 0.962). There were no sex-dependent, fatigue-induced differences in neurophysiological outcomes between the limbs (p > 0.05), but there was a fatigue-induced difference in sEMG MPF (p = 0.005). To summarize, there were no differences in fatigability between males and females. Moreover, there was insufficient evidence to support the presence of a general crossover effect following submaximal unilateral isometric exercise. However, independent of sex, the neurophysiological outcomes suggested that competing inputs from the nervous system may influence the performance of both limbs following unilateral fatigue.

Comparison of Kinematics and Electromyographic Activity in the Last Repetition during Different Repetition Maximums in the Bench Press Exercise

The barbell bench press is often performed at different repetition maximums (RM). However, little is known about the last repetition of these repetition maximums in terms of movement kinematics and electromyographic activity in the bench press. This study compared kinematics and electromyographic activity during the last repetition of 1-RM, 3-RM, 6-RM, and 10-RM on the barbell bench press. Twelve healthy recreationally bench press-trained males (body mass: 84.3 ± 7.8 kg, age: 23.5 ± 2.6 years, height: 183.8 ± 4.2 cm) performed the bench press with a self-chosen grip width with four different repetition maximums. The participants bench pressed 96.5 ± 14.1, 88.5 ± 13.0, 81.5 ± 12.3, and 72.8 ± 10.5 kg with the 1-RM, 3-RM, 6-RM, and 10-RM. No differences were found between the bench press conditions in kinematic or electromyographic activity, except for the 10-RM, where a higher barbell velocity was observed at peak barbell deacceleration and first minimum barbell velocity (p ≤ 0.05) compared to the 1-RM and 3-RM. Overall, triceps medialis activity increased, whereas biceps brachii activity decreased from the pre-sticking to post-sticking region for all bench conditions (p ≤ 0.05). Since slower barbell velocity was observed in the sticking region for the 1-RM and 3-RM conditions compared to the 10-RM condition, we suggest training with these repetition maximums to learn how to grind through the sticking region due to the principle of specificity when the goal is to enhance maximal strength.

Effect of Mental Task on Sex Differences in Muscle Fatigability: A Review

Previous research demonstrated that there are observable sex differences in developing muscle fatigue when mental task during fatiguing activity is present; however, there is no available review on this matter. Therefore, this review aimed to summarize the findings of previous studies investigating the effect of mental task on muscle fatigue in men and women. To conduct the review, we utilized searches using the electronic databases Web of Science, PubMed, Scopus, and EBSCO Cinahl Ultimate. The studies included had no limited publication date and examined the effects of mental task on muscle fatigue in a healthy adult population of any age. The evaluation was performed using the following criteria: time to failure, or subjective scale in various modifications (visual analog scale-VAS, rate of perceived effort-RPE, rate of perceived fatigue-RPF, rate of perceived discomfort-RPD). A total of seven studies met the set criteria, which were subsequently analyzed. Heavy mental task (more demanding math tasks) can reduce the time to failure for both men and women, with the reduction being more pronounced for women than for men. For light mental task (simple math tasks), no reduction in time to failure was observed to a great extent. The mental task in any of the included studies did not affect the subjective perception of fatigue, effort, discomfort, or pain. Although the studies investigating the effect of mental task on sex differences in muscle fatigability are limited, based on our findings we can assume that in jobs requiring heavier mental task, women may be more prone to the faster development of muscle fatigue; thus, employers might consider paying attention to the possibility of adequate rest.

The impact of post-exercise blood flow restriction on local muscle endurance of a remote limb

BACKGROUND

Studies have examined the influence of post-exercise blood flow restriction as a mechanism to activate muscle afferents and assess non-local muscle fatigue. While these studies have assessed fatigue during maximal contractions, less is known on how these afferents may impact submaximal local muscle endurance which was the purpose of the present study.

METHODS

Individuals completed two testing visits which involved completing a set of elbow flexion exercises to volitional failure on the non-dominant followed by the dominant arm. During both trials, a pneumatic cuff was placed at the top of the non-dominant arm prior to exercise. This cuff was inflated to either 0% (control) or 70% (experimental) of the individual's arterial occlusion pressure immediately after the set was completed. We then evaluated how this impacted local muscle endurance of the dominant arm using a Bayesian paired samples t-test with an uninformed prior width of 0.707 centered on 0.

RESULTS

A total of 36 individuals completed the study (18 females). There was a greater discomfort present in the experimental trial when compared to the control trial [control: 4.5 (SD: 2.4), experimental: 5.8 (SD: 1.9); BF₁₀ =61.46], but there were no differences in repetitions completed on the dominant arm [control: 43 (SD: 9), experimental: 43 (SD: 10); BF₁₀ = 0.179].

CONCLUSION

Applying blood flow restriction post-exercise induced sensations of discomfort but did not alter local muscle endurance of the contralateral limb. These results suggest that increasing the activation of muscle afferents does not appear to alter submaximal muscle endurance of a remote limb. This article is protected by copyright. All rights reserved.

Non-local muscle fatigue is mediated at spinal and supraspinal levels

The objective was to measure the corticospinal excitability and motoneuron responsiveness of the right and left Biceps Brachii (BB), and left Abductor Digiti Minimi (ADM) muscles in response to submaximal isotonic fatiguing contractions performed by the right BB muscle. With the familiarization session, ten young moderately active male subjects came to the lab on seven occasions. Three sets of 3 min seated elbow curls at 25% of one-repetition maximum (1RM) separated by a 1-min rest performed by the right BB muscle were used as the fatiguing protocol. The motor evoked potential (MEP), cervicomedullary motor evoked potential (CMEP), and compound muscle action potential (Mmax) of the right BB muscle (baseline and after each set of the fatiguing task), the left BB and ADM muscles (baseline, post-fatigue, post-10, and post-20 min) were measured. MEP and CMEP were then normalized to Mmax for statistical analysis. The results showed that in the right BB muscle, there was a significant reduction in the MEP after performing the fatiguing task (p= 0.03), while no significant effect of time was seen in the CMEP (p= 0.07). In the left BB muscle, the MEP significantly decreased from pre-fatigue to post-fatigue (p= 0.01) and post-10 (p= 0.001), while there was a significant decline in the CMEP post-fatigue (p= 0.03). In the left ADM muscle, MEP significantly decreased post-fatigue (p= 0.03) and no changes were seen in the CMEP (p= 0.12). These results not only confirm the incidence of non-local muscle fatigue (NLMF) in response to performing submaximal isotonic fatiguing contractions but also as a new finding, imply that both spinal and supraspinal modulations account for the NLMF response.

Myofascial Treatment Techniques on the Plantar Surface Influence Functional Performance in the Dorsal Kinetic Chain

Prior studies have shown that self- and manual massage (SMM) increases flexibility in non-adjacent body areas. It is unclear whether this also influences performance in terms of force generation. Therefore, this study investigated the effect of SMM on the plantar surface on performance in the dorsal kinetic chain. Seventeen young participants took part in this within-subject non-randomized controlled study. SMM was applied on the plantar surface of the dominant leg, but not on the non-dominant leg. A functional performance test of the dorsal kinetic chain, the Bunkie Test, was conducted before and after the intervention. We measured the performance in seconds for the so-called posterior power line (PPL) and the posterior stabilizing line (PSL). The performance of the dominant leg in the Bunkie Test decreased significantly by 17.2% from (mean ± SD) 33.1 ± 9.9 s to 27.4 ± 11.1 s for the PPL and by 16.3% from 27.6 ± 9.8 s to 23.1 ± 11.7 s for the PSL. This is in contrast to the non-dominant leg where performance increased significantly by 5.1% from 29.7 ± 9.6 s to 31.1 ± 8.9 s for the PPL and by 3.1% from 25.7 ± 1.5 s to 26.5 ± 1.7 s for the PSL. SMM interventions on the plantar surface might influence the performance in the dorsal kinetic chain.

Effect of the subjective intensity of fatigue and interoception on perceptual regulation and performance during sustained physical activity

Background

The subjective experience of fatigue impairs an individual’s ability to sustain physical endurance performance. However, precise understanding of the specific role perceived fatigue plays in the central regulation of performance remains unclear. Here, we examined whether the subjective intensity of a perceived state of fatigue, pre-induced through prior upper body activity, differentially impacted performance and altered perceived effort and affect experienced during a sustained, isometric contraction in lower body. We also explored whether (cardiac) interoception predicted the intensity of experienced perceptual and affective responses and moderated the relationships between constructs during physical activity.

Methods

Using a repeated-measures study design, thirty male participants completed three experimental conditions, with the intensity of a pre-induced state of fatigue manipulated to evoke moderate (MOD), severe (SEV) and minimal (control; CON) intensity of perceptions prior to performance of the sustained contraction.

Results

Performance of the sustained contraction was significantly impaired under a perceived state of fatigue, with reductions of 10% and 14% observed in the MOD and SEV conditions, respectively. Performance impairment was accompanied by greater perceived effort and more negative affective valence reported during the contraction. However, effects were limited to comparisons to CON, with no difference evident between the two experimental trials (i.e. MOD vs. SEV). Individuals’ awareness of their accuracy in judging resting heartbeats was shown to predict the subjective intensity of fatigue experienced during the endurance task. However, interoception did not moderate the relationships evident between fatigue and both perceived effort and affective valence.

Conclusions

A perceived state of fatigue limits endurance performance, influencing both how effortful activity is perceived to be and the affective experience of activity. Though awareness of interoceptive representations of bodily states may be important to the subjective experience of fatigue, interoception does not modulate the relationships between perceived fatigue and other perceptual (i.e. effort) and affective constructs.

Ipsilateral and contralateral responses following unimanual fatigue with and without illusionary mirror visual feedback

Illusionary mirror visual feedback alters interhemispheric communication and influences cross-limb interactions. Combining forceful unimanual contractions with the mirror illusion is a convenient way to provoke robust alterations within ipsilateral motor networks. It is unknown, however, if the mirror illusion affects cross-limb fatigability. We examine this concept by comparing the ipsilateral and contralateral handgrip force and electromyographic (EMG) responses following unimanual fatigue with and without illusionary mirror visual feedback. Participants underwent three experimental sessions (mirror, no-mirror, and control), performing a unimanual fatigue protocol with and without illusionary mirror visual feedback. Maximal handgrip force and EMG activity were measured before and after each session for both hands during maximal unimanual and bimanual contractions. The associated EMG activity from the inactive forearm during unimanual contraction was also examined. The novel findings demonstrate greater relative fatigability during bimanual versus unimanual contraction following unimanual fatigue (-31.8% vs. -23.4%, P < 0.01) and the mirror illusion attenuates this difference (-30.3% vs. -26.3%, P = 0.169). The results show no evidence for a cross-over effect of fatigue with (+0.62%, -2.72%) or without (+0.26%, -2.49%) the mirror illusion during unimanual or bimanual contraction. The mirror illusion resulted in significantly lower levels of associated EMG activity in the contralateral forearm. There were no sex differences for any of the measures of fatigability. These results demonstrate that the mirror illusion influences contraction-dependent fatigue during maximal handgrip contractions. Alterations in facilitatory and inhibitory transcallosal drive likely explain these findings.NEW & NOTEWORTHY Illusionary mirror visual feedback is a promising clinical tool for motor rehabilitation, yet many features of its influence on motor output are unknown. We show that maximal bimanual force output is compromised to a greater extent than unimanual force output following unimanual fatigue, yet illusionary mirror visual feedback attenuates this difference. The mirror illusion also reduces the unintended EMG activity of the inactive, contralateral forearm during unimanual contraction.

Lack of Evidence for Non-Local Muscle Fatigue and Performance Enhancement in Young Adults

Post-activation performance enhancement (PAPE) is an improvement to voluntary muscle performance following a conditioning activity. There is evidence of fatigue resistance deficits in non-exercised muscles following unilateral fatiguing exercise of a contralateral muscle. The purpose of this study was to determine if a unilateral conditioning exercise protocol could induce PAPE in a contralateral, non-exercised muscle in young healthy adults. Thirty-two recreationally trained (n = 16) and athletically trained (n = 16) participants (16 males; age: 22.9 ± 2.03 years; height: 1.81 ± 0.06 m; weight: 82.8 ± 9.43 kg, and 16 females; age: 23.1 ± 2.80 years; height: 1.67 ± 0.07 m; weight: 66.4 ± 11.09 kg) were randomly allocated into two groups (dominant or non-dominant limb intervention). The experimental intervention, involved a conditioning exercise (4-repetitions of 5-seconds knee extension maximal voluntary isometric contractions: MVIC) with either the dominant (DOM) (n = 16) or non-dominant (ND) (n = 16) knee extensors with testing of the same (exercised) or contralateral (non-exercised) leg as well as a control (no conditioning exercise: n = 32) condition. Testing was performed before, 1-minute and 10-minutes after a high intensity, low volume, conditioning protocol (2 sets of 2x5-s MVIC). Pre- and post-testing included MVIC force and F100 (force developed in the first 100 ms: a proxy measure of rate of force development) and unilateral drop jump (DJ) height and contact time. There were no significant MVIC peak force or EMG nor DJ height or contact time interactions (intervention x limb dominance x time). The pre-test (0.50 ± 0.13) dominant leg MVIC F100 forces exceeded (p = 0.02) both post-test and post-10 min by a small magnitude 8.7% (d = 0.31). There was also a significant (p = 0.02) time x intervention leg x testing leg intervention, although it was observed that the control condition was as likely to demonstrate small to large magnitude changes as were the dominant and non-dominant legs. Following the conditioning activity, there was no significant evidence for non-local improvements (PAPE), or performance decreases.

Unilateral Quadriceps Fatigue Induces Greater Impairments of Ipsilateral versus Contralateral Elbow Flexors and Plantar Flexors Performance in Physically Active Young Adults

Non-local muscle fatigue (NLMF) studies have examined crossover impairments of maximal voluntary force output in non-exercised, contralateral muscles as well as comparing upper and lower limb muscles. Since prior studies primarily investigated contralateral muscles, the purpose of this study was to compare NLMF effects on elbow flexors (EF) and plantar flexors (PF) force and activation (electromyography: EMG). Secondly, possible differences when testing ipsilateral or contralateral muscles with a single or repeated isometric maximum voluntary contractions (MVC) were also investigated. Twelve participants (six males: (27.3 ± 2.5 years, 186.0 ± 2.2 cm, 91.0 ± 4.1 kg; six females: 23.0 ± 1.6 years, 168.2 ± 6.7 cm, 60.0 ± 4.3 kg) attended six randomized sessions where ipsilateral or contralateral PF or EF MVC force and EMG activity (root mean square) were tested following a dominant knee extensors (KE) fatigue intervention (2×100s MVC) or equivalent rest (control). Testing involving a single MVC (5s) was completed by the ipsilateral or contralateral PF or EF prior to and immediately post-interventions. One minute after the post-intervention single MVC, a 12×5s MVCs fatigue test was completed. Two-way repeated measures ANOVAs revealed that ipsilateral EF post-fatigue force was lower (-6.6%, p = 0.04, d = 0.18) than pre-fatigue with no significant changes in the contralateral or control conditions. EF demonstrated greater fatigue indexes for the ipsilateral (9.5%, p = 0.04, d = 0.75) and contralateral (20.3%, p < 0.01, d = 1.50) EF over the PF, respectively. There were no significant differences in PF force, EMG or EF EMG post-test or during the MVCs fatigue test. The results suggest that NLMF effects are side and muscle specific where prior KE fatigue could hinder subsequent ipsilateral upper body performance and thus is an important consideration for rehabilitation, recreation and athletic programs.