High-Intensity Multimodal Resistance Training Improves Muscle Function, Symmetry during a Sit-to-Stand Task, and Physical Function Following Hip Fracture.

OBJECTIVES: Post rehabilitation, older adults with hip fracture display low vertical ground reaction force (vGRF) on the involved lower extremity during a sit-to-stand task and low physical function. The purpose of this study was to test whether muscle performance, involved side vGRF during a sit-to-stand task, and physical function improved following multimodal high-intensity resistance training, when initiated after usual care (2 to 6 months after hip fracture). DESIGN: Case series study, 12 weeks extended high-intensity strength training intervention following hip fracture. SETTING: University hospital outpatient facility. PARTICIPANTS: Twenty-four community-dwelling older adults (mean age 78.4 years (SD 10.4), 16 female/8 male), 3.6 (SD 1.2) months post-hip fracture and discharged from physical therapy participated. Intervention/Measurement: All participants performed sit-to-stand tasks, muscle performance tests, and modified physical performance test (mPPT) before and after 12 weeks (3x/wk) of training. Variables were compared using paired t-tests. RESULTS: The vGRF rate of force development (RFD) and magnitude of discrepancy between limb loading during rising phase of sit-to-stand task (AREA) variables improved post-training (RFD ratio = Pre: 0.78 - Post: 0.82, AREA ratio = Pre: 0.79 - Post: 0.86). Surgical leg extension power gains were large (~65%) while strength gains were moderate (~34%); yielding improved symmetry in both strength (Pre: 0.74 - Post: 0.88) and power (Pre: 0.75 - Post: 0.82). Physical function improved pre-training 25 (SD 5.2) to post training 30 (SD 4.3), (p < 0.001). CONCLUSION: Unique to this study, participants recovering from hip fracture demonstrated improved symmetry in sit-to-stand vGRFs, muscle function, and physical function after training. However, a high percentage of patients continued to experience persistently low vGRF of the involved side compared to previous studies of healthy elderly controls. Developing alternative strategies to improve involved side vGRF may be warranted.

Muscle Quality Improves with Extended High-Intensity Resistance Training after Hip Fracture.

BACKGROUND: Muscle mass deficits endure after hip fracture. Strategies to improve muscle quality may improve mobility and physical function. It is unknown whether training after usual care yields muscle quality gains after hip fracture. OBJECTIVES: To determine whether muscle quality improves after hip fracture with high-intensity resistance training and protein supplementation. DESIGN: Case series. SETTING: University of Utah Skeletal Muscle Exercise Research Facility. PARTICIPANTS: 17 community-dwelling older adults, 3.6+/-1.1 months post-hip fracture, recently discharged from usual-care physical therapy (mean age 77.0+/-12.0 years, 12 female), enrolled. INTERVENTION: Participants underwent 12 weeks (3x/week) of unilaterally-biased resistance training. METHODS/MATERIALS: Participants were measured via a 3.0 Tesla whole-body MR imager for muscle lean and intramuscular adipose tissue (IMAT) of the quadriceps before and after resistance training. Peak isometric knee extension force output was measured with an isokinetic dynamometer. Muscle quality was calculated by dividing peak isometric knee extension force (N) by quadriceps lean muscle mass (cm2). In addition, common physical function variables were measured before and after training. RESULTS: Surgical and nonsurgical lean quadriceps muscle mass improved among participants (mean change: 2.9 cm2+/-1.4 cm2, and 2.7 cm2+/-1.3 cm2, respectively), while IMAT remained unchanged. Peak force improved in the surgical limb by 43.1+/-23N, with no significant change in the nonsurgical limb. Significant gains in physical function were evident after training. CONCLUSION: Participants recovering from hip fracture demonstrated improvements in muscle mass, muscle strength, and muscle quality in the surgical limb after hip fracture. These were in addition to gains made in the first months after fracture with traditional care. Future studies should determine the impact that muscle quality has on long-term functional recovery in this population.

Intramuscular fat and inflammation differ in older adults: the impact of frailty and inactivity.

OBJECTIVES: Intramuscular adipose tissue (IMAT) is recognized as a negative predictor of both muscle and mobility function in older adults, however the mechanism by which IMAT may negatively influence muscle and mobility function is currently unknown. The release of pro-inflammatory cytokines from IMAT provides a potential reason for these negative associations. To explore this hypothesis we compared IMAT and muscular inflammation in age-and BMI-matched older non-obese frail and non-frail adults. We also sought to examine the relationship between IMAT and inflammation, and muscle and mobility function in this group of older adults. DESIGN: A case-control sampling was used for this study. Age-and BMI-matched non-obese frail and non-frail individuals (<65 years) were recruited. MEASUREMENTS: MRI was used to quantify thigh IMAT and lean tissue. Unilateral muscle biopsies were used to quantify muscular inflammation as represented by interleukin-6 (IL-6) and tumor-necrosis factor alpha (TNF-α). Muscle and mobility function was also measured using a maximal voluntary isometric contraction, six-minute walk, and self-selected gait speed. PARTICIPANTS: 26 older (80.7 +/- 5.4 years) individuals (8 frail and 18 non-frail) were enrolled. RESULTS: The frail-group had increased IMAT (p<0.01) and decreased lean tissue (p<0.01), and elevated IL-6 muscle mRNA (p=0.02) and IL-6 protein content (p=0.02) compared to the non-frail group. IMAT was significantly associated with IL-6 mRNA (r=0.43, p=.04) and protein expression within the muscle (r=0.41, p= 0.045). IL-6 mRNA was significantly associated with six-minute walk (r=-0.63, p<0.01), and gait speed (r=-0.60, p <0.01) and IL-6 protein was significantly associated with muscle force (r=-0.54, p=0.01), six-minute walk (r=-0.66, p<0.01), and gait speed (r=-0.76, p<0.01). No significant relationships were found for any variables with TNF-a. CONCLUSION: Non-obese, older, frail individuals have increased IMAT and muscular inflammation when compared to their non-frail, age- and BMI-matched peers. A significant relationship exists between IMAT and muscle IL-6 expression as well as between IL-6 and muscle and mobility function of these older adults. This IMAT-inflammatory pathway provides a potential link between IMATs and decreased muscle and mobility function.

Intramuscular adipose tissue attenuates gains in muscle quality in older adults at high risk for falling. A brief report.

OBJECTIVES: To examine the influence of intramuscular adipose tissue (IMAT) on muscle quality (MQ) changes in older adults after 12 weeks of exercise training. DESIGN: Prospective cohort design. SETTING: Academic health science center clinical exercise facility. PARTICIPANTS: 70 older (mean age 73.4 ± 6.3 years) adults with a history of falls. INTERVENTION: Resistance, endurance and balance exercise three times weekly for 12 weeks. MEASUREMENTS: Quadriceps strength was determined by maximum voluntary isometric contraction. An MRI of the thigh was used to determine cross-sectional area of lean tissue and IMAT. MQ was calculated as the force per unit area of lean tissue. Individuals were stratified into tertiles (Low IMAT, Middle IMAT, High IMAT) based on pre-IMAT levels. Changes in MQ, lean and IMAT were compared across groups. RESULTS: No significant changes in lean or IMAT occurred in any group with training. MQ increased only in the Low IMAT group. The Middle and High IMAT groups did not demonstrate a significant change in MQ following 12 weeks of training. Low IMAT, pre = 2.7 [0.6] post= 3.0 [0.6]; Middle IMAT, pre =2.54 [0.8] post =2.75 [0.7]; High IMAT, pre =2.6 [0.6] to post =2.5 [0.6]. CONCLUSION: High levels of thigh IMAT appear to blunt the adaptive MQ response to training. High levels of thigh IMAT may be a potential reason why some older adults do not change their MQ following training. Future research should confirm these results and determine why IMAT impairs MQ and the adaptive response to training in older adults.

Regional muscle glucose uptake remains elevated one week after cessation of resistance training independent of altered insulin sensitivity response in older adults with type 2 diabetes.

BACKGROUND: Aging is associated with a decline in skeletal muscle size.Muscle is critical both for mobility and glucose disposal. While resistance exercise (RE) increases muscle mass and function in the elderly, its role in improving glucose utilization is less clear. AIMS: To investigate whether muscle size was linked with insulin sensitivity (IS) in elders with diabetes following RE and if regional muscle glucose uptake differed from systemic glucose utilization. METHODS: Seven (68.4 ± 5.9 yr) adults with diabetes participated. After 16 weeks of RE, within 24 h (post 1) and after 1 week of no exercise (post 2), lean tissue cross-sectional area (CSA) and IS via glucose infusion rate (GIR) were assessed along with a standardized 18-F fluorodeoxyglucose (FDG)-positron emission tomography uptake value (SUV). RESULTS: CSA increased between pre-test (108.5 ± 35.3 cm2) and post 1 (116.8 ± 40.9 cm2), p=0.02 and did not differ at post 2 (116.0 ± 39.3 cm2). GIR during the 40 mU/m2/min insulin clamp differed between pretest (22.0 ± 15.8 mg/kg/min) and post 1 (67.9 ± 72.8 mg/kg/min), and post 1 and post 2 (25.0 ± 27.2 mg/kg/min) but not between pre-test and post 2. GIR results during the 200 mU/m2/min insulin clamps also differed between pre-test and post 1, and post 1 and post 2 but not between pre-test and post 2. FDG-SUV increased between pre-test (1.1 ± 0.2) and post 1 (1.4 ± 0.3), and remained stable between post 1 and post 2 (1.4 ± 0.4). CONCLUSION: RE that increased muscle size and FDG-SUV improved IS 24 h but not 1 week after exercise training.

Improved Dynamic Postural Task Performance without Improvements in Postural Responses: The Blessing and the Curse of Dopamine Replacement.

Introduction. Dopamine-replacement medications may improve mobility while not improving responses to postural challenges and could therefore increase fall risk. The purpose of this study was to measure reactive postural responses and gait-related mobility of patients with PD during ON and OFF medication conditions. Methods. Reactive postural responses to the Pull Test and performance of the Functional Gait Assessment (FGA) were recorded from 15 persons with PD during ON and OFF medication conditions. Results. Persons with PD demonstrated no significant difference in the reactive postural responses between medication conditions but demonstrated significantly better performance on the FGA when ON medications compared to OFF. Discussion/Conclusion. Dopamine-replacement medications alone may improve gait-related mobility without improvements in reactive postural responses and therefore could result in iatrogenic increases in fall risk. Rehabilitation providers should be aware of the side effects and limitations of medication treatment and implement interventions to improve postural responses.

Skeletal muscle fat infiltration: impact of age, inactivity, and exercise.

Fat infiltration within the fascial envelope of the thigh or intermuscular adispose tissue (IMAT), has been shown to be associated with both adverse metabolic and mobility impairments in older individuals. More recent findings suggest these fat deposits may be associated with increasing age and inactivity; and perhaps exercise may be able to counter or mitigate this increase in IMAT. This brief report summarizes the literature with respect to IMAT and its relationship to increasing age, physical activity levels, muscle strength, mobility and metabolism in the elderly. Further, we present preliminary data suggesting that IMAT is associated with increasing age in individuals across disease states (r=0.47, p < 0.05), and that resistance exercise can decrease IMAT in older individuals with a variety of co-morbid conditions.

Determinants of functional performance in long-term survivors of allogeneic hematopoietic stem cell transplantation with chronic graft-versus-host disease (cGVHD).

This study examined factors accounting for functional performance limitations in 100 long-term survivors of allogeneic hematopoietic stem cell transplantation with chronic graft-versus-host disease (cGVHD). Functional performance, measured by the SF-36 physical component summary score, was substantially lower (mean=36.8+/-10.7) than the US population norm of 50 (P<0.001). The most severe decrements were in physical function (mean=38.8+/-10.9) and physical role function (mean=37.88+/-11.88); 68% of respondents exceeded the five-point threshold of minimum clinically important difference below the norm on these subscales. Controlling for age and gender, six variables explained 56% of the variance in functional performance: time since cGVHD diagnosis, cGVHD severity, intensity of immunosuppression, comorbidity, functional capacity (distance walked in 2 min, grip strength, and range of motion), and cGVHD symptom bother (F=11.26; P<0.001). Significant independent predictors of impaired performance were intensive systemic immunosuppression, reduced capacity for ambulation, and greater cGVHD symptom bother (P<0.05). Symptom bother had a direct effect on functional performance, as well as an indirect effect partially mediated by functional capacity (Sobel test, P=0.004). Results suggest two possible mechanisms underlying impaired functional performance in survivors with cGVHD and underscore the importance of testing interventions to enhance functional capacity and reduce symptom bother.

Distal radius fractures: therapy practice patterns.

Identifying practice patterns for therapy interventions following distal radius fractures (DRFs) is necessary to define the most frequently used examination and intervention techniques. The purpose of this study was to identify preferred practice patterns and physical and functional outcome measures used during DRF management. Two hundred forty-two therapists (PTs, OTs, and CHTs) were surveyed by questionnaire at an annual hand therapy meeting. A descriptive analysis of data was performed. Preferred practice patterns during the immobilization and the post-immobilization periods were identified. More than 75% of the surveyed therapists used upper extremity range-of-motion exercises and compressive wrap with retrograde massage during the immobilization phase. More than 90% of therapists included range-of-motion exercises and heat/cold modalities in the post-immobilization treatment plans. Physical impairment measures of outcome were used much more frequently than functional outcome questionnaires in assessing progress during treatment. This study advances the evidence-based practice of therapy by establishing a foundation for future research.

Is the spring quality of muscle plastic?

During locomotion, major muscle groups are often activated cyclically. This alternate stretch-shorten pattern of activity could enable muscle to function as a spring, storing and recovering elastic recoil potential energy. Because the ability to store and recover elastic recoil energy could profoundly affect the energetics of locomotion, one might expect this to be an adaptable feature of skeletal muscle. This study tests the hypothesis that chronic eccentric (Ecc) training results in a change in the spring properties of skeletal muscle. Nine female Sprague-Dawley rats underwent chronic Ecc training for 8 wk on a motorized treadmill. The spring properties of muscle were characterized by both active and passive lengthening force productions. A single "spring constant (Deltaforce/Deltalength) from the passive length-tension curves was calculated for each muscle. Results from measurements on long heads of triceps brachii muscle indicate that the trained group produced significantly more passive lengthening force (P = 0.0001) as well as more active lengthening force (P = 0.0001) at all lengths of muscle stretch. In addition, the spring constants were significantly different between the Ecc (1.71 N/mm) and the control (1.31 N/mm) groups. A stiffer spring is capable of storing more energy per unit length stretched, which is of functional importance during locomotion.

Eccentric ergometry: increases in locomotor muscle size and strength at low training intensities.

Lengthening (eccentric) muscle contractions are characterized by several unusual properties that may result in unique skeletal muscle adaptations. In particular, high forces are produced with very little energy demand. Eccentrically trained muscles gain strength, but the specific nature of fiber size and composition is poorly known. This study assesses the structural and functional changes that occur to normal locomotor muscle after chronic eccentric ergometry at training intensities, measured as oxygen uptake, that do not influence the muscle when exercised concentrically. Male subjects trained on either eccentric or concentric cycle ergometers for 8 wk at a training intensity starting at 54% and ending at 65% of their peak heart rates. The isometric leg strength increased significantly in the eccentrically trained group by 36%, as did the cross-sectional area of the muscle fiber by 52%, but the muscle ultrastructure remained unchanged. There were no changes in either fiber size, composition, or isometric strength in the concentrically trained group. The responses of muscle to eccentric training appear to be similar to resistance training.

Chronic eccentric exercise: improvements in muscle strength can occur with little demand for oxygen.

Eccentric contractions, the lengthening of muscle while producing force, are a common part of our everyday movements. This study presents a challenge to the accepted notion that eccentric work causes obligatory muscle injury while demonstrating that an increase in muscle strength, via eccentric work, can occur with little demand for oxygen. Nine healthy subjects, ages 18-34, were randomly placed in either an eccentric or a concentric training group. Both groups trained for 6 wk while progressively increasing training frequency and duration. Significant gains in isometric leg strength were seen in the eccentrically trained subjects only. While training, the oxygen consumption required to do the eccentric work was equal to or less than that required to do the concentric work. The results demonstrate that by progressively increasing the eccentric work rate, significant isometric strength gains can be made without muscle injury and with minimal increase in metabolic demand for oxygen. The potential clinical implications of an eccentric training program that uncouples skeletal muscle strength improvements from the demand for oxygen are alluring.

Electromyography of the shoulder: an analysis of passive modes of exercise.

Passive shoulder motion is standard early rehabilitation in patients undergoing rotator cuff repair. A number of rehabilitation protocols exist to obtain this goal. This article evaluated different rehabilitation protocols using electromyographic analysis of the rotator cuff muscles to determine if the different protocols promote passive motion. Ten healthy volunteers underwent EMG to investigate the relative activity of the rotator cuff muscles during various exercises used postoperatively following shoulder surgery. The exercises tested were continuous passive motion machine (CPM), pulley, pendulum, self-assisted bar raise using the contralateral arm for power, self-assisted internal and external rotation, therapist-assisted elevation in plane of the scapula, and therapist-assisted internal and external rotation. The relative activity of the supraspinatus, infraspinatus, anterior deltoid, and trapezius muscles were measured and expressed as a percentage of maximal activity. For all muscle groups tested, the pulley exercise showed significantly more activity than the CPM machine. In the supraspinatus muscle, the pulley exercise averaged 17.6% of maximal activity and 8.7% for the self-assisted bar raise using contralateral arm power compared with 5.0% for the CPM machine. In general, therapist-assisted exercises and Codman's pendulum exercises showed activity that was not significantly different from the CPM machine. These results indicate that CPM and therapist-assisted passive range of motion, by being more passive, may increase the safety margin for obtaining early passive range of motion without disrupting the rotator cuff repair.

Continuous passive motion after repair of the rotator cuff. A prospective outcome study.

Despite the apparent success of continuous passive motion after soft-tissue procedures or joint replacements, its effect after repair of the rotator cuff is still unknown. The purpose of this prospective, randomized outcome study was to compare the results of continuous passive motion with those of manual passive range-of-motion exercises after repair of the rotator cuff. Thirty-one patients (thirty-two rotator cuffs) were randomly assigned to one of two types of postoperative management: continuous passive motion (seventeen patients) or manual passive range-of-motion exercises (fifteen patients). There were seventeen women and fourteen men, and the mean age was sixty-three years (range, thirty to eighty years). The patients were followed for a mean of twenty-two months (range, six to forty-five months). Five tears of the rotator cuff were small, eighteen were medium, and nine were large. All of the operations were performed by one surgeon. The patients who were managed with continuous passive motion used the device for the first four weeks postoperatively. The patients who were managed with manual passive range-of-motion exercises were assisted by a trained relative, friend, or home-care nurse. After the four-week period, the two groups were managed similarly for two to five months. According to the Shoulder Pain and Disability Index, a valid and reliable self-administered questionnaire, the treatment was extremely successful in both groups. The overall score was excellent for twenty-seven shoulders (84 per cent), good for two (6 per cent), fair for two (7 per cent), and poor for one (3 per cent). With the numbers available, we could detect no significant differences (p > 0.05) between the two groups with respect to the score according to the Index, pain (according to a visual-analog scale), range of motion, or isometric strength. Manual passive range-of-motion exercises were more cost-effective than continuous passive motion. The limited number of physical-therapy visits associated with the manual passive range-of-motion exercises in the present study appeared to be more cost-effective than a traditional physical-therapy schedule of three visits per week. Postoperative therapy with continuous passive motion or manual passive range-of-motion exercises appears to yield favorable results after repair of a small, medium, or large tear of the rotator cuff.

Exercise training in chronic hypoxia has no effect on ventilatory muscle function in humans.

At the highest altitude, aerobic work is limited by environmental oxygen availability. We therefore reasoned that the hyperpnea associated with endurance training at altitude should provide a strong stimulus for adaptation of the ventilatory muscles. We measured peak inspiratory muscle pressure-flow characteristics (inspiring through graded resistors) and maximum sustainable ventilation capacity in ten permanent residents of La Paz, Bolivia (3600 m) prior to and immediately following 6 weeks of incremental endurance training. Additionally, eight local residents did no training and functioned as controls for the capacity test. While V(O2)max measured in hypoxia increased by 19% (Favier et al., 1995b. J. Appl Physiol. 78, 2286-2293.), none of the tested ventilatory variables showed significant changes. The values for the group mean slopes of maximum inspiratory pressure-flow pairs (- 10.5 vs. - 9.8 cm H2O x sec x L(-1), P=0.301; before versus after training, respectively), maximum inspiratory pressure (112.1+/-8.9 vs. 106.9+/-8.6 cmH2O, P=0.163), peak inspiratory flow (9.8+/-0.41 vs. 10.2+/-0.55 L x sec(-1) P=0.172) and the maximum volitional volume in 12 sec (43.9+/-2.4 vs. 45.6+/-2.4 L in 12 sec, P=0.133) were unchanged with exercise training. Likewise, maximal sustainable minute volume was not different between post-training and control subjects (177.4+/-7.9 vs. 165.4+/-8.4 L x min(-1), P=0.141). These data support the concept that endurance training fails to elicit functional adaptations in ventilatory muscles in humans, even when exercise is done in hypoxia.

Reliability of passive wrist flexion and extension goniometric measurements: a multicenter study.

BACKGROUND AND PURPOSE: The purpose of this study was twofold: (1) to determine whether passive wrist flexion and extension goniometric measurements using ulnar alignment, radial alignment, and volar/dorsal alignment were similar or dissimilar and (2) to examine which of these three techniques had the greatest intratester and intertester reliability. SUBJECTS: One hundred forty patients (141 wrists) were measured. The testers were 32 therapists from eight different hand/upper-extremity clinical sites around the United States. METHODS: Randomly paired testers measured passive wrist flexion and extension. The intraclass correlation coefficient (ICC) was used as an estimate of agreement for both intratherapist (model 3.1) and intertherapist (model 2.1) reliability. RESULTS: Six of the eight clinics showed significant differences among the various goniometric techniques. Flexion intratherapist mean ICCs for the radial, ulnar, and dorsal alignment techniques were .86, .87, and .92, respectively. Extension intratherapist mean ICCs were .80, .80, and .84 for the three techniques. Intertherapist flexion mean ICCs were .88, .89, and .93 for the radial, ulnar, and volar alignment techniques, respectively. Extension intertherapist mean ICCs were .80, .80, and .84 for the three techniques. The standard error of measurement was also used to quantify reliability, with the volar/dorsal alignment technique consistently producing less error than the ulnar and radial alignment techniques. The generalizability theory statistical model was utilized to identify the sources of error. The patient contributed to variance the most, although inherent error within the study, diagnostic category, therapeutic approach, and goniometric technique also contributed. CONCLUSION AND DISCUSSION: The overall results indicated there were differences among the three goniometric techniques. The volar/dorsal alignment technique is the goniometric technique of choice, as it consistently had the greatest reliability.