Skeletal muscle morphology and exercise response in congenital generalized lipodystrophy.

OBJECTIVE: Congenital generalized lipodystrophy (CGL) is an autosomal recessive genetic disorder characterized by almost complete absence of adipose tissue, muscular appearance, and severe insulin resistance since birth. We investigated whether insulin resistance in CGL patients is associated with abnormal muscle morphology and whether increased muscularity imparts increased muscle strength and exercise capacity RESEARCH DESIGN AND METHODS: We obtained quadriceps muscle biopsies to study muscle fiber types and capillary density in three African-American women (aged 17-20 years) with CGL. We also assessed quadriceps muscle strength, muscle metabolism, and maximal O2 consumption in the patients. RESULTS: Quadriceps muscle biopsies revealed a markedly higher percentage of type II (fast-twitch glycolytic) muscle fibers in patients with CGL versus sedentary young women (75-78 vs. 47-57%, respectively). The capillary-to-fiber ratio (2.7-3.0), however, was normal. Cross-sectional areas of type I (slow-twitch oxidative) (1,262-2,685 microm2) and type II (2,304-3,594 microm2) fibers were far below the normal values (3,811-4,310 and 3,115-4,193 microm2, respectively), suggesting muscle hyperplasia but not hypertrophy The quadriceps muscle strength, as measured by Cybex, was below average; the maximal O2 consumption (23-32 ml x kg(-1) x min(-1)) was also below average. 31P nuclear magnetic resonance spectroscopy of the forearm muscles revealed normal pH and metabolic responses to static and dynamic exercises. CONCLUSIONS: We conclude that insulin resistance in patients with CGL is associated with an increased proportion of type II muscle fibers but not reduced capillary density. Increased muscularity in CGL is due to muscle hyperplasia and is not associated with increased muscle strength.

A modular NIRS system for clinical measurement of impaired skeletal muscle oxygenation.

Near-infrared spectrometry (NIRS) is a well-known method used to measure in vivo tissue oxygenation and hemodynamics. This method is used to derive relative measures of hemoglobin (Hb) + myoglobin (Mb) oxygenation and total Hb (tHb) accumulation from measurements of optical attenuation at discrete wavelengths. We present the design and validation of a new NIRS oxygenation analyzer for the measurement of muscle oxygenation kinetics. This design optimizes optical sensitivity and detector wavelength flexibility while minimizing component and construction costs. Using in vitro validations, we demonstrate 1) general optical linearity, 2) system stability, and 3) measurement accuracy for isolated Hb. Using in vivo validations, we demonstrate 1) expected oxygenation changes during ischemia and reactive hyperemia, 2) expected oxygenation changes during muscle exercise, 3) a close correlation between changes in oxyhemoglobin and oxymyoglobin and changes in deoxyhemoglobin and deoxymyoglobin and limb volume by venous occlusion plethysmography, and 4) a minimal contribution from movement artifact on the detected signals. We also demonstrate the ability of this system to detect abnormal patterns of tissue oxygenation in a well-characterized patient with a deficiency of skeletal muscle coenzyme Q(10). We conclude that this is a valid system design for the precise, accurate, and sensitive detection of changes in bulk skeletal muscle oxygenation, can be constructed economically, and can be used diagnostically in patients with disorders of skeletal muscle energy metabolism.

Incorporation and utilization of [3-13C]lactate and [1,2-13C]acetate by rat skeletal muscle.

Skeletal muscle can utilize many different substrates, and traditional methodologies allow only indirect discrimination between oxidative and nonoxidative uptake of substrate, possibly with contamination by metabolism of other internal organs. Our goal was to apply 1H- and 13C-nuclear magnetic resonance spectroscopy to monitor the patterns of [3-13C]lactate and [1,2-13C]acetate (model of simple carbohydrates and fats, respectively) utilization in resting vs. contracting muscle extracts of the isolated perfused rat hindquarter. Total metabolite concentrations were measured by using NADH-linked fluorometric assays. Fractional oxidation of [3-13C]lactate was unchanged by contraction despite vascular endogenous lactate accumulation. Although label accumulated in several citric acid cycle (CAC) intermediates, contraction did not increase the concentration of CAC intermediates in any muscle extracts. We conclude that 1) the isolated rat hindquarter is a viable, well-controlled model for measuring skeletal muscle 13C-labeled substrate utilization; 2) lactate is readily oxidized even during contractile activity; 3) entry and exit from the CAC, via oxidative and nonoxidative pathways, is a component of normal muscle metabolism and function; and 4) there are possible differences between gastrocnemius and soleus muscles in utilization of nonoxidative pathways.

Oxidation of lactate and acetate in rat skeletal muscle: analysis by 13C-nuclear magnetic resonance spectroscopy.

The balance between carbohydrate and fatty acid utilization in skeletal muscle previously has been studied in vivo by using a variety of methods such as arteriovenous concentration differences and radioactive isotope tracer techniques. However, these methodologies provide only indirect estimates of substrate oxidation. We used 13C-nuclear magnetic resonance (NMR) spectroscopy and non-steady-state isotopomer analysis to directly quantify the relative oxidation of two competing exogenous substrates in rat skeletal muscles. We infused [1,2-13C]acetate and [3-13C]lactate intravenously in anesthetized rats during the final 30 min of 35 (n = 10) or 95 (n = 10) min of intense, unilateral, rhythmic hindlimb contractions. 13C-NMR spectroscopy and isotopomer analysis were performed on extracts of gastrocnemius and soleus muscles from both the contracting and contralateral resting hindlimbs. We found that 1) [13C]lactate and [13C]acetate were taken up and oxidized by both resting and contracting skeletal muscles; and 2) high-intensity muscle contractions altered the pattern of substrate utilization such that the relative oxidation of acetate decreased while that of lactate remained unchanged or increased. Based on these findings, we propose that 13C-NMR spectroscopy in combination with isotopomer analysis can be used to study the general dynamics of substrate competition between carbohydrates and fats in rat skeletal muscle.

Emerging opportunities with NMR.

Several nuclear magnetic resonance (NMR) methods with potential as tools for the study of neuromuscular fatigue are described briefly. 13C MR spectroscopy (MRS) is presented as a means of studying the regulation of substrate (fuel) flux into the citric acid cycle. 23Na and 39K MRS can be used to study the distribution of sodium and potassium ions across the cell membrane. 1H MR imaging (MRI) takes advantage of the relationship between the environment of water 1H and the mechanisms of nuclear spin relaxation to make static and cine images which present spatial (anatomical) information that can be tied to essential physiological, biochemical, or biophysical phenomena of fatiguing muscle.

Muscle recruitment variations during wrist flexion exercise: MR evaluation.

OBJECTIVE: Many exercise protocols used in physiological studies assume homogeneous and diffuse muscle recruitment. To test this assumption during a "standard" wrist flexion protocol, variations in muscle recruitment were assessed using MRI in eight healthy subjects. MATERIALS AND METHODS: Variations were assessed by comparing the right to the left forearms and the effect of slight (15 degrees) pronation or supination at the wrist. RESULTS: Postexercise imaging showed focal regions of increased signal intensity (SI), indicating relatively strong recruitment, most often in entire muscles, although occasionally only in subvolumes of muscles. In 15 of 26 studies, flexor carpi radialis (FCR) showed more SI than flexor carpi ulnaris, while in 11 studies SI in these muscles increased equivalently. Relatively greater FCR recruitment was seen during pronation and/or use of the nondominant side. Palmaris longus, a wrist flexor, did not appear recruited in 4 of 11 forearms in which it was present. A portion of the superficial finger flexor became hyperintense in 89% of studies, while recruitment of the deep finger flexor was seen only in 43%. CONCLUSION: Inter- and intraindividual variations in forearm muscle recruitment should be anticipated in physiological studies of standard wrist flexion exercise protocols.

Muscle proton T2 relaxation times and work during repetitive maximal voluntary exercise.

We studied the effects of progressive maximal voluntary handgrip contractions (MVCs) on muscle proton spin-spin (T2) relaxation times and work, measured as the integrated force vs. time curve (FTI). Six healthy volunteers performed 10, 20, 40, and 80 MVCs in a 0.35-T magnet on four separate occasions. Repeated measures analyses of variance of increases in T2 and FTI during successive bouts were significant (P < 0.005 and P < 0.001, respectively). FTI increased with successive bouts to a greater extent than did muscle T2 (P < 0.05). For T2, the Helmert contrast judged the 10-MVC response lower than the mean of the remaining responses (P < 0.005), and the differences between all others compared with the means of subsequent responses were not significant, indicating a "flattening" of the T2 response after the increase from 10 to 20 repetitions. For FTI, all the single degree of freedom Helmert contrasts were significant (P < 0.001), indicating a continual increase in response over increased MVCs. The curved nature of the T2 response conformed best to a hyperbolic function, suggesting that a limit of approximately 32% exists for the change in T2 during progressively longer bouts of MVCs. A limit in the T2 response is consistent with the existence of a limit in the amount of water that muscle can take up from the vasculature during exertion.

Muscle metabolism during lactate infusion in human phosphofructokinase deficiency.

We studied the effect of intravenous infusion of sodium lactate (La) on muscle high-energy phosphate metabolism, pH, and venous effluent [NH3] in three patients with muscle phosphofructokinase (PFK) deficiency and three healthy subjects during maximal-effort rhythmic handgrip exercise (5 s of contraction alternated with 5 s of rest) performed for 3 min. Healthy subjects were matched to PFK-deficient patients for gender and maximal handgrip strength. Force production was recorded and during lactate infusion was matched to that without lactate. 31P-magnetic resonance spectroscopy was used to measure intracellular phosphocreatine (PCr), orthophosphate (Pi), ATP, and pH in the flexor digitorum profundus of the exercising forearm. La infusion had no effect on healthy subjects or patients during rest. In healthy subjects, La infusion had no effect on depletion of PCr; accumulation of Pi, ADP, or venous effluent NH3; or decline in pH in exercising muscle. In contrast, during exercise in PFK-deficient patients, [PCr] was higher (17.9 +/- 1.9 vs. 13.1 +/- 1.4 mmol/kg) and [phosphomonoester] (11.4 +/- 1.3 vs. 6.5 +/- 1.4 mmol/kg), [Pi] (9.2 +/- 1.8 vs. 5.0 +/- 0.7 mmol/kg), [ADP] (60.4 +/- 7.0 vs. 37.9 +/- 9.9 mumol/kg), and venous effluent [NH3] (335 +/- 136 vs. 176 +/- 61 mM) were lower (P < 0.05) during La infusion than in control conditions. The effects of La infusion on intracellular [PCr], [Pi], [phosphomonoester], [ADP], and [NH3] in PFK-deficient patients are consistent with the hypothesis that exogenous La augments the rate of oxidative phosphorylation in active muscle by bypassing the enzymatic block at PFK.

31P-magnetic resonance spectroscopy assessment of subnormal oxidative metabolism in skeletal muscle of renal failure patients.

In hemodialysis patients, erythropoietin increases hemoglobin, but often the corresponding increase in peak oxygen uptake is low. The disproportionality may be caused by impaired energy metabolism. 31P-magnetic resonance spectroscopy was used to study muscle energy metabolism in 11 hemodialysis patients, 11 renal transplant recipients, and 9 controls. Measurements were obtained during rest, static hand-grip, and rhythmic hand-grip; recoveries were followed to baseline. During static hand-grip, there were no between-group differences in phosphocreatine (PCr), inorganic phosphate (Pi), or PCr/(PCr + Pi), although intracellular pH was higher in hemodialysis patients than transplant recipients. During rhythmic hand-grip, hemodialysis patients exhibited greater fatigue than transplant recipients or controls, and more reduction in PCr/(PCr + Pi) than transplant recipients. Intracellular pH was higher in controls than either hemodialysis patients or transplant recipients. Recoveries from both exercises were similar in all groups, indicating that subnormal oxidative metabolism was not caused by inability to make ATP. The rhythmic data suggest transplantation normalizes PCr/(PCr + Pi), but not pH. In hemodialysis patients, subnormal oxidative metabolism is apparently caused by limited exchange of metabolites between blood and muscle, rather than intrinsic oxidative defects in skeletal muscle.

Human muscle fatigue after glycogen depletion: a 31P magnetic resonance study.

To differentiate the effects of high energy phosphates, pH, and [H2PO4-] on skeletal muscle fatigue, intracellular acidosis during handgrip exercise was attenuated by prolonged submaximal exercise. Healthy human subjects (n = 6) performed 5-min bouts of maximal rhythmic handgrip (RHG) before (CONTROL) and after prolonged (60-min) handgrip exercise (ATTEN-EX) designed to attenuate lactic acidosis in active muscle by partially depleting muscle glycogen. Concentrations of free intracellular phosphocreatine ([PCr]), adenosine triphosphate ([ATP]), and orthophosphate ([P(i)]) and pH were measured by 31P nuclear magnetic resonance spectroscopy and used to calculate adenosine diphosphate [ADP], [H2PO4-], and [HPO4(2-)]. Handgrip force output was measured with a dynamometer, and fatigue was determined by loss of maximal contractile force. After ATTEN-EX, the normal exercise-induced muscle acidosis was reduced. At peak CONTROL RHG, pH fell to 6.3 +/- 0.1 (SE) and muscle fatigue was correlated with [PCr] (r = 0.83), [P(i)] (r = 0.82), and [H2PO4-] (r = 0.81); [ADP] was 22.0 +/- 5.7 mumol/kg. At peak RHG after ATTEN-EX, pH was 6.9 +/- 0.1 and [ADP] was 116.1 +/- 18.2 mumol/kg, although [PCr] and [P(i)] were not different from CONTROL RHG (P greater than 0.05). After ATTEN-EX, fatigue correlated most closely with [ADP] (r = 0.84). The data indicate that skeletal muscle fatigue 1) is multifactorial, 2) can occur without decreased pH or increased [H2PO4-], and 3) is correlated with [ADP] after exercise-induced glycogen depletion.

Effect of perfusion on exercised muscle: MR imaging evaluation.

An ischemic clamp model of exercise was used to evaluate the potential role of blood flow in mediating changes in the magnetic resonance imaging appearance of skeletal muscle. Proton relaxation times of muscle were serially estimated in 10 healthy subjects (a) before exercise, (b) after exercise in the presence of vascular occlusion (VO1), (c) during vascular reocclusion after 1 minute of reperfusion (VO2), and (d) after reinstitution of continuous flow. T1 and T2 of active muscles were increased during VO1. During VO2, there were additional increases in relaxation times of active muscles. Reinstitution of continuous flow was associated with a continuous decrease in the T2 of exercised muscle. Hence, blood flow was not required for increases in T1 and T2 with exercise. Additional relaxation time increases occurred after a brief period of reperfusion; however, continuous flow was associated with a decrease in T2.

Finger-specific flexor recruitment in humans: depiction by exercise-enhanced MRI.

To evaluate the spatial distribution of human forearm musculature stressed by finger-specific exercise, magnetic resonance imaging was performed in conjunction with exercise protocols designed to separately stress the flexor digitorum superficialis and flexor digitorum profundus. These muscles were shown to consist of subvolumes selectively recruited by flexion of the individual fingers. Knowledge of the finger-specific regions of muscle recruitment during finger flexion could improve sampling accuracy in electromyography, biopsy, magnetic resonance spectroscopy, and invasive vascular sampling studies of hand exercise.

Muscle phosphorus energy state in very-low-birth-weight infants: effect of exercise.

Skeletal muscle hypotonia is a hallmark clinical finding in very-low-birth-weight (VLBW) human infants. Although the biochemical basis for this phenomenon is not completely understood, one hypothesis is that the phosphorylation potential is abnormally low in the skeletal muscle of these infants. Therefore, we used 31P-nuclear magnetic resonance (NMR) spectroscopy to measure phosphorus metabolites in the skeletal muscle of VLBW infants during rest and during reflex-induced muscle contractions. Compared with healthy larger infants or to adults, the total phosphorus NMR signal is lower in VLBW infants. In VLBW infants during rest, [PCr]/([PCr]+[Pi]), where PCr is phosphocreatine and brackets denote concentration, was 89% and [ATP]/[ADP][Pi] was 59% of that found in larger infants (P less than 0.05). During reflex-induced isometric contractions in VLBW infants, [PCr]/([PCr]+[Pi]) declined by 24% and [ATP]/[ADP][Pi] declined by 35% (P less than 0.05 vs. rest). In all conditions, muscle pH remained 7.1. Overall, the differences in skeletal muscle energy state during rest and the corresponding changes in concentration of high-energy phosphates during mild exercise suggest a very limited energy reserve in the hypotonic muscle of VLBW infants.

Locomotor system assessment by muscle magnetic resonance imaging.

Clinical evaluation of the locomotor system has long been hampered by difficulty in assessing the morphologic and functional integrity of skeletal muscles. Diagnostic imaging represents a major advance in the diagnosis and management of patients with locomotor dysfunction through the possibility of probing beyond overlying soft tissues to identify muscle lesions, determine their extent, characterize their composition, direct invasive procedures, and monitor therapies. Magnetic resonance imaging (MRI) appears to be the most promising of available imaging methods, because of its great sensitivity to changes in muscle water distribution and fat content. Also, it can distinguish between individual deep and superficial muscles. Serial evaluations of many muscles are practical because of the safety of MRI. While the cost effectiveness in the workup of locomotor dysfunction remains to be determined, the scientific and practical clinical information now available merits further investigation by clinicians and radiologists alike. The purpose of this review is to describe the potential role of skeletal muscle MRI in evaluating the locomotor system.

Abnormal high-energy phosphate metabolism in human muscle phosphofructokinase deficiency.

We studied the pattern of high-energy phosphate metabolism in five patients with phosphofructokinase deficiency (PFKD) and five healthy subjects (HS) during graded rhythmic handgrip performed for 5 min at 17, 33, 50, and 100% of maximal voluntary contraction (MVC). The range of MVC was similar in both groups. Force production was recorded, and intracellular concentrations of phosphorus compounds and pH were measured in the flexor digitorum profundus of the active forearm. At exercise intensities greater than or equal to 50% MVC, changes in concentrations of high-energy phosphate metabolites were abnormal in PFKD. During maximal effort, [ADP], calculated from the creatine kinase reaction, was 64.3 +/- 13.5 (SE) mumol/kg in PFKD vs. 25.7 +/- 4.0 in HS (P less than 0.05). Ammonia (NH3), a product of AMP deamination and an index of muscle [AMP], increased approximately twofold more in venous effluent during maximal forearm exercise in PFKD than in HS (P less than 0.05). Phosphocreatine concentration was 9.4 +/- 1.3 (SE) mmol/kg in HS and 13.0 +/- 1.7 in PFKD (P less than 0.05). Inorganic phosphate concentration was 15.8 +/- 1.4 mmol/kg in HS and 7.4 +/- 0.5 in PFKD (P less than 0.05). During strenuous exercise, PFKD patients exhibit an impairment in the rephosphorylation of ADP related to a subnormal oxidative capacity, an absence of glycolysis, and an attenuated breakdown of phosphocreatine.

Arterial baroreflex buffering of sympathetic activation during exercise-induced elevations in arterial pressure.

Static muscle contraction activates metabolically sensitive muscle afferents that reflexively increase sympathetic nerve activity and arterial pressure. To determine if this contraction-induced reflex is modulated by the sinoaortic baroreflex, we performed microelectrode recordings of sympathetic nerve activity to resting leg muscle during static handgrip in humans while attempting to clamp the level of baroreflex stimulation by controlling the exercise-induced rise in blood pressure with pharmacologic agents. The principal new finding is that partial pharmacologic suppression of the rise in blood pressure during static handgrip (nitroprusside infusion) augmented the exercise-induced increases in heart rate and sympathetic activity by greater than 300%. Pharmacologic accentuation of the exercise-induced rise in blood pressure (phenylephrine infusion) attenuated these reflex increases by greater than 50%. In contrast, these pharmacologic manipulations in arterial pressure had little or no effect on: (a) forearm muscle cell pH, an index of the metabolic stimulus to skeletal muscle afferents; or (b) central venous pressure, an index of the mechanical stimulus to cardiopulmonary afferents. We conclude that in humans the sinoaortic baroreflex is much more effective than previously thought in buffering the reflex sympathetic activation caused by static muscle contraction.

Impairment of sympathetic activation during static exercise in patients with muscle phosphorylase deficiency (McArdle's disease).

Static exercise in normal humans causes reflex increases in muscle sympathetic nerve activity (MSNA) that are closely coupled to the contraction-induced decrease in muscle cell pH, an index of glycogen degradation and glycolytic flux. To determine if sympathetic activation is attenuated when muscle glycogenolysis is blocked due to myophosphorylase deficiency (McArdle's disease), an inborn enzymatic defect localized to skeletal muscle, we now have performed microelectrode recordings of MSNA in four patients with McArdle's disease during static handgrip contraction. A level of static handgrip that more than doubled MSNA in normal humans had no effect on MSNA and caused an attenuated rise in blood pressure in the patients with myophosphorylase deficiency. In contrast, two nonexercise sympathetic stimuli, Valsalva's maneuver and cold pressor stimulation, evoked comparably large increases in MSNA in patients and normals. The principal new conclusion is that defective glycogen degradation in human skeletal muscle is associated with a specific reflex impairment in sympathetic activation during static exercise.

The effect of high-intensity exercise on the respiratory capacity of skeletal muscle.

The effect of high-intensity exercise on the respiratory capacity of skeletal muscle was studied in horses which ran five 600-m bouts on a track with 2 min of rest between exercise bouts, or once to fatigue on a treadmill at an intensity that elicited the maximal oxygen uptake. Venous blood and biopsy samples of the middle gluteal muscle were collected at rest, after each exercise bout, and 30 and 60 min post-exercise. Blood samples were analyzed for lactate concentration and pH and muscle samples for metabolites, pH, and respiratory capacity. Venous blood and muscle pH declined to 6.91 +/- 0.02 and 6.57 +/- 0.02, respectively, after the fifth track run and to 6.98 +/- 0.02 and 6.71 +/- 0.07, respectively, after treadmill running. Muscle metabolite changes were consistent with the metabolic response to high-intensity exercise. Muscle respiratory capacity declined greater than 20% (P less than 0.05) after a single exercise bout and was 45% of the control value after the fifth track run. Tissue respiration was depressed 60 min post-exercise but was normal 24 h later. These observations suggest that high-intensity exercise impairs the respiratory capacity of the working muscle. Although this occurred in parallel with reductions in pH, other factors could be responsible for this response.