The influence of activity on some contractile characteristics of mammalian fast and slow muscles

[Dynamic graciloplasty in the treatment of severe fecal incontinence. French multicentric retrospective study]

The aim of this study was to retrospectively assess the safety and efficacy of dynamic graciloplasty performed in 5 French surgical centers involved in the treatment of fecal incontinence.

PATIENTS AND METHODS

Between March 1994 and March 2000, a total of 24 patients were treated with dynamic graciloplasty for fecal incontinence excluding case of anal reconstruction for cancer. Intramuscular leads and neurostimulators were implanted to stimulate the transposed gracilis. Continence and safety were evaluated using patients' records during hospitalisation and during the out-patient visit or further hospitalisation.

RESULTS

No death occurred. A successful functional outcome was reported for 19 patients (79%) during the follow up period. Twenty-two complications occurred including wound. Wound infection in 6 patients and tendon detachment in 4. One patient presented with an infected anal erosion leading to material explantation.

CONCLUSION

Dynamic graciloplasty is an effective procedure for patients with refractory fecal incontinence. However, the procedure has significant morbidity which seems to be correlated with the surgeons' experience. Moreover, this procedure should now be compared to the artificial anal sphincter.

Mechanical properties of the latissimus dorsi muscle after cyclic training

Cardiomyoplasty is a procedure developed to improve heart performance in patients suffering from congestive heart failure. The latissimus dorsi (LD) muscle is surgically wrapped around the failing ventricles and stimulated to contract in synchrony with the heart. The LD muscle is easily fatigued and as a result is unsuitable for cardiomyoplasty. For useful operation as a cardiac-assist device, the fatigue resistance of the LD muscle must be improved while retaining a high power output. The LD muscle of rabbits was subjected to a training regime in which cyclic work was performed. Training transformed the fiber-type composition from approximately equal proportions of fast oxidative glycolytic (FOG) and fast glycolytic (FG) fibers to one composed of almost entirely of FOG with no FG, which increased fatigue resistance while retaining rapid contraction kinetics. Muscle mass and cross-sectional area increased but power output decreased, relative to control muscles. This training regime represents a significant improvement in terms of preserving muscle mass and power compared with other training regimes, while enhancing fatigue resistance, although some fiber damage occurred. The power output of the trained LD muscle was calculated to be sufficient to deliver a significant level of assistance to a failing heart during cardiomyoplasty.

Fast-to-slow transformation and nuclear import/export kinetics of the transcription factor NFATc1 during electrostimulation of rabbit muscle cells in culture

Contractile activity imposed by chronic electrical stimulation of a primary skeletal muscle cell culture grown on microcarriers over several days led to an increase of slow myosin heavy chain I (MHCI) and a decrease of fast MHCII expression at mRNA and protein levels, indicating an ongoing fast-to-slow transformation. Only patterns with periods of continuous stimulation of > or = 5 min in a 45 min cycle were capable of inducing a fibre type transformation, and this was independent of the applied stimulation frequency over the range 1-10 Hz. We have shown before that the calcineurin-NFATc1 signalling pathway is indispensable in mediating MHCI upregulation during fibre type transformation. Therefore, subcellular localization of NFATc1 was studied immunocytochemically. This revealed that only one stimulation train lasting for > or = 5 min was sufficient to induce nuclear import of this factor, which was about complete after 20 min of continuous stimulation. For both induction of NFATc1 import and MHCI mRNA upregulation, the minimum stimulation interval of > or = 5 min was sufficient and stimulation frequency was not crucial between 1 and 10 Hz. Repetition of stimulation cycles, with pauses (40 min) shorter than the time required for complete export of NFATc1, led to an accumulation of NFATc1 in the nuclei with each cycle and thus to an amplification of the transformation signal during extended periods of electrostimulation. The temporal behaviour of NFATc import/export appears to determine the effectiveness of various electrostimulation protocols in inducing fast-to-slow fibre transformation.

Training by low-frequency stimulation of tibialis anterior in spinal cord-injured men

The tibialis anterior muscle of nine paraplegic men was chronically stimulated (2-6 h per day; at 10 Hz, 5 s on, 5 s off) under isometric loading conditions for 5 days per week for 4 weeks. After 4 weeks of training, muscle fatigue resistance in an electrically evoked test had increased by an average of 75% (P <.01, n = 9), but there were no changes in the relative composition of the three myosin heavy chain (MHC) isoforms. Five of the subjects continued training for an additional 5 weeks (2 h per day, 3 days per week). Although there was a tendency for twitch time to peak torque to increase after this additional period, no change occurred in relative MHC isoform content. However, in situ hybridization analysis revealed that even after 2 weeks of stimulation, there was evidence of upregulation of the mRNA for the MHC-I isoform and downregulation of the MHC-IIX isoform, a development that continued in weeks 4 and 9. This study provides evidence, at the level of gene transcription, that a fast-to-slow change in MHC isoform composition may be possible in human muscle when its usage is significantly increased.

Calcineurin regulates slow myosin, but not fast myosin or metabolic enzymes, during fast-to-slow transformation in rabbit skeletal muscle cell culture

The addition of cyclosporin A (500 ng ml(-1)) - an inhibitor of the Ca2+-calmodulin-regulated serine/threonine phosphatase calcineurin - to primary cultures of rabbit skeletal muscle cells had no influence on the expression of fast myosin heavy chain (MHC) isoforms MHCIIa and MHCIId at the level of protein and mRNA, but reduced the expression of slow MHCI mRNA. In addition, no influence of cyclosporin A on the expression of citrate synthase (CS) and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) mRNA was found. The level of enzyme activity of CS was also not affected. When the Ca2+ ionophore A23187 (4 x 10(-7) M) was added to the medium, a partial fast-to-slow transformation occurred. The level of MHCI mRNA increased, and the level of MHCIId mRNA decreased. Cotreatment with cyclosporin A was able to prevent the upregulation of MHCI at the level of mRNA as well as protein, but did not reverse the decrease in MHCIId expression. The expression of MHCIIa was also not influenced by cyclosporin A. Cyclosporin A was not able to prevent the upregulation of CS mRNA under Ca2+ ionophore treatment and failed to reduce the increased enzyme activity of CS. The expression of GAPDH mRNA was reduced under Ca2+ ionophore treatment and was not altered under cotreatment with cyclosporin A. When the myotubes in the primary muscle culture were electrostimulated at 1 Hz for 15 min periods followed by pauses of 30 min, a partial fast-to-slow transformation was induced. Again, cotreatment with cyclosporin A prevented the upregulation of MHCI at the level of mRNA and protein without affecting MHCIId expression. The nuclear translocation of the calcineurin-regulated transcription factor nuclear factor of activated thymocytes (NFATc1) during treatment with Ca2+ ionophore, and the prevention of the translocation in the presence of cyclosporin A, were demonstrated immunocytochemically in the myotubes of the primary culture. The effects of cyclosporin A demonstrate the involvement of calcineurin-dependent signalling pathways in controlling the expression of MHCI, but not of MHCIIa, MHCIId, CS and GAPDH, during Ca2+ ionophore- and electrostimulation-induced fast-to-slow transformations. The data indicate a differential regulation of MHCI, of MHCII and of metabolism. Calcineurin alone is not sufficient to mediate the complete transformation.

Dynamic graciloplasty in children with fecal incontinence: a preliminary report

BACKGROUND

Various therapeutic methods have been developed for anal incontinence. A reconstruction of the sphincter system with functional adaptation can be achieved by stimulation of the transposed gracilis muscle with an implanted stimulator.

METHODS

The authors performed a dynamic graciloplasty in 4 boys, aged between 6 and 10 years. Causes for the incontinence were polytrauma with pelvic rupture, VACTERL syndrome with rectal urethral fistula, anal atresia with primary reconstruction and 6 consecutive operations, and coccygeal teratoma in a premature infant with surgical treatment of the recurrent tumour. All children had grade III incontinence. Postoperatively, the duration of stimulation was increased successively by telemetric programming of the pulse generator up to a continuous mode.

RESULTS

One child is now almost continent, 2 show grade I incontinence, 1 is incontinent with frequent soiling (the programming has not been completed yet).

CONCLUSION

An evaluation of this method for children will not be possible until more operations have been performed, under the conditions of a prospective study, which appears indicated in view of the preliminary but encouraging results presented.

Regulation of acetylcholinesterase in cultured muscle by chemical agents and electrical stimulation

Cultures of 11 day old chick embryo pectoral muscle were used to study the effects of direct electrical stimulation and neurochemicals such as acetylcholine, acetyl-beta-methylcholine, tetrodotoxin, and d-tubocurarine on the acetylcholinesterase levels of muscle. The results suggest that excitation-contraction is an important factor in regulation of muscle acetylcholinesterase. Tetrodotoxin, acetylcholine and its analog acetyl-beta-methylcholine increased acetylcholinesterase levels and reduced spontaneous contractions. D-tubocurarine blocked the increase in acetylcholinesterase and the decrease in spontaneous contractions caused by acetyl-beta-methylcholine. Electrical stimulation decreased acetylcholinesterase and increased muscle contractions in normal and in diisopropylfluorophosphate treated cultures. Tetrodotoxin also affected the morphology of the muscle cells, as if it adversely affected normal growth and differentiation. Electrical stimulation did not increase muscle creatine kinase.

Historical Perspectives: plasticity of mammalian skeletal muscle

More than 40 years ago, the nerve cross-union experiment of Buller, Eccles, and Eccles provided compelling evidence for the essential role of innervation in determining the properties of mammalian skeletal muscle fibers. Moreover, this experiment revealed that terminally differentiated muscle fibers are not inalterable but are highly versatile entities capable of changing their phenotype from fast to slow or slow to fast. With the use of various experimental models, numerous studies have since confirmed and extended the notion of muscle plasticity. Together, these studies demonstrated that motoneuron-specific impulse patterns, neuromuscular activity, and mechanical loading play important roles in both the maintenance and transition of muscle fiber phenotypes. Depending on the type, intensity, and duration of changes in any of these factors, muscle fibers adjust their phenotype to meet the altered functional demands. Fiber-type transitions resulting from multiple qualitative and quantitative changes in gene expression occur sequentially in a regular order within a spectrum of pure and hybrid fiber types.

Alterations in contractile properties of human skeletal muscle induced by joint immobilization

The effects of joint immobilization on the contractile properties of human skeletal muscle were examined using the first dorsal interosseous (FDI) muscle. The middle finger, index finger and thumb were immobilized for a period of 6 weeks, and the contractile properties of FDI were tested before immobilization, after 3 and 6 weeks of immobilization, and after a 6 week recovery period. Twitch and tetanic contractions of FDI were evoked by per-cutaneous electrical stimulation. The peak twitch tension (Pt), contraction time (CT) and half-relaxation time (1/2RT) were measured from twitch contractions, while the stimulus frequency-force relationship was obtained from the tetanic contractions (2 s) evoked using various frequencies of stimulation (10-100 Hz). The fatigability of FDI was tested using Burke's fatigue protocol.Pt was significantly increased after 6 weeks of immobilization (P < 0.05) but little alteration was observed in CT or 1/2RT. No change was noted in the FDI fatigue index throughout the immobilization period. The stimulus frequency-force relationship was shifted to the left by immobilization, indicating that a larger percentage of maximal force was evoked by the lower rates of stimulation. Indeed, the tetanic force evoked by a stimulus frequency of 10 Hz was enhanced after immobilization (P < 0.05). On the other hand, the force evoked by frequencies above 50 Hz, including maximal tetanic tension, was decreased (P < 0.05). As a result, the twitch/tetanus ratio was increased (P < 0.01) after immobilization. The changes induced by immobilization in the FDI twitch/tetanus ratio and the estimated maximal firing rate of FDI motoneurones showed a significant correlation (r = 0.80, P < 0.05). It is suggested that the changes in the contractile properties of the FDI muscle seen after joint immobilization are causally linked to the changes in firing rate modulation of FDI motoneurones.

LD Pace II, an easily programmable device for cardiomyoplasty

The efficacy of programmable devices depends heavily on being able to select parameter values matched to the individual patient's needs. In many cases, physicians fail to make use of all of the features of a device because of programming complexities. This paper presents a new cardiomyostimulator, "LD Pace II", emphasising in particular its novel features and the steps taken to make the behaviour of the device easy for the physician to program.

Muscle contraction and relaxation described by tactile stiffness

We developed a tactile sensor system that measures the stiffness of objects (tactile stiffness) and used it to describe the time course of muscle contraction and relaxation. We examined fatigue resistance of the latissimus dorsi muscle (LDM), which is preconditioned for cardiomyoplasty. Time to peak, ripple of LDM, and time constant were calculated from the time course of LDM contraction and relaxation as described by tactile stiffness. We compared conditioned and unconditioned LDMs using these 3 parameters. The time course can be described by tactile stiffness. Tactile stiffness fell exponentially during LDM relaxation. In mean values, time to peak increased 230%, ripple decreased 20%, and time constants increased 424%. Significant differences were shown in 3 parameters between conditioned and unconditioned LDMs (p < 0.05). Our tactile sensor system can describe the time course of LDM contraction and relaxation. Examining the difference in time courses, we might detect the level of LDM preconditioning for cardiomyoplasty.

Myosin isoforms, muscle fiber types, and transitions

Skeletal muscle is an extremely heterogeneous tissue composed of a variety of fast and slow fiber types and subtypes. Moreover, muscle fibers are versatile entities capable of adjusting their phenotypic properties in response to altered functional demands. Major differences between muscle fiber types relate to their myosin complement, i.e., isoforms of myosin light and heavy chains. Myosin heavy chain (MHC) isoforms appear to represent the most appropriate markers for fiber type delineation. On this basis, pure fiber types are characterized by the expression of a single MHC isoform, whereas hybrid fiber type express two or more MHC isoforms. Hybrid fibers bridge the gap between the pure fiber types. The fiber population of skeletal muscles, thus, encompasses a continuum of pure and hybrid fiber types. Under certain conditions, changes can be induced in MHC isoform expression heading in the direction of either fast-to-slow or slow-to-fast. Increased neuromuscular activity, mechanical loading, and hypothyroidism are conditions that induce fast-to-slow transitions, whereas reduced neuromuscular activity, mechanical unloading, and hyperthyroidism cause transitions in the slow-to-fast direction.

Electrical stimulation as a treatment for stress incontinence

Much research has been conducted into the use of electrical stimulation to restore function in weak/atrophied muscle and it is used widely in the field of muscle rehabilitation. As stress incontinence is a condition which is the result of pelvic floor muscle weakness, it is thought that the symptoms of this condition may be alleviated once the strength and endurance characteristics of this muscle group have been improved. Many studies have been conducted to evaluate the efficacy of various types of electrical stimulation, although definitive conclusions have yet to be drawn. Current forms of electrical stimulation for stress incontinence involve the use of uniform frequencies. In animal studies this type of stimulation has been shown to have drawbacks that are unacceptable when trying to rehabilitate muscle. Consequently, there is a need to develop more physiological patterns of stimulation that will enhance both strength and endurance characteristics without causing premature fatigue.

Age related skeletal muscle response to electrical stimulation

We hypothesized that the conditioned muscles of elderly and growing organisms have different responses to electrical stimulation from that of young adult organisms. Five day old lambs, 1 year old sheep, and 8 year old elderly sheep were used for this investigation. The latissimus dorsi muscle (LDM) was partially mobilized and left in situ. Two electrodes were implanted and electrical stimulation (ES) was begun for 8 weeks; it was then stopped for 2 weeks. Biopsies were taken before ES, after 8 weeks of ES, and after the 2 week delay period. The LDM of old sheep has less fatigue resistance than the LDM of younger animals. Conditioned LDM of the lamb continued to be fatigue resistant after a 2 week delay compared with adult sheep. In all animals, lactate dehydrogenase (LDH) fraction five decreased and LDH-1 + 2 fractions increased after ES. After a 2 week delay, the data returned to baseline values only in adult animals. The percentage area occupied by mitochondria in old sheep was less after ES than in younger animals. In all animals, the mitochondrial area increased after ES and reverted to baseline values after the delay. The number of nuclei and fibers considerably increased after ES. Only in the lamb did the number of nuclei and fibers continue to be elevated after the delay. There are more changes in young skeletal muscle than in adult (1 year or 8 year old) muscle during ES, and they "remember" these properties. Elderly skeletal muscle does not convert to a fatigue resistant state as completely as adult skeletal muscle during a conventional 8 week ES protocol. It is necessary to change and prolong the ES protocol for elderly patients.

Calcium ion in skeletal muscle: its crucial role for muscle function, plasticity, and disease

Mammalian skeletal muscle shows an enormous variability in its functional features such as rate of force production, resistance to fatigue, and energy metabolism, with a wide spectrum from slow aerobic to fast anaerobic physiology. In addition, skeletal muscle exhibits high plasticity that is based on the potential of the muscle fibers to undergo changes of their cytoarchitecture and composition of specific muscle protein isoforms. Adaptive changes of the muscle fibers occur in response to a variety of stimuli such as, e.g., growth and differentition factors, hormones, nerve signals, or exercise. Additionally, the muscle fibers are arranged in compartments that often function as largely independent muscular subunits. All muscle fibers use Ca(2+) as their main regulatory and signaling molecule. Therefore, contractile properties of muscle fibers are dependent on the variable expression of proteins involved in Ca(2+) signaling and handling. Molecular diversity of the main proteins in the Ca(2+) signaling apparatus (the calcium cycle) largely determines the contraction and relaxation properties of a muscle fiber. The Ca(2+) signaling apparatus includes 1) the ryanodine receptor that is the sarcoplasmic reticulum Ca(2+) release channel, 2) the troponin protein complex that mediates the Ca(2+) effect to the myofibrillar structures leading to contraction, 3) the Ca(2+) pump responsible for Ca(2+) reuptake into the sarcoplasmic reticulum, and 4) calsequestrin, the Ca(2+) storage protein in the sarcoplasmic reticulum. In addition, a multitude of Ca(2+)-binding proteins is present in muscle tissue including parvalbumin, calmodulin, S100 proteins, annexins, sorcin, myosin light chains, beta-actinin, calcineurin, and calpain. These Ca(2+)-binding proteins may either exert an important role in Ca(2+)-triggered muscle contraction under certain conditions or modulate other muscle activities such as protein metabolism, differentiation, and growth. Recently, several Ca(2+) signaling and handling molecules have been shown to be altered in muscle diseases. Functional alterations of Ca(2+) handling seem to be responsible for the pathophysiological conditions seen in dystrophinopathies, Brody's disease, and malignant hyperthermia. These also underline the importance of the affected molecules for correct muscle performance.

Skeletal muscle as a myocardial substitute

Skeletal muscle has long been used in the field of cardiac surgery. Its use has progressed from providing myocardial reinforcement to assisting the heart by actively pumping blood. Early experiments revealed that skeletal muscle assistance could augment pressures and blood flow; however, the results were short-lived due to muscle fatigue. It was later shown that skeletal muscle can be conditioned electrically to be fatigue resistant and therefore may be useful for performing cardiac-type work. Once the details were formed of how to stimulate and manipulate the muscle to assist the heart, several configurations were devised. Cardiomyoplasty and aortomyoplasty refer to wrapping skeletal muscle around the heart or aorta, respectively. These techniques have been applied in humans; however, the effectiveness is controversial. Although most patients improve clinically, the hemodynamic parameters have not shown consistent improvements, and survival data are unknown. Skeletal muscle ventricles offer a promising alternative to both cardiomyoplasty and aortomyoplasty. These are completely separate pumping chambers constructed from skeletal muscle and connected to the circulation in a variety of configurations. Although these have not been tried in humans, the animal data appear quite convincing. The skeletal muscle ventricles have shown the greatest improvements on hemodynamic parameters with great stability over time.

Alterations in skeletal muscle morphology in glucose-tolerant elderly hypertensive men: relationship to development of hypertension and heart rate

OBJECTIVE

To compare the muscle morphology in hypertensive subjects with that in controls and to test the hypothesis of a relation between heart rate, development of hypertension and muscle morphology that is independent of glucose intolerance.

PATIENTS AND METHODS

We studied 43 glucose-tolerant, untreated hypertensive subjects and 113 healthy controls in a longitudinal cohort of 70-year-old men. Metabolic status (oral glucose tolerance test and euglycemic, hyperinsulinaemic clamp test), muscle fibre distribution (myosin ATPase staining) and capillary supply (amylase-PAS method) were evaluated. Blood pressure and heart rate data were available from both ages 50 and 70 years.

RESULTS

Hypertensive subjects had a significantly smaller mean number of capillaries per fibre than controls (1.53 versus 1.64; P = 0.04). In hypertensive subjects, the proportions of type I and type II fibres were correlated to mean arterial pressure (r = -0.56 and r= 0.52, respectively, P < 0.05 for both). The increase in mean arterial pressure over 20 years was closely correlated to capillary density in mm2 (r= -0.62; P< 0.0001). Capillary supply was inversely related to resting heart rate both at ages 50 and 70 years.

CONCLUSIONS

Skeletal muscle of glucose tolerant hypertensive subjects showed a lower capillary supply than that of controls. This capillary rarefaction was correlated to increase in mean arterial pressure over two decades and to supine heart rate. This is compatible with the suggestion that higher sympathetic drive might generate structural alterations in muscle capillarization.

Chronic contractile activity upregulates the proteasome system in rabbit skeletal muscle

Remodeling of skeletal muscle in response to altered patterns of contractile activity is achieved, in part, by the regulated degradation of cellular proteins. The ubiquitin-proteasome system is a dominant pathway for protein degradation in eukaryotic cells. To test the role of this pathway in contraction-induced remodeling of skeletal muscle, we used a well-established model of continuous motor nerve stimulation to activate tibialis anterior (TA) muscles of New Zealand White rabbits for periods up to 28 days. Western blot analysis revealed marked and coordinated increases in protein levels of the 20S proteasome and two of its regulatory proteins, PA700 and PA28. mRNA of a representative proteasome subunit also increased coordinately in contracting muscles. Chronic contractile activity of TA also increased total proteasome activity in extracts, as measured by the hydrolysis of a proteasome-specific peptide substrate, and the total capacity of the ubiquitin-proteasome pathway, as measured by the ATP-dependent hydrolysis of an exogenous protein substrate. These results support the potential role of the ubiquitin-proteasome pathway of protein degradation in the contraction-induced remodeling of skeletal muscle.

Sequential segmental neuromuscular stimulation: an effective approach to enhance fatigue resistance

Electrical stimulation of skeletal muscle flaps is used clinically in applications that require contraction of muscle and force generation at the recipient site, for example, to assist a failing myocardium (cardiomyoplasty) or to reestablish urinary or fecal continence as a neo-sphincter (dynamic graciloplasty). A major problem in these applications (muscle fatigue) results from the nonphysiologic manner in which most of the fibers within the muscle are recruited in a single burst-like contraction. To circumvent this problem, current protocols call for the muscle to be put through a rigorous training regimen to transform it from a fatigue-prone to a fatigue-resistant state. This process takes several weeks during which, aside from becoming fatigue-resistant, the muscle loses power and contraction speed. This study tested the feasibility of electrically stimulating a muscle flap in a more physiologic way; namely, by stimulating different anatomical parts of the muscle sequentially rather than the entire muscle all at once. Sequential segmental neuromuscular stimulation (SSNS) allows parts of the muscle to rest while other parts are contracting. In a paired designed study in dogs (n = 7), the effects of SSNS on muscle fatigability and muscle blood perfusion in gracilis muscles were compared with conventional stimulation: SSNS on one side and whole muscle stimulation on the other. In SSNS, electrodes were implanted in the muscles in such a way that four separate segments of each muscle could be stimulated separately. Then, each segment was stimulated so that part of the muscle was always contracted while part was always resting. This type of stimulation permitted sequential yet continuous force generation. Muscles in both groups maintained an equal amount of continuous force. In SSNS muscles, separate segments were stimulated so that the duty cycle for any one segment was 25, 50, 75, or 100 percent, thus varying the amount of work and rest that any segment experienced at any one time. With duty cycles of 25, 50, and 75 percent, SSNS produced significantly (p < 0.01) enhanced resistance to fatigue. In addition, muscle perfusion was significantly (p < 0.01) increased in these sequentially stimulated muscles compared with the controls receiving whole muscle stimulation. It was concluded that SSNS reduces muscle fatigue and enhances muscle blood flow during stimulation. These findings suggest that using SSNS in clinical myoplasty procedures could obviate the need for prolonged training protocols and minimize problems associated with muscle training.

Electrical stimulation for faecal incontinence in adults

BACKGROUND

Faecal incontinence is a particularly embarrassing and distressing condition with significant medical, social and economic implications. Electrical stimulation has been used with apparent success in the treatment of faecal incontinence. However, standards of treatment are still lacking and the magnitude of alleged benefits has yet to be established.

OBJECTIVES

To determine the effects of electrical stimulation for the treatment of faecal incontinence in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register, the Cochrane Controlled Trials Register, Medline, Embase and reference lists of potentially eligible articles up to November 1999. Date of the most recent searches: November 1999.

SELECTION CRITERIA

All randomised or quasi-randomised trials evaluating electrical stimulation in adults with faecal incontinence.

DATA COLLECTION AND ANALYSIS

Three reviewers assessed the methodological quality of potentially eligible trials and two reviewers independently extracted data from the included trial. A wide range of outcome measures were considered.

MAIN RESULTS

Only one eligible trial with 40 participants was identified. It was a randomised trial, but it suffered from methodological drawbacks and did not follow up patients beyond the end of the trial period. Findings from this trial suggest that electrical stimulation with anal biofeedback and exercises provides more short-term benefits than vaginal biofeedback and exercises for women with obstetric-related faecal incontinence. No further conclusions could be drawn from the data available.

REVIEWER'S CONCLUSIONS

At present, there are insufficient data to allow reliable conclusions to be drawn on the effects of electrical stimulation in the management of faecal incontinence. There is a suggestion that electrical stimulation may have a therapeutic effect, but this is not certain. Larger, more generalisable trials are needed.

Preliminary results of a multicentre trial of the electrically stimulated gracilis neoanal sphincter

BACKGROUND

The electrically stimulated gracilis neoanal sphincter was initially developed to treat refractory incontinence. Good early results were reported from the two centres that pioneered the technique. The aim of this study was to assess the operation in a prospective multicentre setting.

METHODS

The procedure was performed on 64 patients from seven centres worldwide and was performed in stages. All patients were evaluated clinically and manometrically before and after operation.

RESULTS

There was a high incidence of infective and hardware-related complications. At a median of 10 months following closure of the defunctioning stoma 56 per cent had experienced a good functional result. The major functional problems comprised evacuatory difficulties experienced by 25 per cent.

CONCLUSION

The technique is effective in treating otherwise refractory incontinence. It is, however, a complex procedure and the morbidity rate may be high, particularly during the learning curve, factors that necessitate careful patient selection. Presented to the Association of Surgeons of Great Britain and Ireland in Bournemouth, UK, April 1997 and the European Council of Coloproctology in Edinburgh, UK, June 1997; and published in abstract form as Br J Surg 1997; 88(Suppl): 39 and Int J Colorectal Dis 1997; 12: 144

Acute descending aortomyoplasty induces coronary blood flow augmentation

BACKGROUND

Aortomyoplasty is a procedure aimed to improve cardiac output in patients suffering from heart failure. Stimulation of the latissimus dorsi muscle around the aorta produces hemodynamic effects similar to those of the intraaortic balloon pump. These may be maintained without the accompanying complications or the need for anticoagulation. The objective of this study was to test the acute effects of aortomyoplasty on coronary artery blood flow.

METHODS

Eight mongrel dogs (18 to 30 kg) underwent acute descending aortomyoplasty. Several stimulation protocols were applied after wrapping of the latissimus dorsi muscle around the aorta in different surgical configurations. The left anterior descending coronary blood flow was measured using a transonic Doppler flow probe. Left ventricular and aortic pressures, proximal and distal to the aortomyoplasty site, were monitored continuously.

RESULTS

Significant aortic diastolic pressure augmentation was expressed both as an increase in peak values, from 110 +/- 24 mm Hg to 120 +/- 24 mm Hg (p < 0.001) and as an increase in the diastolic integral, from 64 +/- 23 mm Hg x s to 84 +/- 37 mm Hg x s (p < 0.001). Concomitantly, peak left anterior descending coronary blood flow increased from 26 +/- 10 mL/min to 32 +/- 12 mL/min (p < 0.001). This was associated with an increase in the diastolic flow integral from 11 +/- 4 mL to 14 +/- 6 mL (p < 0.001).

CONCLUSIONS

Descending aortomyoplasty induces significant augmentation of coronary blood flow. Optimal timing of muscle stimulation is important in achieving the best assist. This procedure may prove beneficial for end-stage ischemic patients.

Chronic aortic counterpulsation with latissimus dorsi in heart failure: clinical follow-up

BACKGROUND

Dynamic aortomyoplasty is an alternative technique to heart transplantation. The goal of our study was to evaluate the benefits of aortic counterpulsation obtained by dynamic thoracic aortomyoplasty in patients with heart failure refractory to pharmacologic treatment and contraindications to heart transplant or cardiomyoplasty.

METHODS

In this study we compared preoperative and postoperative data from five out of six carefully selected patients who were treated with dynamic thoracic aortomyoplasty. This surgical technique wraps the right latissimus dorsi muscle flap around the ascending aorta. This muscle flap was electrically stimulated during diastole, following a muscle-conditioning protocol, to obtain diastolic augmentation. At the 6-month follow-up period we evaluated, invasively and noninvasively, the hemodynamic and clinical effects of aortomyoplasty.

RESULTS

We observed a significant decrease in the number of hospitalizations (P = 0.01), NYHA functional class (P = 0.01), cardiothoracic ratio (P = 0.02), right ventricular diameter (P = 0.03), left atrial diameter (P = 0.04), and pulmonary artery systolic pressure (P = 0.04); and a significant increase in the 6-minute walking test (P = 0.01), cardiac index (P = 0.04), noninvasive evaluation of diastolic augmentation (P = 0.01), left ventricular shortening fraction (P = 0.01), and radioisotopic left ventricular ejection fraction (P = 0.02). We also found a nonsignificant decrease in the left ventricular diameter (P = 0.08) and wedge pressure (P = 0.19); and a nonsignificant increase in peak oxygen consumption (P = 0.13).

CONCLUSIONS

Dynamic thoracic aortomyoplasty in heart failure resulted in an important improvement of hemodynamic parameters, heart functional data, and clinical functional class, when comparing preoperative data with the 6-month follow-up data.

Effects of fetal spinal cord tissue transplants and cycling exercise on the soleus muscle in spinalized rats

Studies were carried out to determine if an intraspinal transplant (Trpl) of fetal spinal cord tissue or hind limb exercise (Ex) affected the changes in myosin heavy chain (MyHC) composition or myofiber size that occur following a complete transection (Tx) of the lower thoracic spinal cord of the adult rat. In one group of animals, transplants were made acutely, whereas in a second group, daily cycling exercise was initiated 5 days after injury, with animals in both groups being sacrificed 90 days after injury. The soleus muscle is normally composed of myofibers expressing either type I (90%) or type IIa (10%) MyHC. Following a spinal transection, expression of type I MyHC isoform decreased (18% of myofibers), type IIa MyHC expression increased (65% of myofibers), and the majority of myofibers (80%) expressed type IIx MyHC. Most myofibers coexpressed multiple MyHC isoforms. Compared with Tx only, with Ex or with Trpl, there was a decrease in the number of myofibers expressing type I or IIa isoforms but little change in expression of IIx MyHC. Myofibers expressing the IIb isoform appeared in several transplant recipients but not after exercise. Transection resulted in atrophy of type I myofibers to approximately 50% of normal size, whereas myofibers were significantly larger after exercise (74% of control) and in Trpl recipients (77% of control). Type IIa myofibers also were significantly larger in Trpl recipients compared with the Tx only group. Overall, the mean myofiber size was significantly greater after exercise and in Trpl recipients compared with myofibers in Tx only animals. Thus, although neither strategy shifted the MyHC profile towards the control, both interventions influenced the extent of atrophy observed after spinalization. These data suggest that palliative strategies can be developed to modulate some of the changes in hind limb muscles that occur following a spinal cord injury.

What does chronic electrical stimulation teach us about muscle plasticity?

The model of chronic low-frequency stimulation for the study of muscle plasticity was developed over 30 years ago. This protocol leads to a transformation of fast, fatigable muscles toward slower, fatigue-resistant ones. It involves qualitative and quantitative changes of all elements of the muscle fiber studied so far. The multitude of stimulation-induced changes makes it possible to establish the full adaptive potential of skeletal muscle. Both functional and structural alterations are caused by orchestrated exchanges of fast protein isoforms with their slow counterparts, as well as by altered levels of expression. This remodeling of the muscle fiber encompasses the major, myofibrillar proteins, membrane-bound and soluble proteins involved in Ca2+ dynamics, and mitochondrial and cytosolic enzymes of energy metabolism. Most transitions occur in a coordinated, time-dependent manner and result from altered gene expression, including transcriptional and posttranscriptional processes. This review summarizes the advantages of chronic low-frequency stimulation for studying activity-induced changes in phenotype, and its potential for investigating regulatory mechanisms of gene expression. The potential clinical relevance or utility of the technique is also considered.

Permanent cardiac assistance from skeletal muscle: a prospect for the new millennium

This paper looks at the prospects for new surgical solutions to the problem of end-stage heart failure based on cardiac assistance from skeletal muscle. The current status of the main biological approaches, cardiomyoplasty, aortomyoplasty, and the skeletal muscle ventricle, are discussed, followed by a consideration of some of the important basic issues that need to be addressed if these techniques are to achieve their full potential. Although there is a review element to the paper, the main emphasis is on the work of our own research group and collaborating workers.

A new method of double cardiomyoplasty: "contractile muscular sling"

BACKGROUND

In several experimental studies, double cardiomyoplasty using both latissimus dorsi muscles did not provide sufficient assist to the failing heart and did not clearly show improvement compared with single cardiomyoplasty. This study demonstrated the superior efficacy of our method of double cardiomyoplasty compared with single cardiomyoplasty.

METHODS

In 16 dogs, the two latissimus dorsi muscles were crossed in front of the heart and directly sutured to each other behind the heart. Control hemodynamic measurements were obtained, and acute heart failure was induced by intravenous administration of propranolol. After the hemodynamic changes with bilateral latissimus dorsi muscle assistance were measured, single cardiomyoplasty was done in the same dog, and the hemodynamic variables were measured.

RESULTS

With our double cardiomyoplasty, aortic systolic pressure increased by 25% (p < 0.001); pulmonary artery systolic pressure, by 40% (p < 0.001); end-systolic elastance, by 155% (p < 0.001); and cardiac output, by 55% (p < 0.001). There were significant increases in aortic pressure, pulmonary artery pressure, end-systolic elastance, stroke volume, and cardiac output with our double cardiomyoplasty compared with single cardiomyoplasty.

CONCLUSIONS

In this study, our double cardiomyoplasty provided significant hemodynamic improvement compared with single cardiomyoplasty.

Expression of insulin growth factor-1 splice variants and structural genes in rabbit skeletal muscle induced by stretch and stimulation

1. Skeletal muscle is a major source of circulating insulin growth factor-1 (IGF-1), particularly during exercise. It expresses two main isoforms. One of the muscle IGF-1 isoforms (muscle L.IGF-1) is similar to the main liver IGF-1 and presumably has an endocrine action. The other muscle isoform as a result of alternative splicing has a different 3' exon sequence and is apparently designed for an autocrine/paracrine action (mechano-growth factor, MGF). Using RNase protection assays with a probe that distinguishes these differently spliced forms of IGF-1, their expression and also the expression of two structural genes was measured in rabbit extensor digitorum longus muscles subjected to different mechanical signals. 2. Within 4 days, stretch using plaster cast immobilization with the limb in the plantar flexed position resulted in marked upregulation of both forms of IGF-1 mRNA. Electrical stimulation at 10 Hz combined with stretch (overload) resulted in an even greater increase of both types of IGF-1 transcript, whereas electrical stimulation alone, i.e. without stretch, resulted in no significant increase over muscle from sham-operated controls. Previously, it was shown that stretch combined with electrical stimulation of the dorsiflexor muscles in the adult rabbit results in a marked increase in muscle mass involving increases in both length and girth, within a few days. The expression of both systemic and autocrine IGF-1 growth factors provides a link between the mechanical signal and the marked increase in the structural gene expression involved in tissue remodelling and repair. 3. The expression of the beta actin gene was seen to be markedly upregulated in the stretched and stretched/stimulated muscles. It was concluded that the increased expression of this cytoskeletal protein gene is an indication that the production of IGF-1 may initially be a response to local damage. 4. Switches in muscle fibre phenotype were studied using a specific gene probe for the 2X myosin heavy chain gene. Type 2X expression was found to decrease markedly with stimulation alone and when electrical stimulation was combined with stretch. Unlike the induction of IGF-1 and beta actin, the decreased expression of the 2X myosin mRNA was less marked in the 'stretch only' muscles. This indicates that the interconversion of fibre type 2X to 2A may in some situations be commensurate with, but not under the control of IGF-1.

Anal sphincter reconstruction by dynamic graciloplasty after abdominoperineal resection for cancer

PURPOSE

Chronic low-frequency electrical stimulation can safely transform fatiguing muscle into fatigue-resistant muscle. This fundamental discovery was used to reconstruct the anal sphincter. Dynamic graciloplasty was found to be effective in the treatment of fecal incontinence. Our study was undertaken to investigate the oncologic, functional, and quality of life results of dynamic graciloplasty anal reconstruction after an abdominoperineal resection for carcinoma.

METHODS

Between April 1993 and April 1996, nine patients (4 males) with a median age of 51.2 (range, 29-69) years underwent an abdominoperineal resection for carcinoma (4 had a rectal adenocarcinoma and 5 had an epidermoidal anal tumor) and an anal sphincter reconstruction with electrically stimulated graciloplasty. Oncologic and functional results were evaluated after a mean follow-up of 32 (range, 14-50) months. A quality of life questionnaire was filled out by seven patients.

RESULTS

Sphincter reconstruction required the same hospitalization period as abdominoperineal resection. Two patients died from evolutive disease. Three patients were operated on twice, one for immediate colonic necrosis, two for colonic perforation after enema. One of them refused the graciloplasty and had an abdominoperineal resection. Six patients were dysfunctioned. The mean resting pressure was 24 +/- 10 mmHg, and the mean pressure during stimulation was 95 +/- 25 mmHg. Five patients were continent for solids and liquid; four wore less than three pads per day, and one wore more than three. Four patients used enemas twice a week; one patient had spontaneous evacuation. The quality of life questionnaire showed that the mean scores for social interaction, symptoms, and psychological and physical states were 2.1, 2.2, 2.4, and 2.7, respectively. The mean value was 1.5.

CONCLUSIONS

Total anorectal reconstruction with dynamic graciloplasty is an oncologically safe procedure. Functional results improve with time, but careful patient selection guarantees a successful functional outcome. Technical progress is necessary to improve the quality of life.

Effect of chronic electrostimulation of rabbit skeletal muscle on calmodulin level and protein kinase activity

(a) Chronic electrostimulation of fast-twitch skeletal muscles makes them resemble slow-twitch muscles. The involvement of second-messenger cascades in this muscle reprogramming is not well understood. The goal of this study was to examine protein kinase activities and calmodulin levels as a function of the duration of electrostimulation. (b) Fast-twitch rabbit muscle was subjected to continuous low-frequency electrostimulation for 2 weeks. The extensor digitorum longus was taken and examined for calmodulin concentration and cAMP-dependent (PKA). Ca(2+)-phospholipid-dependent (PKC) and Ca(2+)-calmodulin-dependent (CaM kinase or PKB) protein kinase activities. (c) Electrostimulation for 14 days led to a significant increase in total calmodulin level and PKB activity, both rising in the cytosolic fraction. Protein kinase C translocated to the membrane fraction, although total activity did not change. (d) These changes could be related with electrostimulation-induced changes in excitation-contraction coupling.

Electrical stimulation for stress incontinence

Electrical stimulation has been reported to be effective for stress incontinence, cure and improvement rates being reported to range from 30% to 50%, and from 6% to 90%, respectively. However, clinical application of this treatment is not common because there is little physiological and technical information. Electrodes for electrical stimulation are divided into two types: external (non-implantable) and internal (implantable), and there are two methods of stimulation: chronic (long-term, continuous) and short-term. Frequencies of 20-50 Hz, with a pulse duration of 1-5 ms, have been reported to be effective for urethral closure. The effectiveness of the treatment should be verified with placebo-controlled double-blinded trials, and four such studies using an active and a sham device have been reported. Two of these verified the superiority of the active device over the sham device, but the others did not demonstrate any significant difference between the two with regard to efficacy. Electrical stimulation has been reported to result in a long-term continuation of therapeutic effect. The effect has been explained as a re-education or a reactivation of lost functions of the pelvic floor muscles. As to adverse effects, there may be some complications in relation to anesthesia or surgical procedures, such as infection, pain and bleeding with implantable electrodes. The incidence of adverse effects in short-term electrical stimulation is less than 14%. In conclusion, short-term electrical stimulation using non-implantable anal or vaginal electrodes is the most recommendable because of safety and ease of use.

Effect of spinal cord injury on the heart and cardiovascular fitness

The use of various FES protocols to encourage increases in physical activity and to augment physical fitness and reduce heart disease risk is a relatively new, but growing field of investigation. The evidence so far supports its use in improving potential health benefits for patients with SCI. Such benefits may include more efficient and safer cardiac function; greater stimulus for metabolic, cardiovascular, and pulmonary training adaptations; and greater stimulus for skeletal muscle training adaptations. In addition, the availability of relatively inexpensive commercial FES units to elicit muscular contractions, the ease of use of gel-less, reusable electrodes, and the increasing popularity of home and commercial upper body exercise equipment mean that such benefits are likely to be more accessible to the SCI population through increased convenience and decreased cost. The US Department of Health and Human Services has identified those with SCI as a "special population" whose health problems are accentuated, and so need to be specifically addressed. FES presents "a clear opportunity.... For health promotion and disease prevention efforts to improve the health prospects and functional independence of people with disabilities." As a corollary to this, the Centers for Disease Control and Prevention have recommended the development of techniques to prevent or ameliorate secondary disabilities in persons with a SCI. Patients with SCI have an increased susceptibility to cardiac morbidity and mortality in the acute and early stages of their injury. Most of these patients make an excellent adaptation except when confronted with infection or hypoxia. SCI by itself does not promote atherosclerosis; however, in association with multiple secondary conditions related to SCI, along with advancing age, patients with SCI are predisposed to relatively greater risk of heart disease. The epidemiologic significance of this is reflected in demographic studies that indicate an increasing number of SCI patients becoming aged. Currently 71,000 (40%) of the total 179,000 patients with SCI living in the United States are older than 40 years, and 45,000 have injuries sustained more than 20 years earlier. In addition, new injuries in the older population are increasing (currently 11% of all injuries), and some of these new patients with SCI already have pre-existing cardiac disease. Studies have demonstrated that improved lifestyle, physical activity, lipid management, and dietary restrictions can affect major risk factors for coronary artery disease. Therefore an aggressive cardiac prevention program is appropriate for patients with SCI as part of their rehabilitation. At a given submaximal workload, arm exercise is performed at a greater physiologic cost than is leg exercise. At maximal effort, however, physiologic responses are generally greater in leg exercise than arm exercise. Arm exercise is less efficient and less effective than lower body exercise in developing and maintaining both central and peripheral aspects of cardiovascular fitness. The situation is further compounded in SCI because of poor venous return as a result of lower-limb blood pooling, as a result of lack of sympathetic tone, and a diminished or absent venous "muscle pump" in the legs. This latter mechanism perhaps contributes the greatest diminution in the potential for aerobic performance in the SCI population. Obtaining a cardiopulmonary training effect in individuals with SCI is quite possible. Current studies indicate decreases in submaximal HR, respiratory quotient, minute ventilation, and oxygen uptake, with increases in maximal power output, oxygen uptake, minute ventilation, and lactic acid. Individuals with SCI have been shown to benefit from lower limb functional electrical stimulation (FES)-induced exercise. Studies have consistently reported increases in lower limb strength and cycle endurance performance with these protocols, as well as improvements in metabolic and

Fast to slow transformation of denervated and electrically stimulated rat muscle

1. Denervated fast extensor digitorum longus (EDL) muscles of adult rats were stimulated electrically for up to 4 months with a slow pattern resembling the activity in soleus (Sol) motor units and examined with antibodies against myosin heavy chains (MHCs). 2. The normal EDL contained, on average, 45% type IIB, 29% type IIX, 23% type IIA and 3% type I fibres. All type IIB and almost all type IIX fibres disappeared during the first 3 weeks of stimulation. They were replaced by type IIA and type I fibres, whose percentages increased to about 75 and 15, respectively. Type IIA fibres remained at 75% for nearly 2 months and were then gradually replaced by type I fibres during the next 2 months. The transformation occurred sequentially in the order IIB/IIX-->IIA-->I, the first step (IIB/IIX-->IIA) occurring after a short delay (2 weeks) and the last step (IIA-->I in originally IIB or IIX fibres) after a long delay (> 2 months). During the transformation coexpression of MHCs occurred. 3. It appears that the transformation to type I fibres occurred in pre-existing type II fibres since no signs of fibre damage or regeneration were observed. 4. Normal EDL was also stimulated through an intact nerve with the same pattern for up to 37 days. The effects on fibre type distributions were identical to those observed in the denervated EDL. The result indicated that the Sol-like pattern of evoked muscle activity, rather than nerve-derived trophic influences or denervation per se, was primarily responsible for the fast to slow transformation.

The final common pathway in postural control--developmental perspective

A brief review is given concerning postural specialisations among mammalian muscle fibres and motor units. Most skeletal muscles contain a mixture of fibres with different characteristics, and their slow-twitch (S) units are well-known to possess properties suitable for postural tasks: they are highly fatigue-resistant, well equipped for oxidative metabolism, and their slowness makes them energetically cheap in (semi-)isometric contractions. These features are adequately employed in motor behaviour owing to characteristics of the associated motoneurones. In adult mammals, the way in which a muscle is used can influence its proportion of S units. This adjustment occurs within a restricted 'adaptive range' which differs between muscles and animal species, presumably being preset at an early age. In the course of early foetal development, part of the slow vs. fast differentiation of muscle fibre properties can take place independently of innervation. Once innervation has taken place, however, motoneurones influence the differentiation in various ways. On the whole, a well coordinated timing seems to exist between the early differentiation of central motor mechanisms and of the peripheral machinery, largely causing the neuromuscular system to be/become ready for use when the brain needs it.

Determination of muscle contractile properties: the importance of the nerve

Contractile phenotype of muscle fibres is strongly influenced by hormones, stretch and influences from the motor neurones, although cell lineage probably also plays a role. Motor neurones can affect muscle fibres by releasing neurotrophic substances and by evoking electrical activity in the muscle. For regulating contractile properties such as speed, strength and endurance it has been demonstrated that electrical activity is crucial, while the role of putative neurotrophic substances remains unclear. The signal to change is coded in the pattern of electrical activity. Thus, high amounts of activity lead to slow shortening velocity and myosin heavy chains, while low amounts of activity lead to a fast phenotype. For regulation of twitch duration frequency also plays a role, and for preventing atrophy in denervated muscles high frequency seems to be beneficial, particularly in fast muscles. Little is known about the excitation-adaptation pathway linking action potentials to expression of genes that are relevant for contractile properties. Muscle specific transcription factors of the helix-loop-helix family such as myoD and myogenin could be important for regulating genes related to metabolic profile and fibre size/strength, while their role in determining myosin heavy chain expression and classical fibre type is more uncertain.

Lack of type 1 and type 2A myosin heavy chain isoforms in rat slow muscle regenerating during chronic nerve block

The degeneration-regeneration process was induced by bupivacaine injection in innervated, denervated, and nerve-blocked rat soleus muscles. Nerve block was obtained by superfusion of the sciatic nerve with tetrodotoxin (TTX). Two weeks after bupivacaine injection, immunohistochemical and electrophoretical analyses showed the presence of type 1 myosin heavy chain (MHC) only in innervated regenerated muscles, type 2A in innervated and denervated, but not in TTX-paralyzed muscles, and type 2X under all experimental conditions. The presence of type 1 MHC in the innervated, and its absence in both denervated and TTX-paralyzed muscles were also verified immunohistochemically 1 week after bupivacaine injection. It is concluded that the nerve impulses play a determinant role in the expression of 1 and 2A MHC isoforms in the innervated regenerating muscle. The possible causes of the absence of the type 2A MHC isoform in the TTX-paralyzed muscles are discussed.

Transient regulation of c-fos, alpha B-crystallin, and hsp70 in muscle during recovery from contractile activity

Endurance exercise training increases the oxidative capacity of skeletal muscles, reflecting the induction of genes encoding enzymes of intermediary metabolism. To test the hypothesis that changes in gene expression may be triggered specifically during recovery from contractile activity, we quantified c-fos, alpha B-crystallin, 70-kDa heat shock protein (hsp70), myoglobin, and citrate synthase RNA in rabbit tibialis anterior muscle during recovery from intermittent (8 h/day), low-frequency (10 Hz) motor nerve stimulation. Recovery from a single 8-h bout of stimulation was characterized by large (> 10-fold) transient increases in c-fos, alpha B-crystallin, and hsp70 mRNA. Similar changes were noted during recovery after 7 or 14 days of stimulation (8 h/day). Myoglobin and citrate synthase mRNA were also induced during recovery, but the changes were of lesser magnitude (2- to 2.5-fold) and were observed only following repeated bouts of muscle activity (7th or 14th day) that promoted sustained (> 24 h) increases in these transcripts. These findings indicate that recovery from exercise is associated with specific transient changes in the expression of immediate early and stress protein genes, suggesting that the products of these genes may have specific roles in the remodeling process evoked by repeated bouts of contractile activity.

Gracilis muscle transposition with electrical stimulation for sphincteric incontinence: a new approach

Neurovascularly intact gracilis-muscle transposition to the proximal urethra is an exciting new technique for sphincteric incontinence. The functional urethral closure of gracilis myoplasty assures dryness, permits intermittent self-catheterization when necessary, and avoids the risks of erosion associated with the artificial urinary sphincter. Electrical stimulation of the transposed muscle (dynamic urethral myoplasty) using intramuscular electrodes and a subcutaneously placed pulse generator can alter the molecular physiology of the gracilis muscle from that of predominantly fast-twitch to that of slow-twitch fibers that are fatigue-resistant and more suitable for long-term sphincter function.

Paralysis of rat skeletal muscle equally affects contractile properties as does permanent denervation

The effects of long lasting (4-5 weeks) nerve conduction block and denervation were compared by investigating contractile, morphological and histochemical properties of slow (soleus) and fast (EDL) rat skeletal muscles. The block was based on improved perfusion techniques of the sciatic nerve with a tetrodotoxin (TTX) solution delivered at doses adequate to obtain maximal effects in the muscles. The TTX-inactivated axons retained normal histological and physiological properties such as the ability to evoke full contractile responses, to regenerate, and to completely reinnervate muscle. In spite of their intact innervation or of their full reinnervation, the TTX-paralysed muscles underwent weight loss, fibre atrophy and reduction in force, output quantitatively indistinguishable from those following denervation. The same was true for all other contractile parameters tested, that is, twitch speed, twitch to tetanus ratio, post-tetanic potentiation, endurance, and fibre type composition. The results indicate the fundamental role of activity as a regulatory signal for muscle contractile properties, while they do not support the notion of a participation of chemical, activity-independent factors in this regulation.

Partial transformation from fast to slow muscle fibers induced by deafferentation of capsaicin-sensitive muscle afferents

Mechanical and histochemical characteristics of the lateral gastrocnemius (LG) muscle of the rat were examined 21 days after capsaicin injection into the LG muscle. The capsaicin caused a decrease in generation rate of twitch and tetanic tension and an increase in fatigue resistance of LG muscle. The histochemical muscle fiber profile evaluated by myosin adenosine triphosphatase and reduced nicotinamide adenine dinucleotide tetrazolium reductase methods showed an increase of type I and IIC fibers and a decrease of the type IIB in whole muscle, and a decrease of the IIA, IIX fibers in the red part accompanied by their increase in the white part. Therefore the capsaicin treatment, which selectively eliminated fibers belonging to the III and IV groups of muscle afferents, induced muscle fiber transformation from fast contracting fatiguing fibers to slowly contracting nonfatiguing ones.

Muscle transformation of the sartorius muscle in a canine model: clinical impact for electrodynamic graciloplasty as a "neosphincter"

PURPOSE

Transformation of fast-twitching skeletal muscles to slow-twitching, slowly fatigable muscles has become of clinical interest in the recent past. Transposition and transformation of the gracilis muscle to use it as a substitute for a resected or defected anal sphincter (graciloplasty) have been reported as achieving promising results in the treatment of fecal incontinence caused by sphincter defects or following abdominoperineal anorectal excision for cancer.

METHOD

This experimental study used a canine model and the sartorius muscle to evaluate the functional efficiency of two different configurations of the muscle loop to compare the presently applied transformation program (8 weeks) with a shorter (5 weeks) protocol. In six beagle dogs, both sartorius muscles were wrapped around two stomas, either in an alpha fashion or in the so-called split-sling technique. Muscle transformation was achieved by controlled neuromuscular stimulation either during eight (Program A) or five weeks (Program B). After completion of the transformation period, the function of the muscle slings was evaluated by manometry, and histomorphologic evaluation of the sartorius muscles was performed.

RESULTS

It was shown that muscle transformation led to a slowly fatigable muscle that made it possible to perform continuos (tetanic) contraction, regardless of the configuration or the duration of the transformation. Median pressures created by these muscles also did not differ significantly. In accordance with these functional findings, the histologic evaluation showed the typical, significant increase of Type I fibers in both muscle slings and following both transformation protocols. Although the decrease of fast-twitching Type II fibers was more pronounced following the conventional (8 weeks) program, this finding did not influence the functional results.

CONCLUSIONS

Results of our experiment indicate the possibility for using a shorter transformation protocol for transformation of the gracilis muscle during graciloplasty in the clinical setting. Furthermore, the efficacy and safety of the modified (split-sling) wrap technique was demonstrated.