Fatigue in human metabolic myopathy

Human muscle function and fatigue

Fatigue is defined as a failure to maintain the required or expected force. The force of a voluntary contraction is graded according to both the tension generated in each muscle fibre and the number of fibres recruited. The same is true of fatigue. Percutaneous electrical stimulation of a muscle via its motor nerve allows the contractile function to be measured independently of volition. Studies have been made of the forces generated isometrically at different stimulation frequencies (frequency: force curve), and of fatiguability (tendency to lose force in a given time at specified stimulation frequencies), in the quadriceps and adductor pollicis muscles. Electrical stimulation recordings of the programmed stimulation myograms distinguish forms of muscle fatigue. Low frequency fatigue which implies impaired excitation-contraction coupling is long-lasting, whereas high frequency fatigue which represents impaired muscle membrane excitation recovers rapidly. Electromyographic (EMG) indicators of fatigue are well recognized but their use is limited because they cannot alone indicate whether alterations in excitation-contraction coupling underlie fatigue. Alterations in the power spectrum of the EMG precede (force) fatigue in sustained maximum voluntary contractions. Fatigue may ultimately be due to a failure of the rate of energy supply to meet demand, but the precise expression of this defect may vary, such that failure of excitation or of activation may predominate over failure of the energy supply.

Contractile function and fatigue of the respiratory muscles in man

Ventilation depends on the proper functioning of the respiratory muscles. These muscles, like other skeletal muscles, can endure high work loads for only short time periods. The work of breathing in patients with lung disease in increased and it has therefore been argued that respiratory muscle fatigue may develop and contribute to respiratory failure. We have studied the contractile function and fatigue of the sternomastoid muscle and the diaphragm in normal subjects and found that these respiratory muscles have the same contractile properties as limb muscles. If subjected to a high load they develop similar patterns of fatigue. Studies on the sternomastoid muscle in patients with lung disease also confirmed that respiratory stress produces fatigue.

Muscle fatigue due to changes beyond the neuromuscular junction

A number of changes in function occur beyond the neuromuscular junction during activity; three main types are described. (a) During high frequency stimulation there is a rapid loss of force accompanied by a slowing of the action potential waveform and an increase in the excitation threshold of the muscle. It is suggested that accumulation of K+ in the extracellular spaces of the muscle may be responsible for these changes. (b) Slowing of relaxation is a feature of fatigued muscle. The slowing allows a reduction in activation frequency (minimizing high frequency fatigue) without resulting in an appreciable loss of force. (c) Changes in shape and amplitude of the twitch have considerable effects on the force generated by low frequencies of stimulation. After a brief tetanus there is a reduction in the width of the twitch which increases the fusion frequency of the muscle and may account for the "sag' seen at the start of low frequency contractions. After a prolonged series of contractions the twitch amplitude is reduced and remains so for several hours. This may be the result of some structural damage to the sarcoplasmic reticulum or transverse tubular system.

Reduced levels of skeletal muscle Na+K+ -ATPase in McArdle disease

We evaluated the hypothesis that impaired sarcolemmal function associated with exaggerated potassium release, impaired potassium uptake, or both may contribute to exertional fatigue and abnormal circulatory responses to exercise in McArdle disease (MD). The cellular mechanism of exertional fatigue and muscle injury in MD is unknown but likely involves impaired function of the ATPases that couple ATP hydrolysis to cellular work, including the muscle sodium potassium pump (Na+K+-ATPase). However, the concentration of muscle Na+K+ pumps in MD is not known, and no studies have related exercise increases in blood potassium concentrations to muscle Na+K+ pump levels. We measured muscle Na+K+ pumps (3H-ouabain binding) and plasma K+ in response to 20 minutes of cycle exercise in six patients with MD and in six sex-, age-, and weight-matched sedentary individuals. MD patients had lower levels of 3H-ouabain binding (231 +/- 18 pmol/g w.w., mean +/- SD, range, 210 to 251) than control subjects (317 +/- 37, range, 266 to 371, p < 0.0004), higher peak increases in plasma potassium in response to 45 +/- 7 W cycle exercise (MD, 1.00 +/- 0.15 mmol/L; control subjects, 0.48 +/- 0.09; p < 0.0001), and mean exercise heart rate responses to exercise that were 45 +/- 12 bpm greater than control subjects. Our results indicate that Na+K+ pump levels are low in MD patients compared with healthy subjects and identify a limitation of potassium reuptake that could result in sarcolemmal failure during peak rates of membrane activation and may promote exaggerated potassium-activated circulatory responses to submaximal exercise. The mechanism of the low Na+K+ pump concentrations in MD is unknown but may relate to deconditioning or to disruption of a close functional relationship between membrane ion transport and glycolysis.

Changes in force and intracellular metabolites during fatigue of human skeletal muscle

1. The relationship between intracellular metabolites and the generation of force during fatigue has been examined in the first dorsal interosseous muscle of the hand. With the arm made ischaemic, the muscle was fatigued by three bouts of maximal voluntary contraction, leaving approximately three minutes ischaemic rest between contractions. During one series of experiments intracellular phosphorus metabolites were measured by nuclear magnetic resonance during the intervals between the fatiguing contractions: in the second series contractile properties were tested with brief electrical stimulation during the rest intervals. 2. The relationships between loss of force and change in metabolite concentrations obtained with four normal subjects were compared with those from one subject with myophosphorylase deficiency (MPD) who could not utilize muscle glycogen and therefore produced no hydrogen ion from glycolysis during exercise. 3. For both the MPD and normal subjects the relationship between relative force loss and inorganic phosphate (Pi) concentration was curvilinear, force changing little in the early stages of the contraction when the intracellular Pi was accumulating rapidly but falling faster when the Pi was above 25 mM and increasing relatively slowly. 4. In the normal subjects intracellular pH fell from a mean of 7.03 +/- 0.01 (mean +/- S.E. of mean, n = 19) in the fresh muscle to 6.51 +/- 0.02 at the end of the fatiguing exercise; force, as a percentage of the initial value, fell in proportion to the increase in H+ concentration. In the MPD subject pH did not change and force loss was therefore independent of H+ accumulation. In the normal subjects the force of the fatiguing muscle showed an approximately linear relationship with the concentration of the monobasic form of inorganic phosphate. However, the MPD subject showed a quite different relationship, with force loss being much greater for a given concentration of monobasic phosphate. This result indicates that monobasic phosphate is not a unique determinant of force loss in fatigued muscle. 5. During the first 60 s of recovery in the normal subjects, pH remained low while force recovered, indicating a mechanism of force loss that was independent of H+ accumulation. However, the recovery of force was not complete, so that for comparable phosphocreatine contents the recovering, more acid, muscle generated less force than the muscle that was being fatigued. It was estimated that H(+)-dependent and independent mechanisms contributed roughly equally to the observed force loss. The relationship between force and the concentration of monobasic phosphate differed in fatiguing and recovering muscle.

Effects of thyroid hormones on skeletal muscle bioenergetics. In vivo phosphorus-31 magnetic resonance spectroscopy study of humans and rats

The pathophysiology of the myopathy in dysthyroid states is poorly understood. We therefore tested the effects of thyroid hormones on muscle bioenergetics in humans and rats, using in vivo 31P NMR. Two hypothyroid patients had: low phosphocreatine to inorganic phosphate ratio (PCr/Pi) at rest, increased PCr depletion during exercise and delayed postexercise recovery of PCr/Pi. Eight thyroidectomized rats did not show abnormalities at rest, but muscle work induced by nerve stimulation resulted in a significantly (P less than 0.0001) lower PCr/Pi (35-45% of control) at each of the three stimulation frequencies tested (0.25, 0.5, and 1.0 Hz). Recovery rate was markedly slowed to one-third of normal values. Thyroxine therapy reversed these abnormalities in both human and rat muscle. Five patients and six rats with hyperthyroidism did not differ from normal controls during rest and exercise but had an unusually rapid recovery after exercise. The bioenergetic abnormalities in hypothyroid muscle suggest the existence of a hormone-dependent, reversible mitochondrial impairment in this disorder. The exercise intolerance and fatigue experienced in hypothyroid muscle may be due to such a bioenergetic impairment. The changes in energy metabolism in hyperthyroid muscle probably do not cause the muscular disease in this disorder.

Shoulder abduction fatiguability

Shoulder abduction fatiguability has been measured using a hand held myometer in normal subjects and patients with peripheral neuromuscular diseases. An index of fatiguability was based on the decline in force over a series of ten maximum voluntary contractions performed in under a minute. The technique was repeatable and well tolerated. Patients with myasthenia, mitochondrial myopathy and motor neuron disease tended to show excess fatiguability independent of muscle strength. Serial measurements demonstrated alterations in fatiguability but not necessarily strength, associated with changes in symptoms.

Experimentally induced defects of mitochondrial metabolism in rat skeletal muscle. Biological effects of the mitochondrial uncoupling agent 2,4-dinitrophenol

Infusion of dinitrophenol intra-arterially into rat hind limb caused an irreversible failure of isometric twitch tension and the induction of a severe progressive contracture. Metabolite analysis of muscle in which the twitch response had grossly fatigued revealed low levels of ATP and phosphocreatine together with lactate accumulation. Studies using 31P-n.m.r. confirmed the decrease in ATP and creatine phosphate concentrations and indicated a fall in intracellular pH. It is concluded that dinitrophenol-induced myopathy does not represent a good model for the human mitochondrial myopathic condition as has been previously suggested.

Experimentally induced defects of mitochondrial metabolism in rat skeletal muscle. Biological effects of the NADH: coenzyme Q reductase inhibitor diphenyleneiodonium

An animal model for the human condition of mitochondrial myopathy has been established and characterized physiologically and biochemically. The NADH: coenzyme Q reductase inhibitor diphenyleneiodonium [Bloxham (1979) Biochem. Soc. Trans. 7, 103-106] was either infused acutely in vivo into rat hind limb or injected chronically into rats. Both modes of delivery resulted in a reduced muscle oxidative capacity and increased fatigue. Analysis of muscle metabolites by h.p.l.c. and 31P-n.m.r. indicated that ATP concentrations were similar to control values during periods of stimulation and these were maintained by the phosphocreatine pool. During the recovery period after muscle stimulation in the experimental animals the muscle pH remained depressed and the rate of phosphocreatine synthesis was markedly delayed as compared with controls. Factors thought to be involved in the fatigue response are discussed in relation to this model.

The measurement of muscle strength in patients with peripheral neuromuscular disorders

The variability of voluntary isometric strength measurements has been assessed in normal subjects and patients with peripheral neuromuscular disorders. Knee extensor strength was measured in a muscle testing chair 13 times over 5 months in each of six normal subjects: coefficients of variation (CV) ranged from 4.5 to 14.0% (mean 8.5%) for individual legs in different subjects. Paired measurements of the strength of several clinically weak muscle groups were made 1-4 days apart in 20 patients using both a handheld dynamometer and the muscle chair technique: the test/retest correlation was high (r = 0.97, p less than 0.001). Visual biofeedback did not affect the strength recorded in most cases. Each of five patients had the strength of six or seven clinically weak muscle groups measured by five examiners within a 24 hour period: the CV for the five examiners ranged from 3.6-27.3% (mean 12.8%). A single examiner measuring the same groups on five occasions in three patients obtained a mean CV of 8.9%. Sources of variation are analysed and it is concluded that, with certain precautions, voluntary strength measurements offer a simple, reliable and acceptable method for monitoring change in patients.