Skeletal muscle ATP synthesis and cellular H(+) handling measured by localized (31)P-MRS during exercise and recovery

Correlation between skeletal muscle acetylcarnitine and phosphocreatine metabolism during submaximal exercise and recovery: interleaved 1H/31P MRS 7 T study

Acetylcarnitine is an essential metabolite for maintaining metabolic flexibility and glucose homeostasis. The in vivo behavior of muscle acetylcarnitine content during exercise has not been shown with magnetic resonance spectroscopy. Therefore, this study aimed to explore the behavior of skeletal muscle acetylcarnitine during rest, plantar flexion exercise, and recovery in the human gastrocnemius muscle under aerobic conditions. Ten lean volunteers and nine overweight volunteers participated in the study. A 7 T whole-body MR system with a double-tuned surface coil was used to acquire spectra from the gastrocnemius medialis. An MR-compatible ergometer was used for the plantar flexion exercise. Semi-LASER-localized 1H MR spectra and slab-localized 31P MR spectra were acquired simultaneously in one interleaved exercise/recovery session. The time-resolved interleaved 1H/31P MRS acquisition yielded excellent data quality. A between-group difference in acetylcarnitine metabolism over time was detected. Significantly slower τPCr recovery, τPCr on-kinetics, and lower Qmax in the overweight group, compared to the lean group was found. Linear relations between τPCr on-kinetics, τPCr recovery, VO2max and acetylcarnitine content were identified. In conclusion, we are the first to show in vivo changes of skeletal muscle acetylcarnitine during acute exercise and immediate exercise recovery with a submaximal aerobic workload using interleaved 1H/31P MRS at 7 T.

Postcontraction [acetylcarnitine] reflects interindividual variation in skeletal muscle ATP production patterns in vivo

In addition to its role in substrate selection (carbohydrate vs. fat) for oxidative metabolism in muscle, acetylcarnitine production may be an important modulator of the energetic pathway by which ATP is produced. A combination of noninvasive magnetic resonance spectroscopy measures of cytosolic acetylcarnitine and ATP production pathways was used to investigate the link between [acetylcarnitine] and energy production in vivo. Intracellular metabolites were measured in the vastus lateralis muscle of eight males (mean: 28.4 yr, range: 25-35) during 8 min of incremental, dynamic contractions (0.5 Hz, 2-min stages at 6%, 9%, 12%, and 15% maximal torque) that increased [acetylcarnitine] approximately fivefold from resting levels. ATP production via oxidative phosphorylation, glycolysis, and the creatine kinase reaction was calculated based on phosphorus metabolites and pH. Spearman rank correlations indicated that postcontraction [acetylcarnitine] was positively associated with both absolute (mM) and relative (% total ATP) glycolytic ATP production (rs = 0.95, P = 0.001; rs = 0.93, P = 0.002), and negatively associated with relative (rs = -0.81, P = 0.02) but not absolute (rs = -0.14, P = 0.75) oxidative ATP production. Thus, acetylcarnitine accumulated more when there was a greater reliance on "nonoxidative" glycolysis and a relatively lower contribution from oxidative phosphorylation, reflecting the fate of pyruvate in working skeletal muscle. Furthermore, these data indicate striking interindividual variation in responses to the energy demand of submaximal contractions. Overall, the results of this preliminary study provide novel evidence of the coupling in vivo between ATP production pathways and the carnitine system.NEW & NOTEWORTHY Production of acetylcarnitine from acetyl-CoA and free carnitine may be important for energy pathway regulation in contracting skeletal muscle. Noninvasive magnetic resonance spectroscopy was used to investigate the link between acetylcarnitine and energy production in the vastus lateralis muscle during dynamic contractions (n = 8 individuals). A positive correlation between acetylcarnitine accumulation and "nonoxidative" glycolysis and an inverse relationship with oxidative phosphorylation, provides novel evidence of the coupling between ATP production and the carnitine system in vivo.

Invasive dynamic electrical impedance myography during 100 s of moderate contraction in rats' gastrocnemius muscle

GOAL

The present study aimed to investigate the behavior of dynamic electrical impedance myography (dEIM) signals during a 100-s period of the dynamic contraction of Wistar rats' gastrocnemius evoked by electrical stimulation and to link the variations in bioimpedance with muscular energy systems.

METHODS

Muscle contraction used 30% of the maximum muscular force and persisted for 100 s, along which dynamic bioimpedance signals were acquired. Based on the bioimpedance signals, two parameters, ΔZc and ΔZpc, were calculated to allow the analysis of their changes with the energy systems that supplied adenosine triphosphate (ATP) to the muscle. ΔZc indicated the variation of impedance of a twitch cycle compared to the values observed during the rest period preceding the cycle, and ΔZpc indicated slow bioimpedance variations compared to the values obtained during the rest period.

RESULTS

The results indicated that ΔZc followed the force behavior, achieving a change rate of ∼14%. This parameter was associated with instantaneous impedance changes owing to the occurrence of each twitch.

CONCLUSION

Although the findings of this study were linked to energy system processes, future studies are required for improving the understanding of the underlying mechanisms involved in dEIM.

SIGNIFICANCE

The results contributed to understanding the relation of energy systems that supply ATP to the muscles with dEIM variations that occurred during muscle activity.

Increased adiposity is associated with altered skeletal muscle energetics

The objective of this pilot study was to characterize relationships between skeletal muscle energy metabolism and body composition in healthy adults with varied amounts and distribution of adipose tissue. In vivo muscle energetics were quantified using dynamic 31P magnetic resonance spectroscopy with knee extension exercise standardized to subject lean body mass. Spearman's correlation analysis examined relationships between muscle metabolism indices and measures of adiposity including body mass index (BMI), total body fat, and quadriceps intermuscular adipose tissue (IMAT). Post hoc partial correlations were examined controlling for additional body composition measures. Kruskal-Wallis tests with Dunn-Sidak post hoc comparisons evaluated group differences in energy metabolism based on body composition profiles (i.e., lean, normal-weight obese, and overweight-obese) and IMAT tertiles. BMI negatively correlated with end-exercise muscle pH after correcting for IMAT and total body fat (r = -0.46, P = 0.034). Total adiposity negatively correlated with maximum oxidative capacity after correcting for IMAT (r = -0.54, P = 0.013). IMAT positively correlated with muscle proton buffering capacity after correcting for total body fat (r = 0.53, P = 0.023). Body composition groups showed differences in end-exercise fall in [PCr] with normalized workload (P = 0.036; post hoc: overweight-obese < lean, P = 0.029) and maximum oxidative capacity (P = 0.021; post hoc: normal-weight obese < lean, P = 0.016). IMAT tertiles showed differences in end-exercise fall in [PCr] with normalized workload (P = 0.035; post hoc: 3rd < 1st, P = 0.047). Taken together, these results support increased adiposity is associated with reduced muscle energetic efficiency with more reliance on glycolysis, and when accompanied with reduced lean mass, is associated with reduced maximum oxidative capacity.NEW & NOTEWORTHY Skeletal muscle energy production is influenced by both lean body mass and adipose tissue but the effect of their distribution on energy metabolism is unclear. This study examined variations in quadriceps muscle energy metabolism in healthy adults with varied relative amounts of lean and adipose tissue. Results suggest increased adiposity is associated with reduced muscle energetic efficiency with more reliance on glycolysis, and when accompanied with reduced lean mass, is associated with reduced maximum oxidative capacity.

Evaluation of Acute Supplementation With the Ketone Ester (R)-3-Hydroxybutyl-(R)-3-Hydroxybutyrate (deltaG) in Healthy Volunteers by Cardiac and Skeletal Muscle 31P Magnetic Resonance Spectroscopy

In this acute intervention study, we investigated the potential benefit of ketone supplementation in humans by studying cardiac phosphocreatine to adenosine-triphosphate ratios (PCr/ATP) and skeletal muscle PCr recovery using phosphorus magnetic resonance spectroscopy (³¹P-MRS) before and after ingestion of a ketone ester drink. We recruited 28 healthy individuals: 12 aged 23–70 years for cardiac ³¹P-MRS, and 16 aged 60–75 years for skeletal muscle ³¹P-MRS. Baseline and post-intervention resting cardiac and dynamic skeletal muscle ³¹P-MRS scans were performed in one visit, where 25 g of the ketone monoester, deltaG^®, was administered after the baseline scan. Administration was timed so that post-intervention ³¹P-MRS would take place 30 min after deltaG^® ingestion. The deltaG^® ketone drink was well-tolerated by all participants. In participants who provided blood samples, post-intervention blood glucose, lactate and non-esterified fatty acid concentrations decreased significantly (−28.8%, p ≪ 0.001; −28.2%, p = 0.02; and −49.1%, p ≪ 0.001, respectively), while levels of the ketone body D-beta-hydroxybutyrate significantly increased from mean (standard deviation) 0.7 (0.3) to 4.0 (1.1) mmol/L after 30 min (p ≪ 0.001). There were no significant changes in cardiac PCr/ATP or skeletal muscle metabolic parameters between baseline and post-intervention. Acute ketone supplementation caused mild ketosis in blood, with drops in glucose, lactate, and free fatty acids; however, such changes were not associated with changes in ³¹P-MRS measures in the heart or in skeletal muscle. Future work may focus on the effect of longer-term ketone supplementation on tissue energetics in groups with compromised mitochondrial function.

A Modular Mathematical Model of Exercise-Induced Changes in Metabolism, Signaling, and Gene Expression in Human Skeletal Muscle

Skeletal muscle is the principal contributor to exercise-induced changes in human metabolism. Strikingly, although it has been demonstrated that a lot of metabolites accumulating in blood and human skeletal muscle during an exercise activate different signaling pathways and induce the expression of many genes in working muscle fibres, the systematic understanding of signaling-metabolic pathway interrelations with downstream genetic regulation in the skeletal muscle is still elusive. Herein, a physiologically based computational model of skeletal muscle comprising energy metabolism, Ca2+, and AMPK (AMP-dependent protein kinase) signaling pathways and the expression regulation of genes with early and delayed responses was developed based on a modular modeling approach and included 171 differential equations and more than 640 parameters. The integrated modular model validated on diverse including original experimental data and different exercise modes provides a comprehensive in silico platform in order to decipher and track cause-effect relationships between metabolic, signaling, and gene expression levels in skeletal muscle.

Metabolic Basis of Creatine in Health and Disease: A Bioinformatics-Assisted Review

Creatine (Cr) is a ubiquitous molecule that is synthesized mainly in the liver, kidneys, and pancreas. Most of the Cr pool is found in tissues with high-energy demands. Cr enters target cells through a specific symporter called Na⁺/Cl⁻-dependent Cr transporter (CRT). Once within cells, creatine kinase (CK) catalyzes the reversible transphosphorylation reaction between [Mg²⁺:ATP⁴⁻]²⁻ and Cr to produce phosphocreatine (PCr) and [Mg²⁺:ADP³⁻]⁻. We aimed to perform a comprehensive and bioinformatics-assisted review of the most recent research findings regarding Cr metabolism. Specifically, several public databases, repositories, and bioinformatics tools were utilized for this endeavor. Topics of biological complexity ranging from structural biology to cellular dynamics were addressed herein. In this sense, we sought to address certain pre-specified questions including: (i) What happens when creatine is transported into cells? (ii) How is the CK/PCr system involved in cellular bioenergetics? (iii) How is the CK/PCr system compartmentalized throughout the cell? (iv) What is the role of creatine amongst different tissues? and (v) What is the basis of creatine transport? Under the cellular allostasis paradigm, the CK/PCr system is physiologically essential for life (cell survival, growth, proliferation, differentiation, and migration/motility) by providing an evolutionary advantage for rapid, local, and temporal support of energy- and mechanical-dependent processes. Thus, we suggest the CK/PCr system acts as a dynamic biosensor based on chemo-mechanical energy transduction, which might explain why dysregulation in Cr metabolism contributes to a wide range of diseases besides the mitigating effect that Cr supplementation may have in some of these disease states.

Musculoskeletal MRI at 7 T: do we need more or is it more than enough?

Ultra-high field magnetic resonance imaging (UHF-MRI) provides important diagnostic improvements in musculoskeletal imaging. The higher signal-to-noise ratio leads to higher spatial and temporal resolution which results in improved anatomic detail and higher diagnostic confidence. Several methods, such as T2, T2*, T1rho mapping, delayed gadolinium-enhanced, diffusion, chemical exchange saturation transfer, and magnetisation transfer techniques, permit a better tissue characterisation. Furthermore, UHF-MRI enables in vivo measurements by low-γ nuclei (²³Na, ³¹P, ¹³C, and ³⁹K) and the evaluation of different tissue metabolic pathways. European Union and Food and Drug Administration approvals for clinical imaging at UHF have been the first step towards a more routinely use of this technology, but some drawbacks are still present limiting its widespread clinical application. This review aims to provide a clinically oriented overview about the application of UHF-MRI in the different anatomical districts and tissues of musculoskeletal system and its pros and cons. Further studies are needed to consolidate the added value of the use of UHF-MRI in the routine clinical practice and promising efforts in technology development are already in progress.

31 P magnetic resonance spectroscopy in skeletal muscle: Experts' consensus recommendations

Skeletal muscle phosphorus-31 31 P MRS is the oldest MRS methodology to be applied to in vivo metabolic research. The technical requirements of 31 P MRS in skeletal muscle depend on the research question, and to assess those questions requires understanding both the relevant muscle physiology, and how 31 P MRS methods can probe it. Here we consider basic signal-acquisition parameters related to radio frequency excitation, TR, TE, spectral resolution, shim and localisation. We make specific recommendations for studies of resting and exercising muscle, including magnetisation transfer, and for data processing. We summarise the metabolic information that can be quantitatively assessed with 31 P MRS, either measured directly or derived by calculations that depend on particular metabolic models, and we give advice on potential problems of interpretation. We give expected values and tolerable ranges for some measured quantities, and minimum requirements for reporting acquisition parameters and experimental results in publications. Reliable examination depends on a reproducible setup, standardised preconditioning of the subject, and careful control of potential difficulties, and we summarise some important considerations and potential confounders. Our recommendations include the quantification and standardisation of contraction intensity, and how best to account for heterogeneous muscle recruitment. We highlight some pitfalls in the assessment of mitochondrial function by analysis of phosphocreatine (PCr) recovery kinetics. Finally, we outline how complementary techniques (near-infrared spectroscopy, arterial spin labelling, BOLD and various other MRI and 1 H MRS measurements) can help in the physiological/metabolic interpretation of 31 P MRS studies by providing information about blood flow and oxygen delivery/utilisation. Our recommendations will assist in achieving the fullest possible reliable picture of muscle physiology and pathophysiology.

Interleaved 31 P MRS/1 H ASL for analysis of metabolic and functional heterogeneity along human lower leg muscles at 7T

PURPOSE

MR offers the unique possibility to noninvasively investigate cellular energy metabolism via 31P MRS, while blood perfusion, which provides oxygen and substrates to the tissue, is accessible by arterial spin labeling (ASL) 1H MRI. Because metabolic and hemodynamic parameters are linked, it would be desirable to study them simultaneously. A 3D-resolved method is presented that allows such measurements with high spatiotemporal resolution and has the potential to discern differences along an exercising muscle.

METHODS

Multi-voxel localized ³¹ P MRS was temporally interleaved with multi-slice pASL 1H MRI. Phosphorus spectra were collected from two adjacent positions in gastrocnemius medialis (GM) during rest, submaximal plantar flexion exercise and recovery, while perfusion and T 2 * -weighted axial images were acquired at the same time. Seventeen healthy volunteers (9 f / 8 m) were studied at 7 T.

RESULTS

An increase of postexercise perfusion and T 2 * -weighted signal in GM positively correlated with end-exercise PCr depletion and pH drop. At proximal positions functional and metabolic activity was higher than distally, that is, perfusion increase and peak T 2 * -weighted signal, end-exercise PCr depletion, end-exercise pH, and PCr recovery time constant were significantly different. An NOE-induced SNR increase of approximately 20 % (P < .001), at rest, was found in interleaved ³¹ P spectra, when comparing to ³¹ P-only acquisitions.

CONCLUSIONS

A technique for fast, simultaneous imaging of muscle functional heterogeneity in ASL, T 2 * and acquisition of time-resolved ³¹ P  MRS data is presented. These single exercise recovery experiments can be used to investigate local variations during disease progression in patients suffering from vascular or muscular diseases.

Skeletal Muscle Abnormalities and Iron Deficiency in Chronic Heart FailureAn Exercise 31P Magnetic Resonance Spectroscopy Study of Calf Muscle

BACKGROUND

Heart failure (HF) is often associated with iron deficiency (ID). Skeletal muscle abnormalities are common in HF, but the potential role of ID in this phenomenon is unclear. In addition to hemopoiesis, iron is essential for muscle bioenergetics. We examined whether energetic abnormalities in skeletal muscle in HF are affected by ID and if they are responsive to intravenous iron.

METHODS AND RESULTS

Forty-four chronic HF subjects and 25 similar healthy volunteers underwent ³¹P magnetic resonance spectroscopy of calf muscle at rest and during exercise (plantar flexions). Results were compared between HF subjects with or without ID. In 13 ID-HF subjects, examinations were repeated 1 month after intravenous ferric carboxymaltose administration (1000 mg). As compared with controls, HF subjects displayed lower resting high-energy phosphate content, lower exercise pH, and slower postexercise PCr recovery. Compared with non-ID HF, ID-HF subjects had lower muscle strength, larger PCr depletion, and more profound intracellular acidosis with exercise, consistent with an earlier metabolic shift to anaerobic glycolysis. The exercise-induced PCr drop strongly correlated with pH change in HF group ( r=-0.71, P<0.001) but not in controls ( r=0.13, P=0.61, interaction: P<0.0001). Short-term iron administration corrected the iron deficit but had no effect on muscle bioenergetics assessed 1 month later.

CONCLUSIONS

HF patients display skeletal muscle myopathy that is more severe in those with iron deficiency. The presence of ID is associated with greater acidosis with exercise, which may explain early muscle fatigue. Further study is warranted to identify the strategy to restore iron content in skeletal muscle.

Pros and cons of ultra-high-field MRI/MRS for human application

Magnetic resonance imaging and spectroscopic techniques are widely used in humans both for clinical diagnostic applications and in basic research areas such as cognitive neuroimaging. In recent years, new human MR systems have become available operating at static magnetic fields of 7 T or higher (≥300 MHz proton frequency). Imaging human-sized objects at such high frequencies presents several challenges including non-uniform radiofrequency fields, enhanced susceptibility artifacts, and higher radiofrequency energy deposition in the tissue. On the other side of the scale are gains in signal-to-noise or contrast-to-noise ratio that allow finer structures to be visualized and smaller physiological effects to be detected. This review presents an overview of some of the latest methodological developments in human ultra-high field MRI/MRS as well as associated clinical and scientific applications. Emphasis is given to techniques that particularly benefit from the changing physical characteristics at high magnetic fields, including susceptibility-weighted imaging and phase-contrast techniques, imaging with X-nuclei, MR spectroscopy, CEST imaging, as well as functional MRI. In addition, more general methodological developments such as parallel transmission and motion correction will be discussed that are required to leverage the full potential of higher magnetic fields, and an overview of relevant physiological considerations of human high magnetic field exposure is provided.

Dynamic multivoxel-localized 31 P MRS during plantar flexion exercise with variable knee angle

Exercise studies investigating the metabolic response of calf muscles using ³¹ P MRS are usually performed with a single knee angle. However, during natural movement, the distribution of workload between the main contributors to force, gastrocnemius and soleus is influenced by the knee angle. Hence, it is of interest to measure the respective metabolic response of these muscles to exercise as a function of knee angle using localized spectroscopy. Time-resolved multivoxel ³¹ P MRS at 7 T was performed simultaneously in gastrocnemius medialis and soleus during rest, plantar flexion exercise and recovery in 12 healthy volunteers. This experiment was conducted with four different knee angles. PCr depletions correlated negatively with knee angle in gastrocnemius medialis, decreasing from 79±14 % (extended leg) to 35±23 %(∼40°), and positively in soleus, increasing from 20±21 % to 36±25 %; differences were significant. Linear correlations were found between knee angle and end-exercise PCr depletions in gastrocnemius medialis (R² =0.8) and soleus (R² =0.53). PCr recovery times and end-exercise pH changes that correlated with PCr depletion were consistent with the literature in gastrocnemius medialis and differences between knee angles were significant. These effects were less pronounced in soleus and not significant for comparable PCr depletions. Maximum oxidative capacity calculated for all knee angles was in excellent agreement with the literature and showed no significant changes between different knee angles. In conclusion, these findings confirm that plantar flexion exercise with a straight leg is a suitable paradigm, when data are acquired from gastrocnemius only (using either localized MRS or small surface coils), and that activation of soleus requires the knee to be flexed. The present study comprises a systematic investigation of the effects of the knee angle on metabolic parameters, measured with dynamic multivoxel ³¹ P MRS during muscle exercise and recovery, and the findings should be used in future study design.

Investigating Muscle Function After Stroke Rehabilitation with 31P-MRS: A Preliminary Study

BACKGROUND New evidence reveals significant metabolic changes in skeletal muscle after stroke. However, it is unknown if 31P magnetic resonance spectroscopy (31P-MRS) can evaluate these metabolic changes. Our objective here was to investigate: (a) if muscle energy metabolism changes in the affected side; (b) if muscle energy metabolism changes after rehabilitation; and (c) if energy metabolism measured by 31P-MRS can reflect changes in the Modified Modified Ashworth Scale (MMAS) and Fugl-Meyer assessment-lower extremity (FMA-LE) scores after rehabilitation. MATERIAL AND METHODS We enrolled 13 patients with stroke symptoms and hemiplegia. Lower-limb motor status on the affected side was evaluated by FMA-LE and MMAS. The 31P-MRS measures included phosphocreatine (PCr), inorganic phosphate (Pi), PCr/Pi, and pH. We statistically compared these measures in the affected and unaffected lower leg muscles before rehabilitation and after rehabilitation on the affected side. Spearman correlational analyses was performed to determine correlations between change in energy metabolism and change in FMA-LE score and MMAS score after rehabilitation. RESULTS PCr and PCr/Pi were significantly lower in the affected muscle compared to the unaffected muscle; however, there were no significant differences in Pi or pH. After rehabilitation, PCr, Pi, PCr/Pi, and pH did not significantly change. However, FMA-LE and MMAS score improved significantly after rehabilitation. Changes in energy metabolism measured by 31P-MRS had no correlation with FMA-LE change after rehabilitation. However, changes in PCr and PCr/Pi were correlated with change in MMAS score after rehabilitation. CONCLUSIONS 31P-MRS can evaluate changes in muscle energy metabolism in patients with stroke. PCr measured by 31P-MRS can reflect changes in MMAS after rehabilitation.

Comparison of metabolic adaptations between endurance- and sprint-trained athletes after an exhaustive exercise in two different calf muscles using a multi-slice 31 P-MR spectroscopic sequence

Measurements of exercise-induced metabolic changes, such as oxygen consumption, carbon dioxide exhalation or lactate concentration, are important indicators for assessing the current performance level of athletes in training science. With exercise-limiting metabolic processes occurring in loaded muscles, ³¹ P-MRS represents a particularly powerful modality to identify and analyze corresponding training-induced alterations. Against this background, the current study aimed to analyze metabolic adaptations after an exhaustive exercise in two calf muscles (m. soleus - SOL - and m. gastrocnemius medialis - GM) of sprinters and endurance athletes by using localized dynamic ³¹ P-MRS. In addition, the respiratory parameters VO₂ and VCO₂ , as well as blood lactate concentrations, were monitored simultaneously to assess the effects of local metabolic adjustments in the loaded muscles on global physiological parameters. Besides noting obvious differences between the SOL and the GM muscles, we were also able to identify distinct physiological strategies in dealing with the exhaustive exercise by recruiting two athlete groups with opposing metabolic profiles. Endurance athletes tended to use the aerobic pathway in the metabolism of glucose, whereas sprinters produced a significantly higher peak concentration of lactate. These global findings go along with locally measured differences, especially in the main performer GM, with sprinters revealing a higher degree of acidification at the end of exercise (pH 6.29 ± 0.20 vs. 6.57 ± 0.21). Endurance athletes were able to partially recover their PCr stores during the exhaustive exercise and seemed to distribute their metabolic activity more consistently over both investigated muscles. In contrast, sprinters mainly stressed Type II muscle fibers, which corresponds more to their training orientation preferring the glycolytic energy supply pathway. In conclusion, we were able to analyze the relation between specific local metabolic processes in loaded muscles and typical global adaptation parameters, conventionally used to monitor the training status of athletes, in two cohorts with different sports orientations.

Declining Skeletal Muscle Function in Diabetic Peripheral Neuropathy

PURPOSE

The present review highlights current concepts regarding the effects of diabetic peripheral neuropathy (DPN) in skeletal muscle. It discusses the lack of effective pharmacologic treatments and the role of physical exercise intervention in limb protection and symptom reversal. It also highlights the importance of magnetic resonance imaging (MRI) techniques in providing a mechanistic understanding of the disease and helping develop targeted treatments.

METHODS

This review provides a comprehensive reporting on the effects of DPN in the skeletal muscle of patients with diabetes. It also provides an update on the most recent trials of exercise intervention targeting DPN pathology. Lastly, we report on emerging MRI techniques that have shown promise in providing a mechanistic understanding of DPN and can help improve the design and implementation of clinical trials in the future.

FINDINGS

Impairments in lower limb muscles reduce functional capacity and contribute to altered gait, increased fall risk, and impaired balance in patients with DPN. This finding is an important concern for patients with DPN because their falls are likely to be injurious and lead to bone fractures, poorly healing wounds, and chronic infections that may require amputation. Preliminary studies have shown that moderate-intensity exercise programs are well tolerated by patients with DPN. They can improve their cardiorespiratory function and partially reverse some of the symptoms of DPN. MRI has the potential to bring new mechanistic insights into the effects of DPN as well as to objectively measure small changes in DPN pathology as a result of intervention.

IMPLICATIONS

Noninvasive exercise intervention is particularly valuable in DPN because of its safety, low cost, and potential to augment pharmacologic interventions. As we gain a better mechanistic understanding of the disease, more targeted and effective interventions can be designed.

Dynamic phosphocreatine imaging with unlocalized pH assessment of the human lower leg muscle following exercise at 3T

PURPOSE

To develop a high temporal resolution imaging method that measures muscle-specific phosphocreatine (PCr) resynthesis time constant (τ_PCr ) and pH changes in muscles of the lower leg following exercise on a clinical 3T MRI scanner.

METHODS

We developed a frequency-selective 3D non-Cartesian FLORET sequence to measure PCr with 17-mm nominal isotropic resolution (28 mm actual resolution) and 6-s temporal resolution to capture dynamic metabolic muscle activity. The sequence was designed to additionally collect inorganic phosphate spectra for pH quantification, which were localized using sensitivity profiles of individual coil elements. Nineteen healthy volunteers were scanned while performing a plantar flexion exercise on an in-house developed ergometer. Data were acquired with a dual-tuned multichannel coil array that enabled phosphorus imaging and proton localization for muscle segmentation.

RESULTS

After a 90-s plantar flexion exercise at 0.66 Hz with resistance set to 40% of the maximum voluntary contraction, τ_PCr was estimated at 22.9 ± 8.8 s (mean ± standard deviation) with statistical coefficient of determination r²  = 0.89 ± 0.05. The corresponding pH values after exercise were in the range of 6.9-7.1 in the gastrocnemius muscle.

CONCLUSION

The developed technique allows measurement of muscle-specific PCr resynthesis kinetics and pH changes following exercise, with a temporal resolution and accuracy comparable to that of single voxel ³¹ P-MRS sequences. Magn Reson Med 79:974-980, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Energy demand and supply in human skeletal muscle

The energy required for muscle contraction is provided by the breakdown of ATP but the amount of ATP in muscles cells is sufficient to power only a short duration of contraction. Buffering of ATP by phosphocreatine, a reaction catalysed by creatine kinase, extends the duration of activity possible but sustained activity depends on continual regeneration of PCr. This is achieved using ATP generated by oxidative processes and, during intense activity, by anaerobic glycolysis. The rate of ATP breakdown ranges from 70 to 140 mM min^-1 during isometric contractions of various intensity to as much as 400 mM min^-1 during intense, dynamic activity. The maximum rate of oxidative energy supply in untrained people is ~50 mM min^-1 which, if the contraction duty cycle is 0.5 as is often the case in cyclic activity, is sufficient to match an ATP breakdown rate during contraction of 100 mM min^-1. During brief, intense activity the rate of ATP turnover can exceed the rates of PCr regeneration by combined oxidative and glycolytic energy supply, resulting in a net decrease in PCr concentration. Glycolysis has the capacity to produce between 30 and 50 mM of ATP so that, for example, anaerobic glycolysis could provide ATP at an average of 100 mM min^-1 over 30 s of exhausting activity. The creatine kinase reaction plays an important role not only in buffering ATP but also in communicating energy demand from sites of ATP breakdown to the mitochondria. In that role, creatine kinases acts to slow and attenuate the response of mitochondria to changes in energy demand.

In-vivo31P-MRS of skeletal muscle and liver: A way for non-invasive assessment of their metabolism

In addition to direct assessment of high energy phosphorus containing metabolite content within tissues, phosphorus magnetic resonance spectroscopy (³¹P-MRS) provides options to measure phospholipid metabolites and cellular pH, as well as the kinetics of chemical reactions of energy metabolism in vivo. Even though the great potential of ³¹P-MR was recognized over 30 years ago, modern MR systems, as well as new, dedicated hardware and measurement techniques provide further opportunities for research of human biochemistry. This paper presents a methodological overview of the ³¹P-MR techniques that can be used for basic, physiological, or clinical research of human skeletal muscle and liver in vivo. Practical issues of ³¹P-MRS experiments and examples of potential applications are also provided. As signal localization is essential for liver ³¹P-MRS and is important for dynamic muscle examinations as well, typical localization strategies for ³¹P-MR are also described.

A low-cost Mr compatible ergometer to assess post-exercise phosphocreatine recovery kinetics

OBJECTIVE

To develop a low-cost pedal ergometer compatible with ultrahigh (7 T) field MR systems to reliably quantify metabolic parameters in human lower leg muscle using phosphorus magnetic resonance spectroscopy.

MATERIALS AND METHODS

We constructed an MR compatible ergometer using commercially available materials and elastic bands that provide resistance to movement. We recruited ten healthy subjects (eight men and two women, mean age ± standard deviation: 32.8 ± 6.0 years, BMI: 24.1 ± 3.9 kg/m²). All subjects were scanned on a 7 T whole-body magnet. Each subject was scanned on two visits and performed a 90 s plantar flexion exercise at 40% maximum voluntary contraction during each scan. During the first visit, each subject performed the exercise twice in order for us to estimate the intra-exam repeatability, and once during the second visit in order to estimate the inter-exam repeatability of the time constant of phosphocreatine recovery kinetics. We assessed the intra and inter-exam reliability in terms of the within-subject coefficient of variation (CV).

RESULTS

We acquired reliable measurements of PCr recovery kinetics with an intra- and inter-exam CV of 7.9% and 5.7%, respectively.

CONCLUSION

We constructed a low-cost pedal ergometer compatible with ultrahigh (7 T) field MR systems, which allowed us to quantify reliably PCr recovery kinetics in lower leg muscle using ³¹P-MRS.

Dynamic 31 P-MRSI using spiral spectroscopic imaging can map mitochondrial capacity in muscles of the human calf during plantar flexion exercise at 7 T

Phosphorus MRSI (³¹ P-MRSI) using a spiral-trajectory readout at 7 T was developed for high temporal resolution mapping of the mitochondrial capacity of exercising human skeletal muscle. The sensitivity and localization accuracy of the method was investigated in phantoms. In vivo performance was assessed in 12 volunteers, who performed a plantar flexion exercise inside a whole-body 7 T MR scanner using an MR-compatible ergometer and a surface coil. In five volunteers the knee was flexed (~60°) to shift the major workload from the gastrocnemii to the soleus muscle. Spiral-encoded MRSI provided 16-25 times faster mapping with a better point spread function than elliptical phase-encoded MRSI with the same matrix size. The inevitable trade-off for the increased temporal resolution was a reduced signal-to-noise ratio, but this was acceptable. The phosphocreatine (PCr) depletion caused by exercise at 0° knee angulation was significantly higher in both gastrocnemii than in the soleus (i.e. 64.8 ± 19.6% and 65.9 ± 23.6% in gastrocnemius lateralis and medialis versus 15.3 ± 8.4% in the soleus). Spiral-encoded ³¹ P-MRSI is a powerful tool for dynamic mapping of exercising muscle oxidative metabolism, including localized assessment of PCr concentrations, pH and maximal oxidative flux with high temporal and spatial resolution.