Adverse events associated with eccentric exercise protocols: six case studies

Blood Pressure Responses to Postexercise Circulatory Occlusion Are Attenuated After Exercise-Induced Muscle Weakness

PURPOSE

Exercise blood pressure (BP) responses are thought to be determined by relative exercise intensity (percent maximal voluntary contraction (MVC) strength). However, cross-sectional studies report that during a static contraction, higher absolute force is associated with greater BP responses to relative intensity exercise and subsequent muscle metaboreflex activation with postexercise circulatory occlusion (PECO). We hypothesized that a bout of unaccustomed eccentric exercise would reduce knee extensor MVC and subsequently attenuate BP responses to PECO.

METHODS

Continuous BP, heart rate, muscle oxygenation, and knee extensor electromyography were recorded in 21 young healthy individuals (female, n = 10) during 2 min of 20% MVC static knee extension exercise and 2 min of PECO, performed before and 24 h after 300 maximal knee extensor eccentric contractions to cause exercise-induced muscle weakness. As a control, 14 participants repeated the eccentric exercise 4 wks later to test whether BP responses were altered when exercise-induced muscle weakness was attenuated via the protective effects of the repeated bout effect.

RESULTS

Eccentric exercise reduced MVC in all participants (144 ± 43 vs 110 ± 34 N·m, P < 0.0001). BP responses to matched relative intensity static exercise (lower absolute force) were unchanged after eccentric exercise ( P > 0.99) but were attenuated during PECO (systolic BP: 18 ± 10 vs 12 ± 9 mm Hg, P = 0.02). Exercise-induced muscle weakness modulated the deoxygenated hemoglobin response to static exercise (64% ± 22% vs 46% ± 22%, P = 0.04). When repeated after 4 wks, exercise-induced weakness after eccentric exercise was attenuated (-21.6% ± 14.3% vs -9.3 ± 9.7, P = 0.0002) and BP responses to PECO were not different from control values (all, P > 0.96).

CONCLUSIONS

BP responses to muscle metaboreflex activation, but not exercise, are attenuated by exercise-induced muscle weakness, indicating a contribution of absolute exercise intensity on muscle metaboreflex activation.

The contribution of low-frequency fatigue to the loss of quadriceps contractile function following repeated drop jumps

NEW FINDINGS

What is the central question of this study? Why do some subjects recover slowly following a bout of eccentric exercise and why is recovery faster following a repeated bout? What is the main finding and its importance? The results are consistent with two major causes of the reduction of quadriceps torque, the onset of low-frequency fatigue which recovered relatively fast and a second, delayed form of damage. Differences in the delayed damage process largely accounted for the differences in the rate of torque recovery between subjects after a first bout and it was suppression of the delayed damage which accounted for the faster recovery following a repeated bout of eccentric exercise.

ABSTRACT

The purpose of this study was to determine the extent to which low-frequency fatigue (LFF) accounts for the loss of quadriceps strength and time course of recovery following a series of drop jumps (DJs). Seventeen female subjects (20.8 ± 1.4 years) undertook 100 DJs, which were repeated 4 weeks later. Maximum isometric torque (MIT) and the ratio of torque generated by 20 and 100 Hz electrical stimulation (20/100), as a measure of LFF, were measured over 7 days following each series of DJs. After the first series the 20/100 ratio fell to a greater extent than MIT (to 35 ± 8.7% and 69 ± 11%, respectively) but recovered over 2-3 days, while MIT showed little recovery over this time. Changes of the 20/100 ratio were similar between subjects with fast or slow MIT recovery. Following the second series of DJs, changes in the 20/100 ratio were similar to those of the first bout and there were no differences between fast and slow recovering subjects. MIT, however, recovered more rapidly than after the first bout; the faster recovery was confined to the subjects who recovered slowly following the first bout. The results are consistent with two major causes of the reduction of quadriceps torque, the onset of low-frequency fatigue which recovered relatively fast and a second, delayed, form of damage. The latter largely accounted for the differences in MIT recovery between subjects after the first bout, while suppression of the delayed damage accounted for the faster recovery following the repeated bout.

Eccentric Muscle Contractions: Risks and Benefits

Eccentric contractions, characterized by the lengthening of the muscle-tendon complex, present several unique features compared with other types of contractions, which may lead to unique adaptations. Due to its specific physiological and mechanical properties, there is an increasing interest in employing eccentric muscle work for rehabilitation and clinical purposes. However, unaccustomed eccentric exercise is known to cause muscle damage and delayed pain, commonly defined as “Delayed-Onset Muscular Soreness” (DOMS). To date, the most useful preventive strategy to avoid these adverse effects consists of repeating sessions involving submaximal eccentric contractions whose intensity is progressively increased over the training. Despite an increased number of investigations focusing on the eccentric contraction, a significant gap still remains in our understanding of the cellular and molecular mechanisms underlying the initial damage response and subsequent adaptations to eccentric exercise. Yet, unraveling the molecular basis of exercise-related muscle damage and soreness might help uncover the mechanistic basis of pathological conditions as myalgia or neuromuscular diseases. In addition, a better insight into the mechanisms governing eccentric training adaptations should provide invaluable information for designing therapeutic interventions and identifying potential therapeutic targets.

Effect of different muscle contraction interventions using an isokinetic dynamometer on muscle recovery following muscle injury

The objective of the present study was to examine the effects of different muscle contraction interventions using isokinetic dynamometers on the muscle recovery after muscle injury caused by eccentric exercise. A total of 28 healthy male adults participated in the present study and each subject was randomly assigned to eccentric muscle contraction (EC, n=7), concentric muscle contraction (CC, n=7), both eccentric and concentric muscle contraction (BEC, n=7), and control (CON, n=7) groups after performing eccentric exercise. In all groups, except the control group, a different type of muscle contraction intervention was applied repeatedly for 24–96 hr after eccentric exercise, and maximum strength, muscle soreness, and creatine kinase (CK) levels were measured. The results showed a significant association between time and group, with respect to maximum strength (P<0.05), muscle soreness (P<0.001), and CK (P<0.001) after eccentric exercise. Moreover, BEC group showed faster muscle recovery than other groups. In conclusion, implementing active strategies such as performing BEC using an isokinetic dynamometer after eccentric exercise may be effective in facilitating muscle recovery.

Perspectives on Exertional Rhabdomyolysis

Exertional (exercise-induced) rhabdomyolysis is a potentially life threatening condition that has been the subject of research, intense discussion, and media attention. The causes of rhabdomyolysis are numerous and can include direct muscle injury, unaccustomed exercise, ischemia, extreme temperatures, electrolyte abnormalities, endocrinologic conditions, genetic disorders, autoimmune disorders, infections, drugs, toxins, and venoms. The objective of this article is to review the literature on exertional rhabdomyolysis, identify precipitating factors, and examine the role of the dietary supplement creatine monohydrate. PubMed and SPORTDiscus databases were searched using the terms rhabdomyolysis, muscle damage, creatine, creatine supplementation, creatine monohydrate, and phosphocreatine. Additionally, the references of papers identified through this search were examined for relevant studies. A meta-analysis was not performed. Although the prevalence of rhabdomyolysis is low, instances still occur where exercise is improperly prescribed or used as punishment, or incomplete medical history is taken, and exertional rhabdomyolysis occurs. Creatine monohydrate does not appear to be a precipitating factor for exertional rhabdomyolysis. Healthcare professionals should be able to recognize the basic signs of exertional rhabdomyolysis so prompt treatment can be administered. For the risk of rhabdomyolysis to remain low, exercise testing and prescription must be properly conducted based on professional standards.

Using blood lactate concentration to predict muscle damage and jump performance response to maximal stretch-shortening cycle exercise

BACKGROUND

It is well known that eccentric muscle contractions induce delayed onset muscle soreness (DOMS) and exertional rhabdomyolysis (ERB), both of which are related to high blood levels of muscle damage markers after exercise. Creatine kinase (CK) is, together with some other markers (i.e. myoglobin, α-actin, skeletal troponin), widely used in determination of muscle damage. Moreover, DOMS after eccentric exercise has been shown to be associated with altered blood lactate concentration after subsequent submaximal or maximal cycling exercise. However, it is unknown whether blood lactate can predict muscle damage levels after maximal stretch-shortening cycle (SSC) exercise, as due to the differences in types of contractions between the eccentric and SSC protocol. Additionally, we determined the association between blood lactate concentration and CMJ performance after such a protocol.

METHODS

Forty-three healthy, physically active young men completed a plyometric training session consisting of maximal countermovement jumps (CMJ) to failure. The blood creatine kinase (CK), myoglobin (Mb) and aspartate aminotransferase (AST) samples were taken pre- and 48 hours post-exercise. Blood lactate concentration was determined directly post-exercise.

RESULTS

There was a significant correlation between blood lactate concentration (post) and blood CK (P=0.027), Mb (P=0.007) and AST (P=0.024) (48 hours post), which means that higher blood lactate concentration is associated with higher muscle damage values after exercise. No correlation was found between blood lactate concentration (post) and performance loss which was expressed by the decrease in maximum CMJ height 5 minutes post-exercise.

CONCLUSIONS

Blood lactate concentration could be used as a predictor of muscle damage levels after maximal SSC exercise, which supports the results found in other studies, although after eccentric exercise. However, it cannot predict acute performance loss in jump height.

Can KAATSU Exercise Cause Rhabdomyolysis?

In recent years, there has been increasing interest in using low-load resistance exercise in combination with a reduction in blood flow to promote muscle adaptation (ie, blood flow-restricted exercise or KAATSU exercise). There has been 1 case study reported in the literature of this type of exercise resulting in exertional rhabdomyolysis, and herein, we report the second case of exertional rhabdomyolysis. In this case, a 20-year-old man performed 6 sets of blood flow-restricted exercise (3 sets of knee-extension and 3 sets of elbow-flexion exercise). The subject presented with high levels of delayed onset muscle soreness in the days after the exercise bout exhibited high levels of creatine kinase (peak recorded: 36 000 IU/L), and was hospitalized for exertional rhabdomyolysis. We urge that investigators and practitioners use caution with blood flow-restricted exercise protocols and to begin these exercise programs modestly and gradually progress them with time.

[Exercise-induced rhabdomyolysis - a new trend?]

BACKGROUND

The purpose of this study was to investigate whether or not there has been an increase in the number of admissions for exercise-induced rhabdomyolysis at Stavanger University Hospital (SUS) in recent years.

MATERIAL AND METHOD

The study is a retrospective review of patients discharged over the period January 2010 to March 2015 with a diagnosis of exercise-induced rhabdomyolysis and with maximum creatine kinase (CK) levels more than ten times the upper reference limit.

RESULTS

A total of 33 patients, 21 women and 12 men, with a median age of 28 years (18 - 68), were included in the study. Of the 33 patients, three quarters (25) were admitted in 2014 - 15, compared with eight over the period 2010 - 13. One patient developed kidney failure that required dialysis. The treatment depended more on the attending physician and department than on the patient's clinical condition and CK-level, but this did not seem to affect the rate of complications.

INTERPRETATION

The incidence of exercise-induced rhabdomyolysis at SUS increased from autumn 2014, and this coincided with increased media attention and a new exercise trend. We recommend standardising the treatment of exercise-induced rhabdomyolysis, as current treatment recommendations are based on rhabdomyolysis triggered by causes other than exercise.

Exertional rhabdomyolysis: physiological response or manifestation of an underlying myopathy?

Exertional rhabdomyolysis is characterised by muscle breakdown associated with strenuous exercise or normal exercise under extreme circumstances. Key features are severe muscle pain and sudden transient elevation of serum creatine kinase (CK) levels with or without associated myoglobinuria. Mild cases may remain unnoticed or undiagnosed. Exertional rhabdomyolysis is well described among athletes and military personnel, but may occur in anybody exposed to unaccustomed exercise. In contrast, exertional rhabdomyolysis may be the first manifestation of a genetic muscle disease that lowers the exercise threshold for developing muscle breakdown. Repeated episodes of exertional rhabdomyolysis should raise the suspicion of such an underlying disorder, in particular in individuals in whom the severity of the rhabdomyolysis episodes exceeds the expected response to the exercise performed. The present review aims to provide a practical guideline for the acute management and postepisode counselling of patients with exertional rhabdomyolysis, with a particular emphasis on when to suspect an underlying genetic disorder. The pathophysiology and its clinical features are reviewed, emphasising four main stepwise approaches: (1) the clinical significance of an acute episode, (2) risks of renal impairment, (3) clinical indicators of an underlying genetic disorders and (4) when and how to recommence sport activity following an acute episode of rhabdomyolysis. Genetic backgrounds that appear to be associated with both enhanced athletic performance and increased rhabdomyolysis risk are briefly reviewed.

Designing exercise clinical trials for older adults with cancer: Recommendations from 2015 Cancer and Aging Research Group NCI U13 Meeting

Cancer and its treatment can lead to a myriad of adverse events and negatively impact quality of life of older cancer patients and survivors. Unmet physical activity needs vary across the cancer continuum and remain an important yet understudied area of research in this population. Exercise interventions have been shown to be effective in treating both the physical and psychological declines associated with cancer and its treatment, with a potential to improve cancer-related outcomes. Despite the current evidence, exercise is clearly underutilized due to several barriers and knowledge gaps in existing trials that include appropriate population identification, design, and outcome measures selection. The benefits of regular exercise in both the primary and secondary prevention of chronic conditions are well established in the non-cancer population. In older cancer patients and survivors, further research is needed before exercise gains widespread acceptance. The Cancer and Aging Research Group convened experts in exercise, aging and cancer to evaluate current scientific evidence and knowledge gaps in geriatric exercise oncology. This report summarizes these findings and provides future research directions.

The relationship of creatine kinase variability with body composition and muscle damage markers following eccentric muscle contractions

[Purpose]

The purpose of the study was to investigate the relationship between CK variability and body composition and muscle damage markers following eccentric exercise.

[Methods]

Total 119 healthy male subjects were recruited to perform 50 eccentric contractions consisted of 2 sets of 25 contractions. Then, blood creatine kinase (CK) activity was analyzed to divide into three groups based on their CK activity levels. Maximum isometric strength (MIS), muscle soreness (SOR) and body composition data were obtained before and after exercise.

[Results]

The results showed that high CK responders had a significant decrease in MIS (p<0.001) and greater SOR (p<0.01) following eccentric exercise compared to low CK responders. Percent body fat was also higher in high responders compared to low responders (p=0.014). Peak CK activity was significantly correlated with MIS and SOR but no correlation with % body fat, muscle mass, and body mass index.

[Conclusion]

CK variability following eccentric exercise is closely related to MIS and SOR and % body fat may be a potent factor for CK variability.

Motor unit activity after eccentric exercise and muscle damage in humans

It is well known that unaccustomed eccentric exercise leads to muscle damage and soreness, which can produce long-lasting effects on muscle function. How this muscle damage influences muscle activation is poorly understood. The purpose of this brief review is to highlight the effect of eccentric exercise on the activation of muscle by the nervous system, by examining the change in motor unit activity obtained from surface electromyography (EMG) and intramuscular recordings. Previous research shows that eccentric exercise produces unusual changes in the EMG–force relation that influences motor performance during isometric, shortening and lengthening muscle contractions and during fatiguing tasks. When examining the effect of eccentric exercise at the single motor unit level, there are substantial changes in recruitment thresholds, discharge rates, motor unit conduction velocities and synchronization, which can last for up to 1 week after eccentric exercise. Examining the time course of these changes suggests that the increased submaximal EMG after eccentric exercise most likely occurs through a decrease in motor unit conduction velocity and an increase in motor unit activity related to antagonist muscle coactivation and low-frequency fatigue. Furthermore, there is a commonly held view that eccentric exercise produces preferential damage to high-threshold motor units, but the evidence for this in humans is limited. Further research is needed to establish whether there is preferential damage to high-threshold motor units after eccentric exercise in humans, preferably by linking changes in motor unit activity with estimates of motor unit size using selective intramuscular recording techniques.

Eccentric exercise in rehabilitation: safety, feasibility, and application

This nonexhaustive mini-review reports on the application of eccentric exercise in various rehabilitation populations. The two defining properties of eccentric muscle contractions--a potential for high muscle-force production at an energy cost that is uniquely low--are revisited and formatted as exercise countermeasures to muscle atrophy, weakness, and deficits in physical function. Following a dual-phase implementation, eccentric exercise that induces rehabilitation benefits without muscle damage, thereby making it both safe and feasible in rehabilitation, is described. Clinical considerations, algorithms of exercise progression, and suggested modes of eccentric exercise are presented.

Psychological stress impairs short-term muscular recovery from resistance exercise

PURPOSE

The primary aim of this study was to determine whether chronic mental stress moderates recovery of muscular function, perceived energy, fatigue, and soreness in the first hour after a bout of strenuous resistance exercise.

METHODS

Thirty-one undergraduate resistance training students (age = 20.26 ± 1.34 yr) completed the Perceived Stress Scale and Undergraduate Stress Questionnaire (USQ; a measure of life event stress) and completed fitness testing. After 5 to 14 d of recovery, they performed an acute heavy-resistance exercise protocol (10-repetition maximum (RM) leg press test plus six sets: 80%-100% of 10 RM). Maximal isometric force (MIF) was assessed before exercise, after exercise, and at 20, 40, and 60 min postexercise. Participants also reported their levels of perceived energy, fatigue, and soreness. Recovery data were analyzed with hierarchical linear modeling growth curve analysis.

RESULTS

Life event stress significantly moderated linear (P = 0.013) and squared (P = 0.05) recovery of MIF. This relationship held even when the model was adjusted for fitness, workload, and training experience. Likewise, perceived stress moderated linear recovery of MIF (P = 0.023). Neither USQ nor Perceived Stress Scale significantly moderated changes in energy, fatigue, or soreness.

CONCLUSION

Life event stress and perceived stress both moderated the recovery of muscular function, but not psychological responses, in the first hour after strenuous resistance exercise.

The effects of a downhill running bout on running economy

This study investigated whether downhill (DH) running (10-min @ 214.4 m·min(-1) and -10% grade) would elicit acute and delayed effects on running economy (RE) upon completion of DH running (RE2) and daily over 72 h (RE3, RE4, RE5). Fifteen runners (8 female, 7 male) completed the protocol. RE was measured during level running performed at 70% VO2peak. A baseline RE test (RE1) was used for comparison. Muscle soreness was significantly elevated at RE3 and RE4 vs. RE1. Oxygen uptake was significantly elevated at RE2 relative to RE3, RE4 and RE5 but was not different from RE1. Heart rate was similarly elevated at RE2. Measures of ankle, knee and hip joint angles at heel strike and toe off were not affected at any time-point in a subset of subjects (N = 6). A short DH running bout did not elicit significant delayed adverse effects on oxygen uptake or gait parameters relative to baseline.

Acute exertional rhabdomyolysis and triceps compartment syndrome during a high school football cAMP

Background:

Acute exertional rhabdomyolysis has been infrequently reported among adolescents. In August 2010, several high school football players from one team developed rhabdomyolysis and triceps compartment syndrome following an upper arm exercise held in a non-air-conditioned wrestling room.

Purpose:

To confirm the diagnoses, characterize the spectrum of illnesses, and determine the factors contributing to rhabdomyolysis and triceps compartment syndromes.

Study Design:

Descriptive epidemiology study.

Methods:

The authors reviewed hospital medical records and interviewed players, coaches, school administrators, and hospital staff, using a standardized questionnaire that assessed symptoms, exposures, and activities.

Results:

Among 43 players, 22 (51%) experienced rhabdomyolysis (peak creatine kinase range, 2434-42 000 U/L): 22 patients had upper arm myalgia; 12 were hospitalized; 3 experienced triceps compartment syndrome; none experienced renal failure. Illnesses started 1 to 3 days after the triceps exercise. Forty players (93%) completed questionnaires. Among 19 players receiving at least 1 vote from a teammate as 1 of the 3 hardest working players, 13 (68%) experienced rhabdomyolysis versus 7 (33%) of 21 not considered hardest working (relative risk, 2.1; 95% confidence interval, 1.04-4.0). Of 40 players, 10 (25%) reported creatine supplement use, which was not associated with rhabdomyolysis. No player acknowledged use of alcohol, illicit drugs, or performance-enhancing drugs; results of performance-enhancing drug tests on the 4 players tested were negative. Environmental investigation did not identify additional factors contributing to illness.

Conclusions:

The upper arm exercise, possibly exacerbated by heat, led to rhabdomyolysis and compartment syndrome. Greater awareness of specific exercise hazards and prevention strategies can minimize risk for clinically significant muscle injury.

Do dominant and non-dominant arms respond similarly to maximal eccentric exercise of the elbow flexors?

OBJECTIVES

Two common models to investigate the effect of interventions on muscle damage include using two groups in which one group receives an intervention while the other acts as control, and using contralateral limbs of one group. The latter model is based on the assumption that changes in markers of muscle damage are similar between limbs, but this has not been examined systematically.

DESIGN

This study compared changes in muscle damage markers between dominant and non-dominant arms following maximal eccentric exercise of the elbow flexors.

METHODS

Eighteen men performed 60 maximal eccentric elbow flexions of each arm separated by 4 weeks with the order of testing between arms randomised. Maximal voluntary isometric torque, range of motion, upper arm circumference, plasma creatine kinase (CK) activity and muscle soreness before and for 7 days following exercise were compared between arms using two-way repeated measures ANOVA.

RESULTS

No significant differences between arms were evident for any of the markers, but significant (P<0.05) differences between first and second bouts were evident for changes in strength, circumference and CK with smaller changes following the second bout. A poor correlation was found for the magnitude of changes in the markers between dominant and non-dominant arms, suggesting that responses to eccentric exercise were not necessarily the same between arms.

CONCLUSIONS

These results show that the order affected the responses of dominant and non-dominant arms to the eccentric exercise; however, the contralateral limb design appears to be usable if bout order is counterbalanced and randomised among participants.

Consensus treatment recommendations for late-onset Pompe disease

INTRODUCTION

Pompe disease is a rare, autosomal recessive disorder caused by deficiency of the glycogen-degrading lysosomal enzyme acid alpha-glucosidase. Late-onset Pompe disease is a multisystem condition, with a heterogeneous clinical presentation that mimics other neuromuscular disorders.

METHODS

Objective is to propose consensus-based treatment and management recommendations for late-onset Pompe disease.

METHODS

A systematic review of the literature by a panel of specialists with expertise in Pompe disease was undertaken.

CONCLUSIONS

A multidisciplinary team should be involved to properly treat the pulmonary, neuromuscular, orthopedic, and gastrointestinal elements of late-onset Pompe disease. Presymptomatic patients with subtle objective signs of Pompe disease (and patients symptomatic at diagnosis) should begin treatment with enzyme replacement therapy (ERT) immediately; presymptomatic patients without symptoms or signs should be observed without use of ERT. After 1 year of ERT, patients' condition should be reevaluated to determine whether ERT should be continued.

Effects of the homeopathic remedy arnica on attenuating symptoms of exercise-induced muscle soreness

OBJECTIVE

To evaluate the clinical efficacy of Arnica at a high potency (200c), on moderating delayed onset muscle soreness and accompanying symptoms of muscle dysfunction.

METHODS

Twenty subjects completed a maximal eccentric exercise protocol with the non-dominate elbow flexors to induce delayed onset muscle soreness. Either Arnica or placebo tablets were administered in a random, double- blinded fashion immediately after exercise and at 24 hours and 72 hours after exercise. Before exercise, immediately post-exercise, and at 24, 48, 72, and 96 hours post-exercise, assessments of delayed onset muscle soreness and muscle function included: 1) muscle soreness and functional impairment; 2) maximum voluntary contraction torque; 3) muscle swelling; and 4) range of motion tests to document spontaneous muscle shortening and muscle shortening ability. Blood samples drawn before exercise and at 24, 48, and 96 hours after exercise were used to measure muscle enzymes as indirect indices of muscle damage.

RESULTS

Regardless of the intervention, the extent of delayed onset muscle soreness and elevations in muscle enzymes were similar on the days following the eccentric exercise protocol. The post-exercise time profiles of decreases in maximum voluntary contraction torque and muscle shortening ability and increases in muscle swelling and spontaneous muscle shortening were similar for each treatment intervention.

CONCLUSIONS

The results of this study did not substantiate the clinical efficacy of Arnica at a high potency on moderating delayed onset muscle soreness and accompanying symptoms of muscle dysfunction. Despite the findings of this study, future investigations on the clinical efficacy of homeopathic interventions should consider incorporating research strategies that emphasize differential therapeutics for each patient rather than treating a specific disease or symptom complex, such as DOMS, with a single homeopathic remedy.

Acute effects of dietary ginger on muscle pain induced by eccentric exercise

Zingiber officinale, commonly known as ginger, has analgesic and antiinflammatory properties. The acute effects of ginger on muscle pain, inflammation and dysfunction induced by eccentric exercise were examined. Twenty-seven participants performed 24 eccentric actions of the non-dominant elbow flexors. In a double-blind, cross-over design, participants ingested a 2 g dose of ginger or placebo 24 h and 48 h after exercise. Pain intensity (0-100 mm), arm volume (water displacement), range-of-motion (goniometry) and metabolic rate were assessed before and 45 min after ingestion of ginger or placebo. Eccentric exercise induced moderate arm pain (39 ± 20 mm; mean ± SD) and dysfunction (14% decrease in ROM) and an increase in volume (1.8%). Overall, ginger consumption demonstrated no effect on muscle pain, dysfunction, or metabolic rate compared with placebo. In the sub-set of participants who consumed ginger 24 h after exercise, arm pain was reduced (13%, -5.9 ± 8.8 mm) the following day, 48 h after exercise. Participants who ingested placebo 24 h post-exercise exhibited no change in pain the following day (0.0 ± 14.7 mm). In conclusion, a single 2 g dose of ginger does not attenuate eccentric exercise-induced muscle pain, inflammation or dysfunction 45 min after ingestion. However, ginger may attenuate the day-to-day progression of muscle pain.

Eccentric exercise in patients with chronic health conditions: a systematic review

PURPOSE

The capacity of eccentric actions to produce muscle hypertrophy, strength gains, and neural adaptations without stressing the cardiopulmonary system has led to the prescription of eccentric training programmes in patients with low tolerance to exercise, such as elders or those with chronic health conditions. The purpose of this systematic review was to analyze the evidence regarding the effectiveness and suitability of eccentric training to restore musculoskeletal function in patients with chronic diseases.

SUMMARY OF KEY POINTS

Relevant articles were identified from nine databases and from the reference lists of key articles. Articles were assessed to determine level of evidence and scientific rigour. Nine studies met the inclusion criteria. According to Sackett's levels of evidence, 7 studies were graded at level IIb, 1 study at level IV, and the remaining study at level V. Articles were also graded for scientific rigour according to the PEDro scale. One study was rated as high quality, 4 studies were rated as moderate, and 2 studies were graded as poor quality.

CONCLUSIONS

Eccentric training may be safely used to restore musculoskeletal function in patients with some specific chronic conditions. However, the heterogeneity of diseases makes it very difficult to extrapolate results and to standardize clinical recommendations for adequate implementation of this type of exercise. More studies are needed to establish the potential advantages of eccentric training in chronic conditions.

ACE ID genotype affects blood creatine kinase response to eccentric exercise

Unaccustomed exercise may cause muscle breakdown with marked increase in serum creatine kinase (CK) activity. The skeletal muscle renin-angiotensin system (RAS) plays an important role in exercise metabolism and tissue injury. A functional insertion (I)/deletion (D) polymorphism in the angiotensin I-converting enzyme (ACE) gene (rs4646994) has been associated with ACE activity. We hypothesized that ACE ID genotype may contribute to the wide variability in individuals' CK response to a given exercise. Young individuals performed maximal eccentric contractions of the elbow flexor muscles. Pre- and postexercise CK activity was determined. ACE genotype was significantly associated with postexercise CK increase and peak CK activity. Individuals harboring one or more of the I allele had a greater increase and higher peak CK values than individuals with the DD genotype. This response was dose-dependent (mean +/- SE U/L: II, 8,882 +/- 2,362; ID, 4,454 +/- 1,105; DD, 2,937 +/- 753, ANOVA, P = 0.02; P = 0.009 for linear trend). Multivariate stepwise regression analysis, which included age, sex, body mass index, and genotype subtypes, revealed that ACE genotype was the most powerful independent determinant of peak CK activity (adjusted odds ratio 1.3, 95% confidence interval 1.03-1.64, P = 0.02). In conclusion, we indicate a positive association of the ACE ID genotype with CK response to strenuous exercise. We suggest that the II genotype imposes increased risk for developing muscle damage, whereas the DD genotype may have protective effects. These findings support the role of local RAS in the regulation of exertional muscle injury.

Appraisals of pain from controlled stimuli: relevance to quantitative sensory testing

OBJECTIVE

Sensory testing has been advocated for the diagnosis, prognosis, and outcome evaluation of pain patients, but responses to controlled stimuli have not been well correlated to clinical pain. As an initial step for improving the clinical relevance of sensory testing, this investigation compared appraisals of and responses to controlled pain stimuli.

DESIGN

A prospective within subjects design was used.

METHODS

Heat, ischaemic, and delayed-onset muscle pain were induced in the upper extremity of 44 participants (47.7% women) during four experimental sessions.

RESULTS

The threat of heat and ischaemic pain was higher than delayed-onset muscle pain (F(2,86) = 5.30, p<.01, eta(2) = .11). Threat, challenge, predictability, and controllability were related to heat pain most consistently. The affective-sensory ratios of ischaemic and delayed-onset muscle pain resembled those of clinical pain and were higher than heat pain (F(2,84) = 11.64, p<.01, eta(2) = .22). Delayed-onset muscle pain meaningfully affected daily activities, which correlated to delayed-onset muscle pain ratings (rs = .60-.68, ps <.001).

CONCLUSIONS

Heat stimuli may be well suited for instructional manipulations of appraisals to improve the clinical relevance of quantitative sensory testing and delayed-onset muscle pain's effects on daily activities are clinically relevant.

CK-MM and ACE genotypes and physiological prediction of the creatine kinase response to exercise

Exertional rhabdomyolysis (ERB) is a syndrome of severe skeletal muscle breakdown. Blood levels of creatine kinase (CK) are widely used as a marker to reflect muscle breakdown. Some individuals exhibit extreme increases in blood CK after exercise and have been characterized as high responders (HR), but no clinical definition of HR exists and reasons for the HR phenomenon are not understood. This study investigated possible associations between the magnitude of the CK response to exercise and polymorphisms of two genes: muscle-specific creatine kinase (CK-MM) NcoI and angiotensin-converting enzyme (ACE) I/D. An exercise test for defining HR was also investigated. Participants (n = 88) underwent an exercise test that included stepping up and down two stairs for 5 min followed by 15 squats while wearing a backpack weighted at 30% of their body weight. CK levels were measured before, immediately after, and 48 and 72 h after the test. Nine participants (10.2%) were defined as HR. Participants with the CK-MM NcoI AA genotype had a sixfold higher risk of being HR compared with GG and AG genotypes (P = 0.031). No significant differences were found for the ACE I/D polymorphism. Percent body fat was an independent predictor of being a HR. We conclude that the CK-MM AA genotype and percent body fat may be part of the constellation of mechanisms that explain susceptibility to ERB. A physiological test that may assist in predicting ERB is also presented.

Mechanisms of Variability in Strength Loss after Muscle-Lengthening Actions

PURPOSE

Profound strength loss is a marker of exercise-induced muscle damage; however, there is a large intersubject variability in the response, even when subjects are exposed to standardized exercise protocols. We sought to identify factors including neural drive and peripheral function underlying variability in early development of muscle strength loss after lengthening actions. We objectively characterized subjects on the basis of postexercise strength loss and analyzed voluntary and stimulated muscle function before and after exercise to test the hypothesis that greater strength loss would be associated with greater losses in peripheral, but not central, function.

METHODS

Forty-six subjects were tested. Central measures were integrated electromyographic activity (iEMG), compound muscle action potential (CMAP), and central activation ratio (CAR). Peripheral measures were maximal isometric and eccentric voluntary action torques and stimulated tetanic and twitch torques. Subjects performed 50 maximal lengthening (eccentric) actions of the elbow flexors. Isometric strength was assessed pre- and postexercise and for 4 d after exercise. Central and peripheral functions were assessed before and 5 min after exercise.

RESULTS

Cluster analysis of isometric strength loss at 0 and 24 h after exercise generated three groups: higher responders (HR) (N = 21; 49% average loss), lower responders (LR) (N = 22; 23% average loss), and nonresponders (N = 3; no loss). Maximal eccentric torque losses were greater in the HR group than in the LR group. Greater dysfunction was found for all peripheral measures (torque after tetanic stimuli; torque after twitch stimuli) in the HR group, whereas central measures (iEMG, CMAP, and CAR) were not different between groups (P > 0.05).

CONCLUSION

Greater voluntary strength loss after lengthening exercise was associated with greater impairment of peripheral function, but similar central function, suggesting that the mechanism(s) driving variations in strength loss after lengthening actions are localized within the periphery.

Selective serotonin reuptake inhibitors and rhabdomyolysis after eccentric exercise

PURPOSE

The purpose of this report was to review three cases of clinically significant rhabdomyolysis that developed in research subjects after completing an eccentric exercise protocol. All three cases occurred in subjects who reported use of selective serotonin reuptake inhibitors (SSRI).

METHODS

Sixty-three subjects enrolled in the study. Subjects performed 15 sets of 15 repetitions of maximal eccentric contractions of the elbow flexors. Subjects were then monitored on a daily basis for development of delayed onset muscle soreness (DOMS). Subjects received either microcurrent electrical neuromuscular stimulation (MENS) or sham treatment.

RESULTS

Three subjects developed clinically significant rhabdomyolysis after performing this exercise protocol. Affected subjects were the only subjects who reported use of SSRI during the study period.

CONCLUSION

This report raises suspicion of SSRI use as a predisposing factor to muscle injury after eccentric exercise.

Variability in muscle damage after eccentric exercise and the repeated bout effect

The first purpose of this study was to determine a possible explanation for the variability in the response to eccentric exercise by having participants repeat the same exercise 1 year apart. The second purpose was to examine whether initial injury in response to eccentric exercise was associated with the extent of the repeated bout effect (RBE). Male students performed 30 eccentric contractions (ECC) of the elbow flexors using a dumbbell set at 80% of the pre-exercise maximal isometric force (MIF). Participants were then classified into low (LR; n=6), medium (MR; n=6), high (HR; n=5), and higher (HrR; n=7) based on the increase in blood creatine kinase (CK) activity. A year later, participants repeated this exercise (ECC30). Four days after ECC30, participants performed 70 eccentric contractions (ECC70). Range of motion, MFI upper arm circumference, soreness, and blood CK activity were measured before and up to 9 days after each bout. The change in the criterion measures following ECC and ECC30 were similar for each group. There were no further changes in all parameters after ECC70 for MR, HR, and HrR, although there was a small increase in CK after ECC70 for LR. LR showed a smaller RBE after ECC70 compared with the other groups. It is concluded that participants who exercised 1 year apart showed remarkably similar responses between the bouts. The extent of the RBE following the second bout for the LR group is less for participants who demonstrate the least evidence of muscle damage after a first exercise bout.

Heatstroke in the super-sized athlete

We present a 16-year-old male athlete with hyperthermia, altered mental status, and respiratory distress during summer football practice. Multisystem organ failure ensued, which he survived. Malignant hyperthermia was suspected in this patient who had a history of rhabdomyolysis. Specific muscle contracture testing later eliminated this diagnosis. This case discusses the importance of rapid hydration with isonatremic fluid, aggressive cooling, and full support measures, including plasmapheresis, further diagnostic efforts to evaluate potential causes of rhabdomyolysis, and planning for physical and emotional rehabilitation.

Serum creatine kinase levels and renal function measures in exertional muscle damage

PURPOSE

Serum creatine kinase (CK) levels are commonly used to judge the severity of muscle damage and to determine when to hospitalize patients who present with symptoms of exertional rhabdomyolysis in order to prevent renal failure. However, no CK standard exists because of the limited information available regarding exercise-induced CK elevation and renal function. This study determined the magnitude of CK elevation and the effect on renal function produced by exercise in a large subject group.

METHODS

Blood samples were obtained from 203 volunteers who performed 50 maximal eccentric contractions of the elbow flexor muscles. The samples, taken before and 4, 7, and 10 d after exercise, were analyzed for markers of muscle damage (CK, myoglobin (Mb), lactate dehydrogenase, alanine aminotransferase, and aspartate aminotransferase and for measures of renal function (creatinine, blood urea nitrogen, phosphorus, potassium, osmolality, and uric acid).

RESULTS

All indicators of muscle damage increased significantly after exercise (P < 0.01). CK levels were 6420, 2100, and 311% above baseline on days 4, 7, and 10 after the exercise, respectively (P < 0.01), and Mb was 1137, 170, and 28% above baseline on days 4, 7, and 10 after exercise, respectively (P < 0.01). Of the 203 participants, 111 had CK values at 4 d postexercise > 2,000 U x L(-1) and 51 had values > 10,000 U x L(-1), levels used to diagnose myopathy (e.g., statin myositis) and rhabdomyolysis, respectively. There were no significant increases in any measure of renal function. Despite marked CK and Mb elevations in some subjects, none experienced visible myoglobinuria or required treatment for impaired renal function.

CONCLUSIONS

Exertional muscle damage produced by eccentric exercise in healthy individuals can cause profound CK and Mb elevations without renal impairment.

Review of exercise-induced muscle injury: relevance for athletic populations

Exercise-induced skeletal muscle injury is well understood as the product of unfamiliar or strenuous physical activity. Eccentric or lengthening actions are primarily responsible for inducing injury, which subsequently leads to a variety of signs and symptoms. Although significant research supports this finding, most observations are specific to untrained individuals. In addition, many protocols designed both to induce muscle injury and assess performance following the injury are dissimilar from those utilized by physically trained individuals or are impractical in relation to athletic performance or both. Therefore, difficulty may arise when extrapolating information, from the available literature and applying the findings to athletic populations. This review addresses the efficacy of applying our current understanding of exercise-induced skeletal muscle injury to a physically trained population as well as highlights concerns that require future investigation.

An assessment of statin safety by muscle experts

The National Lipid Association's (NLA) Muscle Safety Expert Panel was charged with the duty of examining the definitions, causative factors, and management of statin myopathy. The Panel was asked to use its evidence-based findings to form recommendations in response to a series of specific questions posed by the Task Force. The panel was composed of a clinical cardiologist, an exercise physiologist and skeletal muscle expert, and an expert in preventive cardiology who also examined skeletal muscle complications of statin use.

Epidemiological analysis of factors influencing an episode of exertional rhabdomyolysis in high school students

BACKGROUND

An episode of rhabdomyolysis occurred after an endurance test in high school students in Taipei County in November 2003.

PURPOSE

To determine the incidence, outcome, and risk factors in an episode of exertional rhabdomyolysis in high school students.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

We enrolled all 225 high school students who had performed an endurance test. Using data from retrospective questionnaires, we estimated the incidence and assessed risk factors of exertional rhabdomyolysis among these students. Multiple logistic regression was used to determine risk factors associated with exertional rhabdomyolysis.

RESULTS

The completed questionnaire was returned by 70% (157 of 225) of the students. Of these, 43.3% (68 of 157) were identified as having exertional rhabdomyolysis, and the incidence was not statistically different between male and female students (P = .49). Dark urine was noted in only 25% of the students. None of the students developed acute renal failure. The risk of exertional rhabdomyolysis was significantly higher in those students who had not exercised 1 day before the endurance test (odds ratio [OR], 6.10; 95% confidence interval [CI], 2.00-18.00) and those who had performed postexercise stretching of the legs (OR, 3.13; 95% CI, 1.28-7.69) or performed complete squats during the test (OR, 3.21; 95% CI, 1.12-10.00). There were no statistically significant differences in gender, body mass index, presence of flulike symptoms, previous exercise routine, and medication history between students with or without exertional rhabdomyolysis.

CONCLUSION

Our findings suggest that exertional rhabdomyolysis is not uncommon in strenuous eccentric exercise in both men and women, but the risk of developing acute renal failure is very low. Exercise 1 day before eccentric exercise was significantly associated with a reduced risk of exertional rhabdomyolysis, whereas postexercise stretching of the involved extremities might increase the risk.

Impact of stretch-shortening cycle rest interval on in vivo muscle performance

INTRODUCTION

Overuse and overtraining models have implicated both metabolic and mechanical disturbances as contributors to muscle damage and performance decrement but have produced equivocal results. The purpose of the present study was to investigate the impact of rest interval between sets of stretch-shortening cycles (SSC) on static and dynamic muscle performance

METHODS

Animals were randomly assigned to groups (N = 8 per group) of 10-s, 1-min, or 5-min rest between sets of isometric contractions (10-s, 1-min, or 5-min CON), or SSC (10-s, 1-min, or 5-min INJ). The dorsiflexor muscles were exposed in vivo to either seven sets of 10 SSC (500 degrees . s) or seven sets of isometric contractions. Performance was characterized by isometric exertions and positive, negative, and net work, at pretest, during the sets of SSC, and 48 h postexposure

RESULTS

The isometric force at 48 h after the 10-s and 5-min INJ groups were statistically different from the 1-min group (P < 0.05), whereas there was no difference in the CON groups. Negative work of the INJ groups were statistically lower at 48 h than pretest values (P < 0.05), whereas there was no change in positive work. Of the real-time parameters, there was a difference in minimum force and positive work (P < 0.05) with treatment with the 10-s INJ group being most affected.

CONCLUSION

SSC conducted at shorter work-rest cycles resulted in a more profound isometric force decrement 48 h postexposure, and in real-time changes in isometric prestretch force and positive work. These results indicate that short rest intervals between athletic or vocational tasks of heightened physical exertion (i.e., high intensity) may adversely affect performance and increase injury susceptibility.

ACTN3 and MLCK genotype associations with exertional muscle damage

Strenuous exercise results in damage to skeletal muscle that is manifested in delayed muscle pain, prolonged strength loss, and increases in muscle proteins in the blood, especially creatine kinase (CK) and myoglobin (Mb). Some individuals experience profound changes in these variables in response to standard laboratory exercise or recreational activities. We proposed that variations in genes coding for two myofibrillar proteins [alpha-actinin 3 (ACTN3) and myosin light chain kinase (MLCK)] may explain the large variability in the response to muscle-damaging exercise. We hypothesized that subjects with specific single nucleotide polymorphisms (SNPs) in ACTN3 and MLCK would show a greater loss in muscle strength and/or a greater increase in blood CK and Mb in response to eccentric exercise. Blood from 157 subjects who performed a standard elbow flexion eccentric exercise protocol was tested for association between genotypes of ACTN3 (1 SNP tested: R577X) and MLCK (2 SNPs tested: C49T and C37885A) and changes in blood CK and Mb and isometric strength. Subjects possessing the ACTN3-deficient genotype (XX) had lower baseline CK compared with the heterozygotes (P = 0.035). After the eccentric exercise, those subjects homozygous for the MLCK 49T rare allele had a significantly greater increase in CK and Mb (P < 0.01) compared with the heterozygotes, and those heterozygous for MLCK C37885A had a significantly greater increase in CK compared with the homozygous wild type (P < 0.05). There was only one subject homozygous for the rare MLCK 37885A allele. MLCK C37885A was also associated with postexercise strength loss (P < 0.05); the heterozygotes demonstrated greater strength loss compared with the homozygous wild type (CC). These results show that variations in genes coding for specific myofibrillar proteins influence phenotypic responses to muscle damaging exercise.

Sex differences in delayed onset muscle pain

OBJECTIVE

In contrast to the research using typical experimental pain stimuli, there is no consensus that women are more sensitive to delayed onset muscle pain than men. The purpose of this study was to examine sex differences in delayed onset muscle pain with use of a quantified stimulus intensity and multidimensional and valid pain measures.

METHODS

Ninety-five participants (49.5% women) completed eccentric exercise and then returned to the laboratory at 24 and 48 hours postexercise. The same relative intensity of the eccentric exercise was administered to women and men based on their eccentric strength.

RESULTS

The occurrence of muscle pain was confirmed by increases in intensity, F2, 182 = 162.28, P<0.01, eta = 0.64, and unpleasantness, F2, 182 = 204.03, P < 0.01, eta = 0.69, and standardized pain ratings, F2, 180 = 67.44, P < 0.01, eta = 0.43. The affective ratios indicated that the muscle pain was more unpleasant than intense. No sex differences were detected except that men reported higher affective ratios than women, F1, 92 = 4.06, P < 0.05, eta = 0.04.

DISCUSSION

The absence of higher muscle pain ratings in women than men in this investigation resembles a review of the delayed onset muscle soreness and pain literature. However, the findings contradict a few other acute muscle pain investigations, in which actual muscle tissue damage was not induced by eccentric contractions. Additional research is required to identify the parameters that influence the detection of sex differences.

Self-care behaviors for muscle pain

This investigation examined self-care behaviors for muscle pain because of the prevalence of musculoskeletal pain and the substitution of self-care for formal medical care. In Study 1, university students (N = 187) completed a retrospective questionnaire about self-care for muscle pain. In Study 2, muscle pain was experimentally induced in university students (N = 79) with subsequent measurement of self-care. In both studies, stretching and massaging were the most frequently performed behaviors, and consuming medication was the least frequently performed. In Study 1, the perceived effectiveness of behaviors and level of pain required to perform self-care accounted for 12% to 32% of the variance in behavior frequency. In Study 2, pain ratings and pain during activities were higher among those who performed self-care (ds = .59 to 1.00). These studies indicated that self-care behaviors are performed for both naturally occurring and experimentally induced muscle pain. However, both studies determined that the performance of self-care behaviors did not always correspond with current evidence of treatment effectiveness for muscle injuries. Unique opportunities for future investigations of self-care behavior models and interventions are permitted by muscle pain induction.

PERSPECTIVE

Self-care for pain reduction is an understudied behavior. This report describes 2 studies of self-care behaviors for naturally occurring and experimentally induced muscle pain. The most frequent types of self-care behaviors are similar for the types of pain, and the perceived effectiveness of behaviors and pain level influence performance of the behaviors.

Impact of muscle length during stretch-shortening contractions on real-time and temporal muscle performance measures in rats in vivo

The objective of the present study was to investigate the impact of muscle length during stretch-shortening cycles on static and dynamic muscle performance. Animals were randomly assigned to an isometric (control, Con, n = 12), a short-muscle-length (S-Inj, 1.22-2.09 rad, n = 12), or a long-muscle-length (L-Inj, 1.57-2.44 rad, n = 12) group. The dorsiflexor muscles were exposed in vivo to 7 sets of 10 stretch-shortening contractions (conducted at 8.72 rad/s) or 7 sets of isometric contractions of the same stimulation duration by using a custom-designed dynamometer. Performance was characterized by multipositional isometric exertions and positive, negative, and net work before exposure, 6 h after exposure, and 48 h after exposure to contractions. Real-time muscle performance during the stretch-shortening cycles was characterized by stretch-shortening parameters and negative, positive, and net work. The S-Inj group recovery (force difference) was similar to the Con group force difference at 48 h, whereas the L-Inj group force difference was statistically greater at 1.39, 1.57, and 1.74 rad than the Con group force difference ( P < 0.05). Negative work ( P < 0.05) and net work ( P < 0.05) were statistically lower in the S-Inj and L-Inj groups than in the Con group 48 h after exposure to contractions. Of the real-time parameters, there was a difference in cyclic force with treatment during the stretch-shortening cycles ( P < 0.0001), with the L-Inj group being the most affected. Thus longer ranges of motion result in a more profound isometric force decrement 48 h after exposure to contractions and in real-time changes in eccentric forces.