Stressor-induced increase in muscle fatigability of young men and women is predicted by strength but not voluntary activation

Adding a sustained attention task to a physically demanding cycling exercise exacerbates neuromuscular fatigue and impairs cognitive performance in both normoxia and hypoxia

PURPOSE

Both cognitive motor dual-tasks (CMDT) protocols and hypoxic environments have been associated with significant impairments in cognitive and physical performance. We aimed to determine the effects of hypoxia on cognitive performance and neuromuscular fatigue during a highly physically demanding CMDT.

METHODS

Fifteen young adults completed a first session involving a cognitive task (CTLCOG) followed by cycling exercise (CTLEX) in normoxia. After that, they randomly participated in CMDT sessions in normoxia (DTNOR) and hypoxia (DTHYP). The physical exercise consisted of 20 min cycling at a "hard" perceived effort, and the cognitive task consisted of 15 min sustained attention to response time task (SART). Concurrent psycho-physiological measurements included: quadriceps neuromuscular fatigue (peripheral/central components from femoral nerve electrostimulation), prefrontal cortex (PFC) oxygenation by near-infrared spectroscopy, and perception of effort.

RESULTS

SART performance significantly decreased in DTNOR (-15.7 ± 15.6%, P < 0.01) and DTHYP (-26.2 ± 16.0%, P < 0.01) compared to CTLCOG (-1.0 ± 17.7%, P = 0.61). Peripheral fatigue similarly increased across conditions, whereas the ability of the central nervous system to activate the working muscles was impaired similarly in DTNOR (-6.1 ± 5.9%, P < 0.001) and DTHYP (-5.4 ± 7.3%, P < 0.001) compared to CTLEX (-1.1 ± 0.2%, P = 0.52). Exercise-induced perception of effort was higher in DTHYP vs. DTNOR and in DTNOR vs. CTLEX. This was correlated with cognitive impairments in both normoxia and hypoxia. PFC deoxygenation was more pronounced in DTHYP compared to DTNOR and CTLEX.

CONCLUSION

In conclusion, performing a sustained attention task together with physically challenging cycling exercise promotes central neuromuscular fatigue and impairs cognitive accuracy; the latter is particularly noticeable when the CMDT is performed in hypoxia.

Time constraint and error corrections contribute to the increase of hand postural tremor during mental calculation

Purpose

Hand postural physiological tremor increases during arithmetic computation. The present work aims at investigating whether this could be attributed to a raise in stress for having to provide a correct answer within a constrained period of time, or to voice vibration for having to speak to report the answer.

Methods

In 16 participants tremor was recorded by using a 3-axial accelerometer during 5 min of a hand postural task performed simultaneously while: 1) subtracting 13 from a 3-digit number within 4 s and with mistakes correction (intervention: math stress task), 2) same as for the "intervention task" but without time limit and mistakes correction (intervention: math nonstress task), 3) adding 1 to a 3-digit number (intervention: voice vibration task), and 4) only postural task while keeping quiet (control task). Electromyographic (EMG) activity from the extensor carpi radialis was measured during the hand postural task.

Results

Compared to control, tremor increased during both math interventions (+30.9 % p = 0.002, math stress; +15.0 % p = 0.01, math nonstress), but not during the voice vibration task (+12.2 % p = 0.239). During the math stress trial tremor was greater compared to both the voice vibration trial (+21.0 % p = 0.021), and the math nonstress trial (+13.5 % p = 0.01). EMG activity was not affected.

Conclusion

The results suggest that during arithmetic computation the "stress component" contributes only partially to the observed increase in hand postural tremor, and that this increase cannot be attributed to voice vibrations.

Influence of visual feedback and cognitive challenge on the age-related changes in force steadiness

Force steadiness can be influenced by visual feedback as well as presence of a cognitive tasks and potentially differs with age and sex. This study determined the impact of altered visual feedback on force steadiness in the presence of a difficult cognitive challenge in young and older men and women. Forty-nine young (19-30 yr; 25 women, 24 men) and 25 older (60-85 yr; 15 women; 10 men) performed low force (5% of maximum) static contractions with the elbow flexor muscles in the presence and absence of a cognitive challenge (counting backwards by 13) either with low or high visual feedback gain. The cognitive challenge reduced force steadiness (increased force fluctuation amplitude) particularly in women (cognitive challenge × sex: P < 0.05) and older individuals (cognitive challenge × age: P < 0.05). Force steadiness improved with high-gain visual feedback compared with low-gain visual feedback (P < 0.01) for all groups (all interactions: P > 0.05). Manipulation of visual feedback had no influence on the reduced force steadiness in presence of the cognitive challenge for all groups (all P > 0.05). These findings indicate that older individuals and women have greater risk of impaired motor performance of the upper extremity if steadiness is required during a low-force static contraction. Manipulation of visual feedback had minimal effects on the reduced force steadiness in presence of a difficult cognitive challenge.

The Biological Basis of Sex Differences in Athletic Performance: Consensus Statement for the American College of Sports Medicine

ABSTRACT

Biological sex is a primary determinant of athletic performance because of fundamental sex differences in anatomy and physiology dictated by sex chromosomes and sex hormones. Adult men are typically stronger, more powerful, and faster than women of similar age and training status. Thus, for athletic events and sports relying on endurance, muscle strength, speed, and power, males typically outperform females by 10%-30% depending on the requirements of the event. These sex differences in performance emerge with the onset of puberty and coincide with the increase in endogenous sex steroid hormones, in particular testosterone in males, which increases 30-fold by adulthood, but remains low in females. The primary goal of this consensus statement is to provide the latest scientific knowledge and mechanisms for the sex differences in athletic performance. This review highlights the differences in anatomy and physiology between males and females that are primary determinants of the sex differences in athletic performance and in response to exercise training, and the role of sex steroid hormones (particularly testosterone and estradiol). We also identify historical and nonphysiological factors that influence the sex differences in performance. Finally, we identify gaps in the knowledge of sex differences in athletic performance and the underlying mechanisms, providing substantial opportunities for high-impact studies. A major step toward closing the knowledge gap is to include more and equitable numbers of women to that of men in mechanistic studies that determine any of the sex differences in response to an acute bout of exercise, exercise training, and athletic performance.

Cognitive challenge as a probe to expose sex- and age-related differences during static contractions

Despite activities of daily living being frequently performed simultaneously with a cognitive task, motor function is often investigated in isolation, which can hinder the applicability of findings. This brief review presents evidence that 1) performing a cognitive challenge simultaneously with a motor task can negatively impact force steadiness and fatigability of limb muscles during a static contraction, 2) the negative impact on old adults (>65 years old), particularly older women is greater than young when a cognitive challenge is simultaneously performed with a static motor task, 3) age-related mechanisms potentially explain impairments in motor performance in the presence of a cognitive challenge, and 4) the mechanisms for the age-related decrements in motor performance can be distinct between men and women. These observations are highly relevant to the older adults, given the increased risk of accidents and injury when a motor task is performed with a high cognitive-demand task, especially in light of the expanding reliance on an aging workforce.

Effect of Mental Task on Sex Differences in Muscle Fatigability: A Review

Previous research demonstrated that there are observable sex differences in developing muscle fatigue when mental task during fatiguing activity is present; however, there is no available review on this matter. Therefore, this review aimed to summarize the findings of previous studies investigating the effect of mental task on muscle fatigue in men and women. To conduct the review, we utilized searches using the electronic databases Web of Science, PubMed, Scopus, and EBSCO Cinahl Ultimate. The studies included had no limited publication date and examined the effects of mental task on muscle fatigue in a healthy adult population of any age. The evaluation was performed using the following criteria: time to failure, or subjective scale in various modifications (visual analog scale-VAS, rate of perceived effort-RPE, rate of perceived fatigue-RPF, rate of perceived discomfort-RPD). A total of seven studies met the set criteria, which were subsequently analyzed. Heavy mental task (more demanding math tasks) can reduce the time to failure for both men and women, with the reduction being more pronounced for women than for men. For light mental task (simple math tasks), no reduction in time to failure was observed to a great extent. The mental task in any of the included studies did not affect the subjective perception of fatigue, effort, discomfort, or pain. Although the studies investigating the effect of mental task on sex differences in muscle fatigability are limited, based on our findings we can assume that in jobs requiring heavier mental task, women may be more prone to the faster development of muscle fatigue; thus, employers might consider paying attention to the possibility of adequate rest.

Mind over body: A neuroergonomic approach to assessing motor performance under stress in older adults

Stress impairs motor performance, which is exacerbated with age. Stress also impairs brain activity in the prefrontal cortex, which communicates with the motor areas of the brain to regulate exercise and motor performance. To develop ergogenic strategies for the aging workforce, mind (brain)-body mechanisms behind the effect of stress on neuromuscular performance need to be well understood. This study investigated the influence of social stress on motor performance and information flow between the frontal and motor regions of the brain during intermittent handgrip contractions among older adults. Thirty older adults, balanced by gender, performed intermittent handgrip contractions at 30% of maximum strength before and after being subjected to a social stressor. Force steadiness, strength loss, root mean square electromyogram (EMG) activity, activation of the brain regions, and functional and effective connectivity between the frontal and motor brain regions were computed for pre- and post-stressor handgrip contractions. Older men exhibited improved motor performance after the stressor and concomitant reduction in functional connectivity between the frontal-motor brain regions ipsilateral to the contracting hand. Additionally, while both sexes exhibited significant causal information flow, i.e., effective connectivity, from the frontal to the motor regions of the brain, irrespective of the stressor, older women exhibited a bidirectional effective connectivity between the frontal-motor brain regions after the stressor. Stress had a facilitative effect on the motor performance of older men through compensatory brain network reorganization. Older women exhibited comparable motor performance pre/post stress, despite showing an increase in bidirectional information flow between the frontal-motor areas. Employing brain hemodynamics can facilitate better understanding of the impact of stress on neuromuscular performance and its differential impacts on brain network reorganization between the sexes.

A Methodological Framework to Capture Neuromuscular Fatigue Mechanisms Under Stress

Neuromuscular fatigue is exacerbated under stress and is characterized by shorter endurance time, greater perceived effort, lower force steadiness, and higher electromyographic activity. However, the underlying mechanisms of fatigue under stress are not well-understood. This review investigated existing methods of identifying central mechanisms of neuromuscular fatigue and the potential mechanisms of the influence of stress on neuromuscular fatigue. We found that the influence of stress on the activity of the prefrontal cortex, which are also involved in exercise regulation, may contribute to exacerbated fatigue under stress. We also found that the traditional methods involve the synchronized use of transcranial magnetic stimulation, peripheral nerve stimulation, and electromyography to identify the contribution of supraspinal fatigue, through measures such as voluntary activation, motor evoked potential, and silent period. However, these popular techniques are unable to provide information about neural alterations upstream of the descending drive that may contribute to supraspinal fatigue development. To address this gap, we propose that functional brain imaging techniques, which provide insights on activation and information flow between brain regions, need to be combined with the traditional measures of measuring central fatigue to fully understand the mechanisms behind the influence of stress on fatigue.

Men Exhibit Greater Pain Pressure Thresholds and Times to Task Failure but Not Performance Fatigability Following Self-Paced Exercise

The purpose of the current study was to determine if, and to what extent, sex differences in performance fatigability after a sustained, bilateral leg extension, anchored to a moderate rating of perceived exertion (RPE), could be attributed to muscle size, muscular strength, or pain pressure threshold (PPT) in young, healthy adults. Thirty adults (men: n = 15, women: n = 15) volunteered to complete a sustained leg extension task anchored to RPE = 5 (10-point OMNI scale) as well as pretest and posttest maximal voluntary isometric contraction (MVIC) trials. The fatigue-induced decline in MVIC force was defined as performance fatigability. We used muscle cross-sectional area (mCSA) to quantify muscle size and a dolorimeter to assess PPT. The sustained task induced fatigue such that both men and women exhibited significant (p < 0.05) decreases in MVIC force from pretest to posttest (M = 113.3, SD =24.2 kg vs. M = 98.3, SD = 23.1 kg and M = 73.1, SD =14.5 kg vs. M = 64.1, SD = 16.2 kg, respectively), with no significant sex differences in performance fatigability (grand M = 12.6, SD =10.6%). Men, however, exhibited significantly (p < 0.05) longer time to task failure (TTF) than women (M = 166.1, SD =83.0 seconds vs. M = 94.6, SD =41.7) as well as greater PPT (M = 5.9, SD = 2.2 kg vs. M = 3.4, SD =1.1 kg). The only significant predictor of performance fatigability was PPT. In conclusion, differences in PPT, at least in part, mediate variations in TTF during self-paced exercise anchored to a specific RPE and resulting in performance fatigability.

Less Is More-Cyclists-Triathlete's 30 min Cycling Time-Trial Performance Is Impaired With Multiple Feedback Compared to a Single Feedback

Purpose: The purpose of this article was to (i) compare different modes of feedback (multiple vs. single) on 30 min cycling time-trial performance in non-cyclist’s and cyclists-triathletes, and (ii) investigate cyclists-triathlete’s information acquisition.

Methods: 20 participants (10 non-cyclists, 10 cyclists-triathletes) performed two 30 min self-paced cycling time-trials (TT, ∼5–7 days apart) with either a single feedback (elapsed time) or multiple feedback (power output, elapsed distance, elapsed time, cadence, speed, and heart rate). Cyclists-triathlete’s information acquisition was also monitored during the multiple feedback trial via an eye tracker. Perceptual measurements of task motivation, ratings of perceived exertion (RPE) and affect were collected every 5 min. Performance variables (power output, cadence, distance, speed) and heart rate were recorded continuously.

Results: Cyclists-triathletes average power output was greater compared to non-cyclists with both multiple feedback (227.99 ± 42.02 W; 137.27 ± 27.63 W; P < 0.05) and single feedback (287.9 ± 60.07 W; 131.13 ± 25.53 W). Non-cyclist’s performance did not differ between multiple and single feedback (p > 0.05). Whereas, cyclists-triathletes 30 min cycling time-trial performance was impaired with multiple feedback (227.99 ± 42.02 W) compared to single feedback (287.9 ± 60.07 W; p < 0.05), despite adopting and reporting a similar pacing strategy and perceptual responses (p > 0.05). Cyclists-triathlete’s primary and secondary objects of regard were power (64.95 s) and elapsed time (64.46 s). However, total glance time during multiple feedback decreased from the first 5 min (75.67 s) to the last 5 min (22.34 s).

Conclusion: Cyclists-triathletes indoor 30 min cycling TT performance was impaired with multiple feedback compared to single feedback. Whereas non-cyclist’s performance did not differ between multiple and single feedback. Cyclists-triathletes glanced at power and time which corresponds with the wireless sensor networks they use during training. However, total glance time during multiple feedback decreased over time, and therefore, overloading athletes with feedback may decrease performance in cyclists-triathletes.

Effects of dual-task demands on the complexity and task performance of submaximal isometric handgrip force control

PURPOSE

To determine the effect of cognitive-motor dual-task load on temporal structure irregularity (complexity) of motor output and task performance of submaximal isometric contractions.

METHODS

Twelve young, sedentary subjects performed handgrip isometric contractions until failure at 50% of maximal voluntary contraction under mathematical self-regulated dual-task (own pace; SDT), regulated dual-task (imposed pace; RDT), and control. Force signal complexity was calculated by sample entropy at the initial, middle, and final thirds. Task performance was assessed by muscle fatigue (time to failure and rate of median frequency of the radial flexor of the carpus), force and math task error, and self-perceived difficulty.

RESULTS

Only RDT decreased complexity with respect to control (17.4% ± 12.6%, p = 0.005), all conditions decreased complexity by the final third (Control: 52.8% ± 18.7%, p < 0.001; SDT: 41.1% ± 32.1%, p = 0.003; RDT: 19.1% ± 21.9%, p = 0.035). Conditions did not affect time to failure, and only RDT decreased the rate of median frequency (0.1%/s ± 0.1%/s, p = 0.020). Inferior force error rate was increased by conditions (SDT: 1.5% ± 0.8%, p < 0.001; RDT: 2% ± 1.5%, p = 0.002). Math error was only augmented by RDT (from 9.9 ± 6.7 to 51.7 ± 18.8, p < 0.001), categorized as "very hard" in 85.7% of participants (p = 0.015).

CONCLUSION

Only the RDT condition reduced complexity and neuromuscular fatigue while increasing force error rate of the handgrip's motor output, without affecting time to failure. A highly demanding dual-task may become a strategy to modify the organization of the hand force motor output, which may contribute to its motor adaptations.

Oscillations in neural drive and age-related reductions in force steadiness with a cognitive challenge

A cognitive challenge when imposed during a low-force isometric contraction will exacerbate sex- and age-related decreases in force steadiness, but the mechanism is not known. We determined the role of oscillations in the common synaptic input to motor units on force steadiness during a muscle contraction with a concurrent cognitive challenge. Forty-nine young adults (19-30 yr; 25 women, 24 men) and 36 old adults (60-85 yr; 19 women, 17 men) performed a cognitive challenge (counting backward by 13) during an isometric elbow flexion task at 5% of maximal voluntary contraction. Single-motor units were decomposed from high-density surface EMG recordings. For a subgroup of participants, motor units were matched during control and cognitive challenge trials, so the same motor unit was analyzed across conditions. Reduced force steadiness was associated with greater oscillations in the synaptic input to motor units during both control and cognitive challenge trials ( r = 0.45-0.47, P < 0.01). Old adults and young women showed greater oscillations in the common synaptic input to motor units and decreased force steadiness when the cognitive challenge was imposed, but young men showed no change across conditions (session × age × sex, P < 0.05). Oscillations in the common synaptic input to motor units is a potential mechanism for altered force steadiness when a cognitive challenge is imposed during low-force contractions in young women and old adults. NEW & NOTEWORTHY We found that oscillations in the common synaptic input to motor units were associated with a reduction in force steadiness when a cognitive challenge was imposed during low-force contractions of the elbow flexor muscles in young women and old men and women but not young men. Age- and sex-related muscle weakness was associated with these changes.

Skeletal Muscle Fatigability in Heart Failure

Evidence suggests that heart failure (HF) patients experience skeletal muscle fatigability in the lower extremity during single-limb tasks. The contribution of skeletal muscle fatigability to symptoms of exercise intolerance (perceived fatigue and dyspnea) is relatively unclear. Symptomatic or ‘perceived’ fatigue is defined by the sensations of exhaustion or tiredness that patients experience either at rest or while performing a motor task. Although factors that contribute to symptoms of fatigue in patients with HF are multifactorial; the skeletal muscle likely plays a major role. Skeletal muscle fatigability, as opposed to symptomatic fatigue, is an objective measure of a reduction in muscle force or power or reduced ability of the muscles to perform over time. Indeed, evidence suggests that patients with HF experience greater skeletal muscle fatigability which may contribute to a diminution in motor performance and the overall symptomatology that is hallmark of exercise intolerance in HF. This review will discuss (1) skeletal muscle fatigability in patients with HF, (2) the mechanisms contributing to locomotor skeletal muscle fatigability in HF and (3) the relationship of fatigability to symptoms of perceived fatigue and exercise intolerance in HF patients. Evidence suggests that cardiac dysfunction alone does not contribute to exercise intolerance. Therefore, mechanisms of skeletal muscle fatigability and their contribution to symptoms of fatigue and exercise intolerance, is an increasingly important consideration as we develop rehabilitative strategies for improving motor performance and functional capacity in patients with HF.

Influence of cognitive load on the dynamics of neurophysiological adjustments during fatiguing exercise

We aimed to determine the neurophysiological mechanisms associated with reduced endurance performance during cognitive-motor dual task at different levels of cognitive load, compared to a motor task alone. Eighteen healthy men performed isometric quadriceps contractions at 15% of maximal voluntary contraction (blocks of 170 s interspaced by neuromuscular evaluations) until exhaustion. This task was performed on three separate days: (a) in the absence of concomitant cognitive task, (b) with concomitant 1-back task, and (c) with concomitant 2-back task. Autonomic nervous system activity, perceived exertion, and cognitive performance were continuously monitored. Peripheral and central determinants of neuromuscular function were assessed at rest, between each block, and at task failure using femoral nerve stimulation. Endurance time was shorter during 2-back (982 ± 545 s) and 1-back (1,128 ± 592 s) conditions, compared with control (1,306 ± 836 s). Voluntary activation level was lower in 2-back (87.1%; p < 0.001) and 1-back (88.6%; p = 0.04) conditions compared to control (91.2%) at isotime (100% of the shortest test duration). Sympathetic activity showed a greater increase in 2-back condition compared to control. Perceived muscular exertion was higher during 2-back than during control. Cognitive performance decreased similarly with time during both cognitive-motor dual task but was always lower during 2-back condition. Motor performance is reduced when adding a concomitant demanding memory task to a prolonged isometric exercise. This can be explained by the interaction of various psychological and neurophysiological factors including higher perceived exertion, greater perturbations of autonomic nervous system activity, and cerebral impairments leading to earlier onset of central fatigue.

Force Steadiness During a Cognitively Challenging Motor Task Is Predicted by Executive Function in Older Adults

Motor performance and cognitive function both decline with aging. Older adults for example are usually less steady for a constant-force task than young adults when performing low-intensity contractions with limb muscles. Healthy older adults can also show varying degrees of cognitive decline, particularly in executive function skills. It is not known, however, whether age-related changes in steadiness of low-force tasks and cognitive function are independent of one another. In this study, we determined if executive function skills in aging are associated with the steadiness during a low-force muscle contraction performed with and without the imposition of a cognitive challenge. We recruited 60 older adults (60–85 years old, 34 women, 26 men) and 48 young adults (19–30 years old, 24 women, 24 men) to perform elbow flexor muscle contractions at 5% of maximal voluntary contraction (MVC) force in the presence and absence of a difficult mental-math task (counting backward by 13 from a four-digit number). Force steadiness was quantified as the coefficient of variation (CV) of force and executive function was estimated with the Trail-making Test part A and B. The cognitive challenge increased the CV of force (i.e., decreased force steadiness) with greater changes in older adults than young adults (5.2 vs. 1.3%, respectively, cognitive challenge × age: P < 0.001). Older adults were 35% slower in both parts A and B of the Trail-making Test (P < 0.001), and to eliminate the effects of age and education on this variable, all further analyses were performed with the age-corrected z-scores for each individual using established normative values. Hierarchical regression models indicated that decreased force steadiness during a cognitive challenge trial was in part, explained by the performance in the Trail-making Test part A and B in older (r = 0.53 and 0.50, respectively, P < 0.05), but not in young adults (P > 0.05). Thus, healthy community-dwelling older adults, who have poorer executive function skills, exhibit reduced force steadiness during tasks when also required to perform a high cognitive demand task, and are likely at risk of reduced capacity to perform daily activities that involve cognitively challenging motor tasks.

Adjustments in Torque Steadiness During Fatiguing Contractions Are Inversely Correlated With IQ in Persons With Multiple Sclerosis

Fatigue is one of the most debilitating symptoms of multiple sclerosis (MS), and the underlying mechanisms are poorly understood. When exposed to a physical or cognitive challenge, individuals with MS tend to exhibit greater declines in task performance (performance fatigability) and increased levels of self-reported fatigue (perceived fatigability), but these effects may be attenuated by greater intellectual capacity. The purpose of our study was to examine the influence of intelligence on fatigability in persons with MS. We hypothesized that greater intellectual capacity confers some protection against heightened levels of fatigue and fatigability associated with MS. Twelve adults with relapsing-remitting MS were compared with 12 control (CO) subjects who were matched for age, sex, and premorbid intellectual capacity. Performance fatigability was measured as the decline in maximal voluntary contraction (MVC) torque after 60 isometric contractions (10 s contraction at 25% MVC, 5 s rest) performed with the knee extensor muscles. Perceived fatigability was assessed with the modified fatigue impact scale (MFIS) questionnaire (trait fatigability) and the Borg rating of perceived exertion (RPE, state fatigability). Persons with MS reported greater MFIS scores (MS: 43 ± 14; CO: 11 ± 8, P ≤ 0.001). Initial MVC torque for the knee extensors did not differ between the groups (MS: 112 ± 38 N⋅m; CO: 107 ± 44 N⋅m) and the decline (performance fatigability) was similar for both groups (MS: -16 ± 19 N⋅m; CO: -13 ± 16 N⋅m). RPE increased during the fatiguing contraction for both groups (P < 0.001) but was significantly greater in magnitude (main effect for group, P = 0.03) and increased more for the MS group (group × time interaction, P = 0.05). Torque steadiness declined during the fatiguing contractions (main effect for time, P = 0.05) and was less steady for the MS group (main effect for group, P = 0.02). Performance and full-4 IQ was correlated with the decline in torque steadiness for the MS group (r = -0.63, P < 0.05; r = -0.64, P < 0.05). Intellectual capacity was not associated with fatigability in persons with MS but was associated with adjustments in muscle activation during the fatiguing contractions.

Fatigue in Chronic Respiratory Diseases: Theoretical Framework and Implications For Real-Life Performance and Rehabilitation

Fatigue is a primary disabling symptom in chronic respiratory diseases (CRD) with major clinical implications. However, fatigue is not yet sufficiently explored and is still poorly understood in CRD, making this symptom underdiagnosed and undertreated in these populations. Fatigue is a dynamic phenomenon, particularly in such evolving diseases punctuated by acute events which can, alone or in combination, modulate the degree of fatigue experienced by the patients. This review supports a comprehensive inter-disciplinary approach of CRD-related fatigue and emphasizes the need to consider both its performance and perceived components. Most studies in CRD evaluated perceived fatigue as a trait characteristic using multidimensional scales, providing precious information about its prevalence and clinical impact. However, these scales are not adapted to understand the complex dynamics of fatigue in real-life settings and should be augmented with ecological assessment of fatigue. The state level of fatigue must also be considered during physical tasks as severe fatigue can emerge rapidly during exercise. CRD patients exhibit alterations in both peripheral and central nervous systems and these abnormalities can be exacerbated during exercise. Laboratory tests are necessary to provide mechanistic insights into how and why fatigue develops during exercise in CRD. A better knowledge of the neurophysiological mechanisms underlying perceived and performance fatigability and their influence on real-life performance will enable the development of new individualized countermeasures. This review aims first to shed light on the terminology of fatigue and then critically considers the contemporary models of fatigue and their relevance in the particular context of CRD. This article then briefly reports the prevalence and clinical consequences of fatigue in CRD and discusses the strengths and weaknesses of various fatigue scales. This review also provides several arguments to select the ideal test of performance fatigability in CRD and to translate the mechanistic laboratory findings into the clinical practice and real-world performance. Finally, this article discusses the dose-response relationship to training and the feasibility and validity of using the fatigue produced during exercise training sessions in CRD to optimize exercise training efficiency. Methodological concerns, examples of applications in selected diseases and avenues for future research are also provided.

Fatigability of the Lumbopelvic Stabilizing Muscles in Women 8 and 26 Weeks Postpartum

Background

Pregnancy and childbirth are associated with lumbopelvic pain and instability. Fatigability of the lumbopelvic stabilizing muscles after childbirth is unknown, and no clinical tests exist to assess this important metric of muscle function.

Objectives

To compare fatigability of the lumbopelvic stabilizing muscles in postpartum and nulligravid (control) women using the Active Straight Leg Raise (ASLR) Fatigue Task, and to determine if fatigability is associated with inter-recti distance (IRD), physical function, and pain/disability.

Study design

Longitudinal case-control study.

Methods

Twenty-nine nulligravid (25.4 ± 9.1 years) and 31 postpartum women (31.4 ± 5.2 years; vaginal delivery n=18) were tested at two time points, 16 weeks apart (postpartum women tested at 8-10 and 24-26 weeks postpartum). Muscular function was assessed with manual muscle testing (MMT), the ASLR Test, and a new ASLR Fatigue Task. Other measures included IRD, rectus abdominis thickness, physical activity, and six-minute walk distance.

Results

Postpartum women were 23% more fatigable (p=0.028) and were weaker (MMT) (p<0.001) than controls up to 26 weeks postpartum. The ASLR fatigue task (time-to-failure) was associated with smaller IRD, greater rectus abdominis thickness, higher physical activity levels, greater MMT strength, and further distance walked in six minutes (p<0.05).

Conclusion

Postpartum women (up to 6 months) had greater fatigability of the lumbopelvic stabilizing muscles and lower physical function than nulligravid women, suggesting core muscle function and fatigability should be assessed after pregnancy and childbirth. The ASLR Fatigue Task could be a clinically useful tool to determine fatigability of the lumbopelvic stabilizing muscles in women postpartum.

Performance Fatigability: Mechanisms and Task Specificity

Performance fatigability is characterized as an acute decline in motor performance caused by an exercise-induced reduction in force or power of the involved muscles. Multiple mechanisms contribute to performance fatigability and originate from neural and muscular processes, with the task demands dictating the mechanisms. This review highlights that (1) inadequate activation of the motoneuron pool can contribute to performance fatigability, and (2) the demands of the task and the physiological characteristics of the population assessed, dictate fatigability and the involved mechanisms. Examples of task and population differences in fatigability highlighted in this review include contraction intensity and velocity, stability and support provided to the fatiguing limb, sex differences, and aging. A future challenge is to define specific mechanisms of fatigability and to translate these findings to real-world performance and exercise training in healthy and clinical populations across the life span.

Maximal Voluntary Activation of the Elbow Flexors Is under Predicted by Transcranial Magnetic Stimulation Compared to Motor Point Stimulation Prior to and Following Muscle Fatigue

Transcranial magnetic (TMS) and motor point stimulation have been used to determine voluntary activation (VA). However, very few studies have directly compared the two stimulation techniques for assessing VA of the elbow flexors. The purpose of this study was to compare TMS and motor point stimulation for assessing VA in non-fatigued and fatigued elbow flexors. Participants performed a fatigue protocol that included twelve, 15 s isometric elbow flexor contractions. Participants completed a set of isometric elbow flexion contractions at 100, 75, 50, and 25% of maximum voluntary contraction (MVC) prior to and following fatigue contractions 3, 6, 9, and 12 and 5 and 10 min post-fatigue. Force and EMG of the bicep and triceps brachii were measured for each contraction. Force responses to TMS and motor point stimulation and EMG responses to TMS (motor evoked potentials, MEPs) and Erb's point stimulation (maximal M-waves, M_max) were also recorded. VA was estimated using the equation: VA% = (1−SITforce/PTforce) × 100. The resting twitch was measured directly for motor point stimulation and estimated for both motor point stimulation and TMS by extrapolation of the linear regression between the superimposed twitch force and voluntary force. MVC force, potentiated twitch force and VA significantly (p < 0.05) decreased throughout the elbow flexor fatigue protocol and partially recovered 10 min post fatigue. VA was significantly (p < 0.05) underestimated when using TMS compared to motor point stimulation in non-fatigued and fatigued elbow flexors. Motor point stimulation compared to TMS superimposed twitch forces were significantly (p < 0.05) higher at 50% MVC but similar at 75 and 100% MVC. The linear relationship between TMS superimposed twitch force and voluntary force significantly (p < 0.05) decreased with fatigue. There was no change in triceps/biceps electromyography, biceps/triceps MEP amplitudes, or bicep MEP amplitudes throughout the fatigue protocol at 100% MVC. In conclusion, motor point stimulation as opposed to TMS led to a higher estimation of VA in non-fatigued and fatigued elbow flexors. The decreased linear relationship between TMS superimposed twitch force and voluntary force led to an underestimation of the estimated resting twitch force and thus, a reduced VA.

The Relevance of Sex Differences in Performance Fatigability

Performance fatigability differs between men and women for a range of fatiguing tasks. Women are usually less fatigable than men, and this is most widely described for isometric fatiguing contractions and some dynamic tasks. The sex difference in fatigability is specific to the task demands so that one mechanism is not universal, including any sex differences in skeletal muscle physiology, muscle perfusion, and voluntary activation. However, there are substantial knowledge gaps about the task dependency of the sex differences in fatigability, the involved mechanisms, and the relevance to clinical populations and with advanced age. The knowledge gaps are in part due to the significant deficits in the number of women included in performance fatigability studies despite a gradual increase in the inclusion of women for the last 20 yr. Therefore, this review 1) provides a rationale for the limited knowledge about sex differences in performance fatigability, 2) summarizes the current knowledge on sex differences in fatigability and the potential mechanisms across a range of tasks, 3) highlights emerging areas of opportunity in clinical populations, and 4) suggests strategies to close the knowledge gap and understanding the relevance of sex differences in performance fatigability. The limited understanding about sex differences in fatigability in healthy and clinical populations presents as a field ripe with opportunity for high-impact studies. Such studies will inform on the limitations of men and women during athletic endeavors, ergonomic tasks, and daily activities. Because fatigability is required for effective neuromuscular adaptation, sex differences in fatigability studies will also inform on optimal strategies for training and rehabilitation in both men and women.

Recovery of central and peripheral neuromuscular fatigue after exercise

Sustained physical exercise leads to a reduced capacity to produce voluntary force that typically outlasts the exercise bout. This “fatigue” can be due both to impaired muscle function, termed “peripheral fatigue,” and a reduction in the capacity of the central nervous system to activate muscles, termed “central fatigue.” In this review we consider the factors that determine the recovery of voluntary force generating capacity after various types of exercise. After brief, high-intensity exercise there is typically a rapid restitution of force that is due to recovery of central fatigue (typically within 2 min) and aspects of peripheral fatigue associated with excitation-contraction coupling and reperfusion of muscles (typically within 3–5 min). Complete recovery of muscle function may be incomplete for some hours, however, due to prolonged impairment in intracellular Ca2+ release or sensitivity. After low-intensity exercise of long duration, voluntary force typically shows rapid, partial, recovery within the first few minutes, due largely to recovery of the central, neural component. However, the ability to voluntarily activate muscles may not recover completely within 30 min after exercise. Recovery of peripheral fatigue contributes comparatively little to the fast initial force restitution and is typically incomplete for at least 20–30 min. Work remains to identify what factors underlie the prolonged central fatigue that usually accompanies long-duration single joint and locomotor exercise and to document how the time course of neuromuscular recovery is affected by exercise intensity and duration in locomotor exercise. Such information could be useful to enhance rehabilitation and sports performance.

Sex Differences in Neuromuscular Fatigability of the Knee Extensors Post-Stroke

BACKGROUND AND PURPOSE

Despite the implications of optimizing strength training post-stroke, little is known about the differences in fatigability between men and women with chronic stroke. The purpose of this study was to determine the sex differences in knee extensor muscle fatigability and potential mechanisms in individuals with stroke.

METHODS

Eighteen participants (10 men, eight women) with chronic stroke (≥6 months) and 23 (12 men, 11 women) nonstroke controls participated in the study. Participants performed an intermittent isometric contraction task (6 s contraction, 3 s rest) at 30% of maximal voluntary contraction (MVC) torque until failure to maintain the target torque. Electromyography was used to determine muscle activation and contractile properties were assessed with electrical stimulation of the quadriceps muscles.

RESULTS

Individuals with stroke had a briefer task duration (greater fatigability) than nonstroke individuals (24.1 ± 17 min vs. 34.9 ± 16 min). Men were more fatigable than women for both nonstroke controls and individuals with stroke (17.9 ± 9 min vs. 41.6 ± 15 min). Individuals with stroke had less fatigue-related changes in muscle contractile properties and women with stroke differed in their muscle activation strategy during the fatiguing contractions.

CONCLUSIONS

Men and women fatigue differently post-stroke and this may be due to the way they neurally activate muscle groups.

The aging neuromuscular system and motor performance

Age-related changes in the basic functional unit of the neuromuscular system, the motor unit, and its neural inputs have a profound effect on motor function, especially among the expanding number of old (older than ∼60 yr) and very old (older than ∼80 yr) adults. This review presents evidence that age-related changes in motor unit morphology and properties lead to impaired motor performance that includes 1) reduced maximal strength and power, slower contractile velocity, and increased fatigability; and 2) increased variability during and between motor tasks, including decreased force steadiness and increased variability of contraction velocity and torque over repeat contractions. The age-related increase in variability of motor performance with aging appears to involve reduced and more variable synaptic inputs that drive motor neuron activation, fewer and larger motor units, less stable neuromuscular junctions, lower and more variable motor unit action potential discharge rates, and smaller and slower skeletal muscle fibers that coexpress different myosin heavy chain isoforms in the muscle of older adults. Physical activity may modify motor unit properties and function in old men and women, although the effects on variability of motor performance are largely unknown. Many studies are of cross-sectional design, so there is a tremendous opportunity to perform high-impact and longitudinal studies along the continuum of aging that determine 1) the influence and cause of the increased variability with aging on functional performance tasks, and 2) whether lifestyle factors such as physical exercise can minimize this age-related variability in motor performance in the rapidly expanding numbers of very old adults.

Measurement of voluntary activation based on transcranial magnetic stimulation over the motor cortex

This article reviews the use of transcranial magnetic stimulation (TMS) over the motor cortex to make estimates of the level of voluntary drive to muscles. The method, described in 2003 (Todd et al. J Physiol 551: 661-671, 2003), uses a TMS pulse to produce descending corticospinal volleys that synaptically activate motoneurons, resulting in a muscle twitch. Linear regression of the superimposed twitch amplitude and voluntary force (or torque) can generate an "estimated" resting twitch for muscles involved in a task. This procedure has most commonly been applied to elbow flexors but also to knee extensors and other muscle groups. Data from 44 papers using the method were tabulated. We identify and discuss five major technical challenges, and the frequency with which they are addressed. The technical challenges include inadvertent activation of the cortical representation of antagonist muscles, the role of antagonist torques at the studied joint, uncertainty about the effectiveness of the TMS pulse in activating the motoneuron pool, the linearity of the voluntary force (or torque) and superimposed twitch relationship, and variability in the TMS-evoked EMG and force/torque responses. The ideal situation in which the descending corticospinal volleys recruit all of the agonist motoneurons and none of the antagonist motoneurons is unlikely to ever occur, and hence results must be carefully examined to assess the authenticity of the voluntary activation estimates in the context of the experimental design. A partial compromise lies in the choice of stimulus intensity. We also identify aspects of the procedure that require further investigation.

Set Configuration in Resistance Exercise: Muscle Fatigue and Cardiovascular Effects

Purpose

Cardiovascular responses of traditional resistance (TS) training have been extensively explored. However, the fatigue mechanisms associated with an intra-set rest configuration (ISR) have not been investigated. This study compares two modalities of set configurations for resistance exercise that equates work to rest ratios and measures the central and peripheral fatigue in combination with cortical, hemodynamic and cardiovascular measures.

Methods

11 subjects performed two isometric knee extension training sessions using TS and ISR configurations. Voluntary activation (VA), single twitch amplitude, low frequency fatigue (LFF), Mwave, motor evoked potential (MEP), short intracortical inhibition (SICI), intracortical facilitation (ICF) and heart rate variability were evaluated before and after each training session. During each session beat to beat heart rate, blood pressure and rate pressure product (RPP) were also evaluated.

Results

After exercise VA decreased significantly for TS but not for ISR (P < 0.001), single twitch amplitude and LFF values were lower for TS than ISR (P < 0.004), and SICI was reduced only for the TS configuration (P = 0.049). During exercise RPP values were significantly higher for the TS than for ISR (P = 0.001). RPP correlated with VA for TS (r = -.85 P < 0.001) suggesting a relationship between central fatigue and cardiovascular stress.

Conclusions

We conclude that ISR induced lower central and peripheral fatigue as well as lower cardiovascular stress in comparison with TS configuration. Our study suggests that set configuration is a key factor in the regulation of the neuromuscular and cardiovascular responses of resistance training.

Sex Differences in Arm Muscle Fatigability With Cognitive Demand in Older Adults

BACKGROUND

Muscle fatigability can increase when a stressful, cognitively demanding task is imposed during a low-force fatiguing contraction with the arm muscles, especially in women. Whether this occurs among older adults (>60 years) is currently unknown.

QUESTIONS/PURPOSES

We aimed to determine if higher cognitive demands, stratified by sex, increased fatigability in older adults (>60 years). Secondarily, we assessed if varying cognitive demand resulted in decreased steadiness and was explained by anxiety or cortisol levels.

METHODS

Seventeen older women (70±6 years) and 13 older men (71±5 years) performed a sustained, isometric, fatiguing contraction at 20% of maximal voluntary contraction until task failure during three sessions: high cognitive demand (high CD=mental subtraction by 13); low cognitive demand (low CD=mental subtraction by 1); and control (no subtraction).

RESULTS

Fatigability was greater when high and low CD were performed during the fatiguing contraction for the women but not for the men. In women, time to failure with high CD was 16±8 minutes and with low CD was 17±4 minutes, both of which were shorter than time to failure in control contractions (21±7 minutes; high CD mean difference: 5 minutes [95% confidence interval {CI}, 0.78-9.89], p=0.02; low CD mean difference: 4 minutes [95% CI, 0.57-7.31], p=0.03). However, in men, no differences were detected in time to failure with cognitive demand (control: 13±5 minutes; high CD mean difference: -0.09 minutes [95% CI, -2.8 to 2.7], p=1.00; low CD mean difference: 0.75 minutes [95% CI, -1.1 to 2.6], p=0.85). Steadiness decreased (force fluctuations increased) more during high CD than control. Elevated anxiety, mean arterial pressure, and salivary cortisol levels in both men and women did not explain the greater fatigability during high CD.

CONCLUSIONS

Older women but not men showed marked increases in fatigability when low or high CD was imposed during sustained static contractions with the elbow flexor muscles and contrasts with previous findings for the lower limb. Steadiness decreased in both sexes when high CD was imposed.

CLINICAL RELEVANCE

Older women are susceptible to greater fatigability of the upper limb with heightened mental activity during sustained postural contractions, which are the foundation of many work-related tasks.

Sex differences with aging in the fatigability of dynamic contractions

This study determined the sex difference with aging in fatigability of the elbow flexor muscles during a dynamic fatiguing task, and explored the associated mechanisms. We compared fatigability of the elbow flexor muscles in 18 young (20.2 ± 1 years: 9 men) and 36 old adults (73.5 ± 1 years: 16 men) during and in recovery from repeated dynamic contractions (~60°/s) with a load equivalent to 20% of maximal voluntary isometric contraction (MVIC) torque until failure. Transcranial magnetic stimulation (TMS) was used to assess supraspinal fatigue (an increase in the superimposed twitch, SIT) and the peak rate of muscle relaxation. Time to failure was briefer for the men than the women (6.1 ± 2.1 vs. 9.7 ± 5.5 min, respectively; P=0.02) with no difference between young and old adults (7.2 ± 2.9 vs. 8.4 ± 5.2 min, respectively, P=0.45) and no interaction (P>0.05). The relative decline in peak relaxation rate with fatigability was similar for young and old adults (P=0.11), but greater for men than women (P=0.046). Supraspinal fatigue increased for all groups and was associated with the time to failure (P<0.05). Regression analysis however, indicated that the time to failure was best predicted by the peak relaxation rate (baseline values and slowing with fatigability) (r(2)=0.55). Rate-limiting contractile mechanisms (e.g. excitation-contraction coupling) were responsible for the increased fatigability of the elbow flexors of men compared with women for a dynamic fatiguing task of slow angular velocity, and this sex difference was maintained with aging. The age difference in fatigability for the dynamic task was diminished for both sexes relative to what is typically observed with isometric fatiguing contractions.

Age and sex differences in steadiness of elbow flexor muscles with imposed cognitive demand

PURPOSE

These studies determined (1) age- and sex-related differences in steadiness of isometric contractions when high cognitive demand was imposed across a range of forces with the elbow flexor muscles (study 1) and; (2) sex differences in steadiness among older adults when low cognitive demand was imposed (study 2).

METHODS

36 young adults (18-25 years; 18 women) and 30 older adults (60-82 years; 17 women) performed isometric contractions at 5, 30 and 40 % of maximum voluntary contraction (MVC). Study 1 involved a high-cognitive demand session (serial subtractions by 13 during the contraction) and a control session (no mental math). Study 2 (older adults only) involved a low-cognitive demand session (subtracting by 1s).

RESULTS

Older individuals exhibited greater increases in force fluctuations (coefficient of variation of force, CV) with high cognitive demand than young adults, with the largest age difference at 5 % MVC (P = 0.01). Older adults had greater agonist EMG activity with high-cognitive demand and women had greater coactivation than men (P < 0.05). In study 2, CV of force increased with low cognitive demand for the older women but not for the older men (P = 0.03).

CONCLUSION

Older adults had reduced steadiness and increased muscle activation when high cognitive demand was imposed while low cognitive demand induced increased force fluctuations in older women but not older men. These findings have implications for daily and work-related tasks that involve cognitive demand performed simultaneously during submaximal isometric contractions in an aging workforce.

Motor Variability during Sustained Contractions Increases with Cognitive Demand in Older Adults

To expose cortical involvement in age-related changes in motor performance, we compared steadiness (force fluctuations) and fatigability of submaximal isometric contractions with the ankle dorsiflexor muscles in older and young adults and with varying levels of cognitive demand imposed. Sixteen young (20.4 ± 2.1 year: 8 men, 9 women) and 17 older adults (68.8 ± 4.4 years: 9 men, 8 women) attended three sessions and performed a 40 s isometric contraction at 5% maximal voluntary contraction (MVC) force followed by an isometric contraction at 30% MVC until task failure. The cognitive demand required during the submaximal contractions in each session differed as follows: (1) high-cognitive demand session where difficult mental math was imposed (counting backward by 13 from a 4-digit number); (2) low-cognitive demand session which involved simple mental math (counting backward by 1); and (3) control session with no mental math. Anxiety was elevated during the high-cognitive demand session compared with other sessions for both age groups but more so for the older adults than young adults (p  < 0.05). Older adults had larger force fluctuations than young adults during: (1) the 5% MVC task as cognitive demand increased (p  = 0.007), and (2) the fatiguing contraction for all sessions (p  = 0.002). Time to task failure did not differ between sessions or age groups (p  > 0.05), but the variability between sessions (standard deviation of three sessions) was greater for older adults than young (2.02 ± 1.05 vs. 1.25 ± 0.51 min, p  < 0.05). Thus, variability in lower limb motor performance for low- and moderate-force isometric tasks increased with age and was exacerbated when cognitive demand was imposed, and may be related to modulation of synergist and antagonist muscles and an altered neural strategy with age originating from central sources. These data have significant implications for cognitively demanding low-force motor tasks that are relevant to functional and ergonomic in an aging workforce.

Sex differences in human fatigability: mechanisms and insight to physiological responses

Sex-related differences in physiology and anatomy are responsible for profound differences in neuromuscular performance and fatigability between men and women. Women are usually less fatigable than men for similar intensity isometric fatiguing contractions. This sex difference in fatigability, however, is task specific because different neuromuscular sites will be stressed when the requirements of the task are altered, and the stress on these sites can differ for men and women. Task variables that can alter the sex difference in fatigability include the type, intensity and speed of contraction, the muscle group assessed and the environmental conditions. Physiological mechanisms that are responsible for sex-based differences in fatigability may include activation of the motor neurone pool from cortical and subcortical regions, synaptic inputs to the motor neurone pool via activation of metabolically sensitive small afferent fibres in the muscle, muscle perfusion and skeletal muscle metabolism and fibre type properties. Non-physiological factors such as the sex bias of studying more males than females in human and animal experiments can also mask a true understanding of the magnitude and mechanisms of sex-based differences in physiology and fatigability. Despite recent developments, there is a tremendous lack of understanding of sex differences in neuromuscular function and fatigability, the prevailing mechanisms and the functional consequences. This review emphasizes the need to understand sex-based differences in fatigability to shed light on the benefits and limitations that fatigability can exert for men and women during daily tasks, exercise performance, training and rehabilitation in both health and disease.