Functional Limitations and Exercise Intolerance in Patients With Post-COVID Condition: A Randomized Crossover Clinical Trial

Importance

Many patients with post-COVID condition (PCC) experience persistent fatigue, muscle pain, and cognitive problems that worsen after exertion (referred to as postexertional malaise). Recommendations currently advise against exercise in this population to prevent symptom worsening; however, prolonged inactivity is associated with risk of long-term health deterioration.

Objective

To assess postexertional symptoms in patients with PCC after exercise compared with control participants and to comprehensively investigate the physiologic mechanisms underlying PCC.

Design, Setting, and Participants

In this randomized crossover clinical trial, nonhospitalized patients without concomitant diseases and with persistent (≥3 months) symptoms, including postexertional malaise, after SARS-CoV-2 infection were recruited in Sweden from September 2022 to July 2023. Age- and sex-matched control participants were also recruited.

Interventions

After comprehensive physiologic characterization, participants completed 3 exercise trials (high-intensity interval training [HIIT], moderate-intensity continuous training [MICT], and strength training [ST]) in a randomized order. Symptoms were reported at baseline, immediately after exercise, and 48 hours after exercise.

Main Outcomes and Measures

The primary outcome was between-group differences in changes in fatigue symptoms from baseline to 48 hours after exercise, assessed via the visual analog scale (VAS). Questionnaires, cardiopulmonary exercise testing, inflammatory markers, and physiologic characterization provided information on the physiologic function of patients with PCC.

Results

Thirty-one patients with PCC (mean [SD] age, 46.6 [10.0] years; 24 [77%] women) and 31 healthy control participants (mean [SD] age, 47.3 [8.9] years; 23 [74%] women) were included. Patients with PCC reported more symptoms than controls at all time points. However, there was no difference between the groups in the worsening of fatigue in response to the different exercises (mean [SD] VAS ranks for HIIT: PCC, 29.3 [19.5]; controls, 28.7 [11.4]; P = .08; MICT: PCC, 31.2 [17.0]; controls, 24.6 [11.7]; P = .09; ST: PCC, 31.0 [19.7]; controls, 28.1 [12.2]; P = .49). Patients with PCC had greater exacerbation of muscle pain after HIIT (mean [SD] VAS ranks, 33.4 [17.7] vs 25.0 [11.3]; P = .04) and reported more concentration difficulties after MICT (mean [SD] VAS ranks, 33.0 [17.1] vs 23.3 [10.6]; P = .03) compared with controls. At baseline, patients with PCC showed preserved lung and heart function but had a 21% lower peak volume of oxygen consumption (mean difference: -6.8 mL/kg/min; 95% CI, -10.7 to -2.9 mL/kg/min; P < .001) and less isometric knee extension muscle strength (mean difference: -37 Nm; 95% CI, -67 to -7 Nm; P = .02) compared with controls. Patients with PCC spent 43% less time on moderate to vigorous physical activity (mean difference, -26.5 minutes/d; 95% CI, -42.0 to -11.1 minutes/d; P = .001). Of note, 4 patients with PCC (13%) had postural orthostatic tachycardia, and 18 of 29 (62%) showed signs of myopathy as determined by neurophysiologic testing.

Conclusions and Relevance

In this study, nonhospitalized patients with PCC generally tolerated exercise with preserved cardiovascular function but showed lower aerobic capacity and less muscle strength than the control group. They also showed signs of postural orthostatic tachycardia and myopathy. The findings suggest cautious exercise adoption could be recommended to prevent further skeletal muscle deconditioning and health impairment in patients with PCC.

Trial Registration

ClinicalTrials.gov Identifier: NCT05445830.

[Challanges and possibilities with space travel]

Human space flight poses several challenges to human health, such as microgravity, space radiation, and prolonged confinement. Humans are anatomically and physiologically adapted to the gravitation on earth, and microgravity affects crucial functions. We review the pathophysiological consequences of spaceflight on the sensomotoric, cardiovascular, cerebral, and musculoskeletal systems, as well as effects of space radiation and psychosocial considerations. We also look at the medical capabilities in space, and different research methods on earth and in space.

Increased maximal oxygen uptake after sprint-interval training is mediated by central hemodynamic factors as determined by right heart catheterization

There is a lack of knowledge regarding the contribution of central and peripheral factors to the increases in VO_2max following sprint-interval training (SIT). This study investigated the importance of maximal cardiac output (Q_max ) in relation to VO_2max improvements following SIT and the relative importance of the hypervolemic response on Q_max and VO_2max . We also investigated if systemic O₂ extraction increased with SIT as has been previously suggested. Healthy men and women (n = 9) performed 6 weeks of SIT. State-of-the-art measurements: right heart catheterization, carbon monoxide rebreathing and respiratory gas exchange analysis were used to assess Q_max , arterial O₂ content (c_a O₂ ), mixed venous O₂ content (c_v O₂ ), blood volume (BV) and VO_2max before and after the intervention. In order to assess the relative contribution of the hypervolemic response to the increases in VO_2max , BV was reestablished to pre-training levels by phlebotomy. Following the intervention, VO_2max , BV and Q_max increased by 11% (p<0.001), 5.4% (p = 0.013), and 8.8% (p = 0.004) respectively. c_v O₂ decreased by 12.4% (p = 0.011) and systemic O₂ extraction increased by 4.0% (p = 0.009) during the same period, both variables were unaffected by phlebotomy (p = 0.589 and p = 0.548, respectively). After phlebotomy, VO_2max and Q_max reverted back to pre-intervention values (p = 0.064 and p = 0.838 respectively) and were significantly lower compared to post-intervention (p = 0.016 and p = 0.018 respectively). The decline in VO2_max after phlebotomy was linear to the amount of blood removed (p = 0.007, R = -0.82). The causal relationship between BV, Q_max and VO_2max shows that the hypervolemic response is a key mediator of the increases in VO_2max following SIT. KEY POINTS: Sprint-interval training (SIT) is an exercise model involving supramaximal bouts of exercise interspersed with periods of rest known for its efficiency in improving maximal oxygen uptake (VO_2max ). In contrast to the commonly accepted view where central hemodynamic adaptations are considered to be the key mediators of increases in VO_2max there have been propositions highlighting peripheral adaptations as the main mediators in the context of SIT-induced changes in VO_2max . By combining right heart catheterization, carbon monoxide rebreathing and phlebotomy this study shows that increases in maximal cardiac output due to the expansion of the total blood volume is a major explanatory factor for the improvement in VO_2max following SIT. With a smaller contribution from improved systemic oxygen extraction. The present work not only clarifies a controversy in the field by using state-of-the-art methods, but also encourages future research to investigate regulatory mechanisms that could explain how SIT can lead to similar improvements in VO_2max and maximal cardiac output to what has previously been reported for traditional endurance exercise. Abstract figure legend This study aimed to understand the factors contributing to increases in maximal oxygen uptake (VO_2max ) after sprint-interval training (SIT). The study involved 9 healthy subjects who completed 6 weeks of SIT. Measurements were taken before and after the intervention to assess factors such as maximal cardiac output (Q_max ), arterial and mixed venous oxygen content (c_a O₂ and c_v O₂ ), blood volume (BV), and VO_2max . To determine the importance of the hypervolemic response on Q_max and VO_2max , BV was reduced to pre-training levels through phlebotomy. Following the intervention, VO_2max , BV, and Q_max increased, while c_v O₂ decreased, and systemic O₂ extraction increased. After phlebotomy, VO_2max and Q_max decreased to pre-intervention levels, and were significantly lower than post-intervention values. The study suggests that the hypervolemic response is a key factor in the increases in VO_2max following SIT. This article is protected by copyright. All rights reserved.

Improvements in Maximal Oxygen Uptake After Sprint-Interval Training Coincide with Increases in Central Hemodynamic Factors

INTRODUCTION

Sprint-interval training has been shown to improve maximal oxygen uptake, in part through peripheral muscle adaptations that increase oxygen utilization. In contrast, the adaptations of central hemodynamic factors in this context remain unexplored.

PURPOSE

The aim of the current study was to explore the effects of sprint-interval training on maximal oxygen uptake and central hemodynamic factors.

METHODS

Healthy men and women (n = 29; mean age, 27 ± 5 yr; height, 175 ± 8 cm; body mass, 72.5 ± 12.0 kg) performed 6 wk of sprint-interval training consisting of three weekly sessions of 10-min low-intensity cycling interspersed with 3 × 30-s all-out sprints. Maximal oxygen uptake, total blood volume, and maximal cardiac output were measured before and after the intervention.

RESULTS

Maximal oxygen uptake increased by 10.3% (P < 0.001). Simultaneously, plasma volume, blood volume, total hemoglobin mass, and cardiac output increased by 8.1% (276 ± 234 mL; P < 0.001), 6.8% (382 ± 325 mL; P < 0.001), 5.7% (42 ± 41 g; P < 0.001), and 8.5% (1.0 ± 0.9 L·min-1; P < 0.001), respectively. Increased total hemoglobin mass along with measures of body surface area had a significant impact on the improvements in maximal oxygen uptake.

CONCLUSIONS

Six weeks of sprint-interval training results in significant increases in hemoglobin mass, blood volume, and cardiac output. Because these changes were associated with marked improvements in maximal oxygen uptake, we conclude that central hemodynamic adaptations contribute to the improvement in maximal oxygen uptake during sprint-interval training.

Differential responsiveness of glabrous and nonglabrous skin to local transmural pressure elevations: impact of 5 weeks of iterative local pressure loading

We examined the in vivo pressure-flow relationship in human cutaneous vessels during acute and repeated elevations of local transmural pressure. In 10 healthy men, red blood cell flux was monitored simultaneously on the nonglabrous skin of the forearm and the glabrous skin of a finger during a vascular pressure provocation, wherein the blood vessels of an arm were exposed to a wide range of stepwise increasing distending pressures. Forearm skin blood flux was relatively stable at slight and moderate elevations of distending pressure, whereas it increased approximately three- to fourfold at the highest levels (P = 0.004). Finger blood flux, on the contrary, dropped promptly and consistently throughout the provocation (P < 0.001). Eight of the subjects repeated the provocation trial after a 5-wk pressure-training regimen, during which the vasculature in one arm was exposed intermittently (40 min, 3 times/wk) to increased transmural pressure (from +65 mmHg week 1 to +105 mmHg week 5). The training regimen diminished the pressure-induced increase in forearm blood flux by ∼34% (P = 0.02), whereas it inhibited the reduction in finger blood flux (P < 0.001) in response to slight and moderate distending pressure elevations. The present findings demonstrate that during local pressure perturbations, the cutaneous autoregulatory function is accentuated in glabrous compared with in the nonglabrous skin regions. Prolonged intermittent regional exposures to augmented intravascular pressure blunt the responsiveness of the glabrous skin but enhance arteriolar pressure resistance in the nonglabrous skin.

Comparison of Joint and Muscle Biomechanics in Maximal Flywheel Squat and Leg Press

The aim was to compare the musculoskeletal load distribution and muscle activity in two types of maximal flywheel leg-extension resistance exercises: horizontal leg press, during which the entire load is external, and squat, during which part of the load comprises the body weight. Nine healthy adult habitually strength-training individuals were investigated. Motion analysis and inverse dynamics-based musculoskeletal modelling were used to compute joint loads, muscle forces, and muscle activities. Total exercise load (resultant ground reaction force; rGRF) and the knee-extension net joint moment (NJM) were slightly and considerably greater, respectively, in squat than in leg press (p ≤ 0.04), whereas the hip-extension NJM was moderately greater in leg press than in squat (p = 0.03). Leg press was performed at 11° deeper knee-flexion angle than squat (p = 0.01). Quadriceps muscle activity was similar in squat and leg press. Both exercise modalities showed slightly to moderately greater force in the vastii muscles during the eccentric than concentric phase of a repetition (p ≤ 0.05), indicating eccentric overload. That the quadriceps muscle activity was similar in squat and leg press, while rGRF and NJM about the knee were greater in squat than leg press, may, together with the finding of a propensity to perform leg press at deeper knee angle than squat, suggest that leg press is the preferable leg-extension resistance exercise, both from a training efficacy and injury risk perspective.

Interval-induced metabolic perturbation determines tissue fluid shifts into skeletal muscle

Intense interval exercise has proven to be as effective as traditional endurance exercise in improving maximal oxygen uptake. Shared by these two exercise regimes is an acute reduction in plasma volume, which is a suggested stimulus behind exercise-induced increases in blood volume and maximal oxygen uptake. This study aimed to link exercise-induced metabolic perturbation with volume shifts into skeletal muscle tissue. Ten healthy subjects (mean age 33 ± 8 years, 5 males and 5 females) performed three 30 s all-out sprints on a cycle ergometer. Upon cessation of exercise magnetic resonance imaging, ³¹ Phosphorus magnetic resonance spectroscopy and blood samples were used to measure changes in muscle volume, intramuscular energy metabolites and plasma volume. Compared to pre-exercise, muscle volume increased from 1147.1 ± 35.6 ml to 1283.3 ± 11.0 ml 8 min post-exercise. At 30 min post-exercise, muscle volume was still higher than pre-exercise (1147.1 ± 35.6 vs. 1222.2 ± 6.8 ml). Plasma volume decreased by 16 ± 3% immediately post-exercise and recovered back to - 5 ± 6% after 30 min. Principal component analysis of exercise performance, muscle and plasma volume changes as well as changes in intramuscular energy metabolites showed generally strong correlations between metabolic and physiological variables. The strongest predictor for the volume shifts of muscle and plasma was the magnitude of glucose-6-phosphate accumulation post-exercise. Interval training leads to large metabolic and hemodynamic perturbations with accumulation of glucose-6-phosphate as a possible key event in the fluid flux between the vascular compartment and muscle tissue.

Adaptation to 5 weeks of intermittent local vascular pressure increments; mechanisms to be considered in the development of primary hypertension?

The aims were to study effects of iterative exposures to moderate elevations of local intravascular pressure on arterial/arteriolar stiffness and plasma levels of vasoactive substances. Pressures in the vasculature of an arm were increased by 150 mmHg in healthy men (n = 11) before and after a 5-wk regimen, during which the vasculature in one arm was exposed to fifteen 40-min sessions of moderately increased transmural pressure (+65 to +105 mmHg). This vascular pressure training and the pressure-distension determinations were conducted by exposing the subjects' arm versus remaining part of the body to differential ambient pressure. During the pressure-distension determinations, venous samples were simultaneously obtained from pressurized and unpressurized vessels. Pressure training reduced arterial pressure distension by 40 ± 23% and pressure-induced flow by 33 ± 30% (P < 0.01), but only in the pressure-trained arm, suggesting local adaptive mechanisms. The distending pressure-diameter and distending pressure-flow curves, with training-induced increments in pressure thresholds and reductions in response gains, suggest that the increased precapillary stiffness was attributable to increased contractility and structural remodeling of the walls. Acute vascular pressure provocation induced local release of angiotensin-II (ANG II) and endothelin-1 (ET-1) (P < 0.05), suggesting that these vasoconstrictors limited the pressure distension. Pressure training increased basal levels of ET-1 and induced local pressure release of matrix metalloproteinase 7 (P < 0.05), suggesting involvement of these substances in vascular remodeling. The findings are compatible with the notion that local intravascular pressure load acts as a prime mover in the development of primary hypertension.NEW & NOTEWORTHY Adaptive responses to arterial/arteriolar pressure elevation have typically been investigated in cross-sectional studies in hypertensive patients or in longitudinal studies in experimental animals. The present investigation shows that in healthy individuals, fifteen 40-min, carefully controlled, moderate transmural pressure elevations markedly increase in vivo stiffness (i.e. reduce pressure distension) in arteries and arterioles. The response is mediated via local mechanisms, and it appears that endothelin-1, angiotensin-II, and matrix metalloproteinase 7 may have key roles.

Influence of gravity on biomechanics in flywheel squat and leg press

Resistance exercise on Earth commonly involves both body weight and external load. When developing exercise routines and devices for use in space, the absence of body weight is not always adequately considered. This study compared musculoskeletal load distribution during two flywheel resistance knee-extension exercises, performed in the direction of (vertical squat; S) or perpendicular to (horizontal leg press; LP) the gravity vector. Eleven participants performed these two exercises at a given submaximal load. Motion analysis and musculoskeletal modelling were used to compute joint loads and to simulate a weightless situation. The flywheel load was more than twice as high in LP as in S (p < 0.001). Joint moments and forces were greater during LP than during S in the ankle, hip and lower back (p < 0.01) but were similar in the knee. In the simulated weightless situation, hip and lower-back loadings in S were higher than corresponding values at Earth gravity (p ≤ 0.01), whereas LP joint loads did not increase. The results suggest that LP is a better terrestrial analogue than S for knee-extension exercise in weightlessness and that the magnitude and direction of gravity during resistance exercise should be considered when designing and evaluating countermeasure exercise routines and devices for space.

Effects of training with flow restriction on the exercise pressor reflex

Purpose

We hypothesized that 5 weeks of endurance training with blood flow restriction (R-training), providing relative ischemia and stimulation of the muscle chemoreflex, would decrease the exercise pressor reflex (EPR) when compared to training with the same workload in a free-flow condition (NR-training).

Methods

10 subjects performed one-leg knee-extension training four times a week during a 5-week period. Both legs were trained with identical workload, with one leg being trained during flow-restriction induced by lower body positive pressure. The EPR was assessed by measuring the increase in heart rate (HR) and mean arterial pressure (MAP) during an isometric knee extension of 35% of max torque for 90 s, this was done before (C), and after training in each leg (R and NR, respectively).

Results

At the end of isometric contraction, the increase in mean AP (MAP) in the NR-trained leg and in the control condition were 41 ± 4 and 38 ± 4 mmHg, respectively, whereas the increase in the R-trained leg was 30 ± 4 mmHg (p < 0.05 R vs C and NR), corresponding to a decrease of about 25%. A similar patter was observed with respect to responses in HR, where the increase was 28 ± 3 and 28 ± 3 bpm in the NR and C, and 22 ± 4 in the R condition (p < 0.05 R vs C and NR).

Conclusions

Peripheral metabolic changes induced by relative ischemia are important in modifying the EPR in response to exercise training.

Measuring Uptake and Elimination of Nitrogen in Humans at Different Ambient Pressures

BACKGROUND

To measure nitrogen (N2) wash-out and uptake requires elaborate set-ups, especially when doing the measurements at increased or decreased ambient pressure. Here we present a transportable device for quantifying N2 turnover in humans which can be used at different ambient pressures.

METHODS

A modified close-circuit electronic rebreather was used to assess N2 turnover. Changes in N2 volume within the rebreathing circuit, reflecting N2 uptake or washout, were derived from the continuously monitored total system volume and the calculated volumes of oxygen and water vapor. The calculation of continuous N2 volume curves was performed off-line using dedicated computer software.

RESULTS

Four subjects participated in the proof-of-concept tests. At steady state, the drift in calculated N2 volume in the rebreathing circuit over a 1-h duration was minimal. Three of the subjects participated in additional N2 steady-state measurements where 1019 mL (BTPD) of N2 was injected into the rebreathing circuit over 20 min and the measured volume increase was 1006 ± 32 mL. Lastly, N2 elimination was assessed during decompression to 0.5 atm and while breathing hyperoxic gas. N2 uptake was measured during compression to 1.8 atm. The elimination and uptake curves were deemed to be realistic.

DISCUSSION

A method for assessing N2 turnover in humans has been developed and a first evaluation has been performed. It is easy to work with operationally and can be used at different ambient pressures. More research is needed in order to further validate it as a method for assessing N2 turnover in humans.Sundblad P, Frånberg O, Siebenmann C, Gennser M. Measuring uptake and elimination of nitrogen in humans at different ambient pressures. Aerosp Med Hum Perform. 2016; 87(12):1045-1050.

The arterial baroreflex and inherent G tolerance

PURPOSE

High G tolerance is based on the capacity to maintain a sufficient level of arterial pressure (AP) during G load; therefore, we hypothesized that subjects with high G tolerance (H group) would have stronger arterial baroreflex responses compared to subjects with low G tolerance (L group). The carotid baroreflex was evaluated using the neck pressure method (NP), which assesses open-loop responses.

METHODS

The carotid baroreflex was tested in 16 subjects, n = 8 in the H and L group, respectively, in the supine and upright posture. Heart rate and AP were measured.

RESULTS

There were no differences between groups in the maximum slopes of the carotid baroreflex curves. However, the H group had a larger systolic and mean AP (SAP, MAP) increase to the initial hypotensive stimuli of the NP sequence in the upright position compared to the L group, 7.5 ± 6.6 vs 2.0 ± 2.4 and 4.1 ± 3.4 vs 1.1 ± 1.1 mmHg for SAP and MAP, respectively. Furthermore, the L group exhibited an increased latency between stimuli and response in AP in the upright compared to supine position, 4.1 ± 1.0 vs 3.1 ± 0.9 and 4.7 ± 1.1 vs 3.6 ± 0.9 s, for SAP and MAP. No differences in chronotropic responses were observed between the groups.

CONCLUSIONS

It is concluded that the capacity for reflexive vasoconstriction and maintained speed of the vascular baroreflex during orthostatic stress are coupled to a higher relaxed GOR tolerance.

Time courses of central hemodynamics during rapid changes in posture

Changes in posture cause blood volume redistribution, affecting cardiac filling and stroke volume (SV). We hypothesized that the time courses of ventricular filling would differ between the right and left ventricle during a rapid (2 s) tilt and that changes in right ventricular filling pressure would be more swift because of the direct coupling to the systemic circulation. We further hypothesized that the transient imbalance between right and left ventricular filling pressure would influence left ventricular SV changes. Right atrial pressure (RAP), pulmonary capillary wedge pressure (PCWP), left ventricular stroke volume, heart rate, and arterial pressure were recorded beat-by-beat during rapid tilts from supine to upright positions and back again, during rest and dynamic 100-W leg exercise. RAP changes had a faster time course than PCWP during down-tilts, both during rest and exercise (1 ± 1 vs. 6 ± 2 s and 2 ± 2 vs. 6 ± 2 s, respectively; P < 0.05). This discrepancy caused a transient decrease in the end-diastolic pressure difference between the right and left ventricle. The decreased pressure difference in diastole impeded left ventricular filling because of ventricular interdependence, causing SV to fall transiently. The mechanisms of ventricular interdependence were also involved in reverse during up-tilt, where SV was maintained for 2–3 s despite falling PCWP. Furthermore, the decrease in RAP during up-tilt in the resting condition was biphasic with an initial fast and a second slower component, which might suggest the effect of venous valves. This was not seen during dynamic leg exercise where blood pooling is prevented by the venous muscle pump.

G tolerance vis-à-vis pressure-distension and pressure-flow relationships of leg arteries

During increased gravitoinertial (G) load in the head-to-foot direction, pressures in dependent vascular beds are commonly raised to levels capable of distending precapillary vessels, which, in turn, may reduce arterial pressure, and hence compromise the capacity to withstand G load (G tolerance). We hypothesized that distensibility in precapillary leg vessels would be lower in a group of subjects possessing high G tolerance (H; n = 7; relaxed G tolerance = 6.6 ± 0.8 G) than in a group with low G tolerance (L; n = 8; G tolerance = 3.9 ± 0.3 G). The groups were matched with regard to gender, age, weight, height, and resting arterial pressure. Arterial pressure-distension and pressure-flow experiments were performed with the subject supine in a pressure chamber with a lower leg protruding to the outside. Increased intravascular pressure in the blood vessels of the outside leg was accomplished by stepwise increasing chamber pressure to 240 mmHg. Diameter and flow in the posterior tibial artery were measured by ultrasonographic/Doppler techniques. Pressure-induced increments in arterial diameter and flow were more pronounced (p < 0.03) in the L (14.1 ± 4.2% and 32 ± 21 ml/min respectively) than in the H (1.7 ± 5.0% and 1.6 ± 25 ml/min) group, and the pressure thresholds at which these increments commenced were lower (by 52 and 48 mmHg, respectively) in the L than in the H group (p < 0.04). Negative correlations were observed between G tolerance and the increments in diameter and flow (p < 0.02). Thus, the wall stiffness of precapillary leg vessels is greater in individuals with high relaxed G tolerance; whether a causal relationship exists remains to be established.

Activation of the erythropoietin receptor in human skeletal muscle

OBJECTIVE

Erythropoietin receptor (EPOR) expression in non-hematological tissues has been shown to be activated by locally produced and/or systemically delivered EPO. Improved oxygen homeostasis, a well-established consequence of EPOR activation, is very important for human skeletal muscle performance. In the present study we investigate whether human skeletal muscle fibers and satellite cells express EPOR and if it is activated by exercise.

DESIGN AND METHODS

Ten healthy males performed 65 min of cycle exercise. Biopsies were obtained from the vastus lateralis muscle and femoral arterio-venous differences in EPO concentrations were estimated.

RESULTS

The EPOR protein was localized in areas corresponding to the sarcolemma and capillaries. Laser dissection identified EPOR mRNA expression in muscle fibers. Also, EPOR mRNA and protein were both detected in human skeletal muscle satellite cells. In the initial part of the exercise bout there was a release of EPO from the exercising leg to the circulation, possibly corresponding to an increased bioavailability of EPO. After exercise, EPOR mRNA and EPOR-associated JAK2 phosphorylation were increased.

CONCLUSIONS

Interaction with JAK2 is required for EPOR signaling and the increase found in phosphorylation is therefore closely linked to the activation of EPOR. The receptor activation by acute exercise suggests that signaling through EPOR is involved in exercise-induced skeletal muscle adaptation, thus extending the biological role of EPO into the skeletal muscle.

Baroreflex impairment during rapid posture changes at rest and exercise after 120 days of bed rest

Orthostatic intolerance is common after space flight and head-down tilt (HDT) bed rest. We hypothesized that HDT-induced impairments of arterial blood pressure (AP) control would be more marked during exercise and that recovery of baroreflex function after very long-term HDT would be delayed. Six subjects were studied before (BDC) during (day 60, D60; D113) and after (recovery day 0, R0; R3; R15) 120 days of HDT. Supine resting subjects were exposed to repeated 1 min passive tilts to upright at 3-min interval. During 50 W steady-state exercise corresponding tilt had a 2-min duration at 4-min interval. The amplitudes of the tilt-induced transient beat-by-beat deviations in AP and rate (HR) were determined during the gravity transients. At rest these deviations did not change over time, but during exercise the total peak-to-nadir range of deviations in systolic AP (SAP) at up-tilt and down-tilt increased to 168+/-16% (mean+/-SEM) of BDC at D113 with no clear recovery upto and including R15. Counter-regulatory HR responses were not increased proportionally and especially not tachycardic responses to up-tilt, resulting in a reduction of baroreflex sensitivity (deltaRR-interval/deltaSAP) by 55+/-9% of BDC at D113 with no recovery upto and including R15. We conclude that prolonged bed rest cause long-lasting impairments in AP control and baroreflex function in exercising humans.

Residual heterogeneity of intra- and interregional pulmonary perfusion in short-term microgravity

We hypothesized that the perfusion heterogeneity in the human, upright lung is determined by nongravitational more than gravitational factors. Twelve and six subjects were studied during two series of parabolic flights. We used cardiogenic oscillations of O2/SF6 as an indirect estimate of intraregional perfusion heterogeneity ( series 1) and phase IV amplitude (P4) as a indirect estimate of interregional perfusion heterogeneity ( series 2). A rebreathing-breath holding-expiration maneuver was performed. In flight, breath holding and expiration were performed either in microgravity (0 G) or in hypergravity. Controls were performed at normal gravity (1 G). In series 1, expiration was performed at 0 G. Cardiogenic oscillations of O2/SF6 were 19% lower when breath holding was performed at 0 G than when breath holding was performed at 1 G [means (SD): 1.7 (0.3) and 2.3 (0.6)% units] ( P = 0.044). When breath holding was performed at 1.8 G, values did not differ from 1-G control [2.6 (0.8)% units, P = 0.15], but they were 17% larger at 1.8 G than at 1 G. In series 2, expiration was performed at 1.7 G. P4 changed with gravity ( P < 0.001). When breath holding was performed at 0 G, P4 values were 45 (46)% of control. When breath holding was performed at 1.7 G, P4 values were 183 (101)% of control. We conclude that more than one-half of indexes of perfusion heterogeneity at 1 G are caused by nongravitational mechanisms.

Long-term bed rest-induced reductions in stroke volume during rest and exercise: cardiac dysfunction vs. volume depletion

Long-term head-down-tilt bed rest (HDT) causes cardiovascular deconditioning, attributed to reflex dysfunctions, plasma volume reduction, or cardiac impairments. Our objective with the present study was to evaluate the functional importance and relative contribution of these during rest and exercise in supine and upright postures. We studied six subjects before (baseline), during [days 60 (D60) and 113 (D113)], and after [recovery days 0 (R0), 3 (R3), and 15 (R15)] 120 days of -6 degrees HDT. We determined cardiac output, stroke volume (SV), mean arterial pressure, and heart rate during rest and exercise in supine and upright postures. Cardiac output and SV decreased significantly in all four conditions, but the time courses differed for rest and exercise. Upright resting SV was decreased by 24 +/- 9% at D60 compared with baseline but had recovered already at R3. Supine exercise SV decreased more slowly (by 5 +/- 8% at D60 and by 18 +/- 4% at D113) and recovered more slowly after HDT termination. Steady-state mean arterial pressure showed no changes. Heart rate had increased by 18 +/- 4% at D60 and had recovered partially at R3. Our data indicate that long-term HDT causes both a rapid, preload-dependent reduction in SV, most evident during rest in the upright position, and a more slowly developing cardiac dysfunction, most evident during supine exercise. However, the ability to maintain blood pressure and to perform sustained low levels of dynamic exercise is not influenced by HDT.

Effects of hypergravity on the distributions of lung ventilation and perfusion in sitting humans assessed with a simple two-step maneuver

Increased gravity impairs pulmonary distributions of ventilation and perfusion. We sought to develop a method for rapid, simultaneous, and noninvasive assessments of ventilation and perfusion distributions during a short-duration hypergravity exposure. Nine sitting subjects were exposed to one, two, and three times normal gravity (1, 2, and 3 G) in the head-to-feet direction and performed a rebreathing and a single-breath washout maneuver with a gas mixture containing C2H2, O2, and Ar. Expirograms were analyzed for cardiogenic oscillations (COS) and for phase IV amplitude to analyze inhomogeneities in ventilation (Ar) and perfusion [CO2-to-Ar ratio (CO2/Ar)] distribution, respectively. COS were normalized for changes in stroke volume. COS for Ar increased from 1-G control to 128 ± 6% (mean ± SE) at 2 G ( P = 0.02 for 1 vs. 2 G) and 165 ± 13% at 3 G ( P = 0.002 for 2 vs. 3 G). Corresponding values for CO2/Ar were 135 ± 12% ( P = 0.04) and 146 ± 13%. Phase IV amplitude for Ar increased to 193 ± 39% ( P = 0.008) at 2 G and 229 ± 51% at 3 G compared with 1 G. Corresponding values for CO2/Ar were 188 ± 29% ( P = 0.02) and 219 ± 18%. We conclude that not only large-scale ventilation and perfusion inhomogeneities, as reflected by phase IV amplitude, but also smaller-scale inhomogeneities, as reflected by the ratio of COS to stroke volume, increase with hypergravity. Except for small-scale ventilation distribution, most of the impairments observed at 3 G had been attained at 2 G. For some of the parameters and gravity levels, previous comparable data support the present simplified method.

Effects of gravity on lung diffusing capacity and cardiac output in prone and supine humans

Both in normal subjects exposed to hypergravity and in patients with acute respiratory distress syndrome, there are increased hydrostatic pressure gradients down the lung. Also, both conditions show an impaired arterial oxygenation, which is less severe in the prone than in the supine posture. The aim of this study was to use hypergravity to further investigate the mechanisms behind the differences in arterial oxygenation between the prone and the supine posture. Ten healthy subjects were studied in a human centrifuge while exposed to 1 and 5 times normal gravity (1 G, 5 G) in the anterioposterior (supine) and posterioanterior (prone) direction. They performed one rebreathing maneuver after approximately 5 min at each G level and posture. Lung diffusing capacity decreased in hypergravity compared with 1 G (ANOVA, P = 0.002); it decreased by 46% in the supine posture compared with 25% in the prone (P = 0.01 for supine vs. prone). At the same time, functional residual capacity decreased by 33 and 23%, respectively (P < 0.001 for supine vs. prone), and cardiac output by 40 and 31% (P = 0.007 for supine vs. prone), despite an increase in heart rate of 16 and 28% (P < 0.001 for supine vs. prone), respectively. The finding of a more impaired diffusing capacity in the supine posture compared with the prone at 5 G supports our previous observations of more severe arterial hypoxemia in the supine posture during hypergravity. A reduced pulmonary-capillary blood flow and a reduced estimated alveolar volume can explain most of the reduction in diffusing capacity when supine.

Relationship between breath-synchronous arterial pressure and heart rate variations during orthostatic stress

It has recently been shown that the phase relationship between respiration-induced changes in arterial pressure (AP) and heart rate (HR) are different in supine and upright postures. We wanted to further analyse the coupling between respiration, arterial blood pressure and HR in the time domain, and how this coupling was altered during orthostatic stress. Nine healthy subjects were studied. Respiration-induced changes in AP and HR were recorded during frequency- and volume-controlled breathing. This was done during supine rest with and without lower body negative pressure (-50 mmHg) (LBNP). All experiments were performed after beta1-blockade. Responses were averaged breath-by-breath to enhance the time resolution and to eliminate noise. The respiration-induced changes in arterial pulse pressure (PP) were different between control and LBNP: The peak in PP during the respiratory cycle occurred 0.9 +/- 0.8 (mean +/- SD) s before the onset of inspiration during supine control and 0.8 +/- 2.1 s after the onset of inspiration during LBNP (P = 0.03). These changes in the timing of peak PP significantly distorted the cyclic systolic AP and mean AP fluctuations during LBNP. Despite the altered AP response with LBNP, HR fluctuations closely correlated in time with respiration in all conditions, albeit with a significantly reduced amplitude during LBNP (-49%, P = 0.01). The results points to a lack of coupling between AP and HR during paced breathing and thus suggest that respiratory sinus dysrhythmia at least, to a large extent, is independent of the arterial baroreflex.

Influence of posture on left ventricular long- and short-axis shortening

End-diastolic volume and left ventricular stroke volume are increased in the supine compared with upright position, but the contribution of long-axis (LAS) and short-axis shortening (SAS) to these changes with change in posture has not been established. We examined long- and short-axis motion and dimensions with echocardiography in 10 healthy subjects in the upright and supine position. Long-axis length at end diastole was almost identical, whereas the diastolic short-axis diameter was increased in the supine position. At end systole, there was a decreased long-axis length and increased short-axis length in the supine vs. upright position. Both LAS and SAS were enhanced in supine vs. upright positions [LAS: 9.3 +/- 2.2 vs. 15.1 +/- 3.1 mm (P < 0.001); SAS: 12.7 +/- 3.2 vs. 16.3 +/- 2.8 mm (P < 0.001)], presumably via Starling mechanisms. LAS increased more in the lateral part of the mitral annulus than in the septal part [7.7 +/- 2.6 vs. 4.0 +/- 2.8 mm (P < 0.006)], which implies that the more spherical form, in the supine position, induces more stretch at the lateral free wall than in the ventricular septum. These findings support the notion that Starling mechanisms affect systolic LAS.

Impaired pressor response after spaceflight and bed rest: evidence for cardiovascular dysfunction

We hypothesized that impaired cardiovascular responses to isometric muscle action contribute to the cardiovascular deconditioning that occurs after space flight (SF) and head-down-tilt bed rest (HDT). Six subjects were studied before, during and after 120 days of -6 degrees HDT, and four subjects were studied before, during (two subjects) and after 179-389 days of SF. Subjects performed a sustained handgrip (SHG) at a force equivalent to 30% of maximum contraction force for 2 min, and heart-rate (HR) and pressor (mean arterial pressure, deltaMAP) responses were recorded. At the same relative force, both deltaHR and deltaMAP were significantly reduced during the first days after HDT (-54%, P<0.05 and -43%, P<0.05). In two subjects studied within 24 h after their return from SF, deltaMAP was practically absent (-79%, P<0.05) whereas in four subjects studied 1-4 days after return from SF, deltaMAP was reduced by 35% (P<0.05). deltaHR was not significantly changed. Our finding of attenuated pressor responses to SHG after HDT and SF supports the notion of impairments at both the neurocirculatory control and effector organ levels.

Cardiovascular responses to upright and supine exercise in humans after 6 weeks of head-down tilt (-6 degrees)

Seven healthy men performed steady-state dynamic leg exercise at 50 W in supine and upright postures, before (control) and repeatedly after 42 days of strict head-down tilt (HDT) (-6 degrees) bedrest. Steady-state heart rate (fc), mean arterial blood pressure, cardiac output (Qc), and stroke volume (SV) were recorded. The following data changed significantly from control values. The fc was elevated in both postures at least until 12 days, but not at 32 days after bedrest. Immediately after HDT, SV and Qc were decreased by 25 (SEM 3)% and 19 (SEM 3)% in supine, and by 33 (SEM 5)% and 20 (SEM 3)% in upright postures, respectively. Within 2 days there was a partial recovery of SV in the upright but not in the supine posture. The SV and Qc during supine exercise remained significantly decreased for at least a month. Submaximal oxygen uptake did not change after HDT. We concluded that the cardiovascular response to exercise after prolonged bedrest was impaired for so long that it suggested that structural cardiac changes had developed during the HDT period.

Haemodynamic and baroreflex responses to whole-body tilting in exercising men before and after 6 weeks of bedrest

We sought to determine whether the cardiovascular deconditioning that occurs in exercising men after prolonged (42 days) bedrest in the head-down tilt (HDT) position is primarily related to mechanical changes in the heart or to an impaired arterial-cardiacchronotropic baroreflex. Seven subjects were studied before (C, control) and repeatedly after HDT with rapid tilting between the upright and supine positions during steady-state 50-W dynamic leg exercise. Ventricular interdependence was assumed to be an index of cardiac size; it was assessed on the basis of the initial dip of arterial pulse pressure (PP) induced by a sudden tilt from the upright to the supine position (down-tilt). Arterialcardiac-chronotropic baroreflex sensitivity (ABS) was assessed as the ratio between tilt-induced heart rate transients and the preceding (and reciprocal) transient in arterial pressure. On the first day of recovery, the initial PP dip was -4 (2) mmHg (where 1 mmHg is 0.13 kPa), less than half of the control value; on subsequent recovery days, the initial PP dip was not significantly different from the control value. When tilting from the upright to the supine position, mean ABS ranged from 1.02 to 1.06 bpm/mmHg during three separate control sessions. Tilts in the opposite direction gave lower ABS values because of the more sluggish HR response and ranged from 0.43 to 0.45 bpm/mmHg in the control situations. ABS did not change after HDT. Our results indicate that impairments of the cardiovascular system after long-term bedrest are of haemodynamic rather than baroreflex origin.

Short-term cardiovascular responses to rapid whole-body tilting during exercise

Our objective was to characterize the responses of heart rate (HR) and arterial blood pressure (BP) to changes in posture during concomitant dynamic leg exercise. Ten men performed dynamic leg exercise at 50, 100, and 150 W and were rapidly and repeatedly tilted between supine (0 degrees ) and upright (80 degrees ) positions at 2-min intervals. Continuous recordings of BP and HR were made, and changes in central blood volume were estimated from transthoracic impedance. Short-lasting increases in BP were observed immediately upon tilting from the upright to the supine position (down-tilt), averaging +18 mmHg (50 W) to +31 mmHg (150 W), and there were equally short-lasting decreases in BP, ranging from -26 to -38 mmHg upon tilting from supine to upright (up-tilt). These components occurred for all pressure parameters (systolic, mean, diastolic, and pulse pressures). We propose that these transients reflect mainly tilt-induced changes in total peripheral resistance resulting from decreases and increases of the efficiency of the venous muscle pump. After 3-4 s (down-tilt) and 7-11 s (up-tilt) there were large HR transients in a direction opposite to the pressure transients. These HR transients were larger during the down-tilt (-15 to -26 beats. min(-1)) than during the up-tilt (+13 to +17 beats. min(-1)), and increased in amplitude with work intensity during the down-tilt. The tilt-induced HR fluctuations could be modelled as a basically linear function of an arterial baroreflex input from a site half-way between the heart and the carotid sinus, and with varying contributions of fast vagal and slow sympathetic HR responses resulting in attenuated tachycardic responses to hypotensive stimuli during exercise.

Oxygen-conserving effects of apnea in exercising men

We sought to determine whether apnea-induced cardiovascular responses resulted in a biologically significant temporary O(2) conservation during exercise. Nine healthy men performing steady-state leg exercise carried out repeated apnea (A) and rebreathing (R) maneuvers starting with residual volume +3.5 liters of air. Heart rate (HR), mean arterial pressure (MAP), and arterial O(2) saturation (Sa(O(2)); pulse oximetry) were recorded continuously. Responses (DeltaHR, DeltaMAP) were determined as differences between HR and MAP at baseline before the maneuver and the average of values recorded between 25 and 30 s into each maneuver. The rate of O(2) desaturation (DeltaSa(O(2))/Deltat) was determined during the same time interval. During apnea, DeltaSaO(2)/Deltat had a significant negative correlation to the amplitudes of DeltaHR and DeltaMAP (r(2) = 0.88, P < 0.001); i.e., individuals with the most prominent cardiovascular responses had the slowest DeltaSa(O(2))/Deltat. DeltaHR and DeltaMAP were much larger during A (-44 +/- 8 beats/min, +49 +/- 4 mmHg, respectively) than during R maneuver (+3 +/- 3 beats/min, +30 +/- 5 mmHg, respectively). DeltaSa(O(2))/Deltat during A and R maneuvers was -1.1 +/- 0.1 and -2.2 +/- 0.2% units/s, respectively, and nadir Sa(O(2)) values were 58 +/- 4 and 42 +/- 3% units, respectively. We conclude that bradycardia and hypertension during apnea are associated with a significant temporary O(2) conservation and that respiratory arrest, rather than the associated hypoxia, is essential for these responses.

Arterial baroreflex control during mild-to-moderate nitrous oxide narcosis

We hypothesized that light-to-moderate inert gas narcosis might play a role in bradycardia in divers by altering sensitivity or response dynamics of arterial baroreflexes. Carotid-cardiac and carotid-mean arterial pressure (MAP) baroreflex response curves were generated by applying multiple levels of neck pressure and suction. Seven healthy volunteers were studied during air breathing (control) and during inhalation of 39% nitrous oxide (N2O). Baseline (pre-stimulus) heart rate (HR) and MAP were not altered by N2O. Range, threshold level, saturation level, and delay of responses did not differ between conditions. For hypertensive stimuli, sensitivity of responses did not differ between air control and N2O inhalation, but for hypotensive stimuli, maximal response gain for HR tended to be reduced with N2O inhalation (P = 0.054). Our results speak against inert gas narcosis as a primary mechanism for hyperbaric bradycardia, but it remains possible that an attenuation of tachycardic responses to hypotensive stimuli plays a role.

Human carotid baroreflex during isometric lower arm contraction and ischemia

Our aim was to determine the roles of somatomotor activation and muscle ischemia for the tachycardia and hypertension of isometric arm contraction. Carotid-cardiac and carotid-mean arterial pressure (MAP) baroreflex response curves were determined in 10 men during rest, during isometric arm contraction at 30% of maximum, and during postcontraction ischemia. Carotid distending pressure (CDP) was changed by applying pressure and suction in a neck chamber. Pressures ranged from +40 to -80 mmHg and were applied repeatedly for 15 s during the three conditions. Maximum slopes and ranges of the response curves did not differ among conditions. The heart rate (HR) curve was shifted to a 14 +/- 1.8 (mean +/- SE) beats/min higher HR and a 9 +/- 5.7 mmHg higher CDP during contraction and to a 14 +/- 5.9 mmHg higher CDP during postcontraction ischemia with no change of HR compared with rest. The MAP curve was shifted to a 20 +/- 2.8 mmHg higher MAP and to a 18 +/- 5.4 mmHg higher CDP during contraction, and the same shifts were recorded during postcontraction ischemia. We conclude that neither somatomotor activation nor muscle ischemia changes the sensitivity of arterial baroreflexes. The upward shift of the MAP response curve, with no shift of the HR response curve during postexercise ischemia, supports the notion of parallel pathways for MAP and HR regulation in which HR responses are entirely caused by somatomotor activation and the pressor response is mainly caused by muscle ischemia.

Influence of apnea on cardiovascular responses to neck suction during exercise

Short-lasting neck suction (NS) is a common method to assess the carotid-cardiac baroreflex, and NS is usually applied during apnea to avoid breath-synchronous variations of heart rate (HR) and blood pressure. We hypothesized that the apnea might provoke cardiovascular effects that could confound the HR and blood pressure responses to NS. HR and blood pressure responses to 10-s trains of 50-mmHg pulses of NS were studied in six male subjects during supine rest, upright rest, isometric arm exercise at 30% of maximal voluntary contraction, and dynamic leg exercise at 100 W in the sitting position. Repeated NS sequences were performed during apnea preceded by a relaxed expiration to functional residual capacity and during eupnea. Initial HR responses to NS were similar during eupnea and apnea in all conditions. However, during isometric and dynamic exercise, recordings made under eupneic and apneic conditions differed during the second half of the NS period. During apneic isometric arm contraction, the elevation of mean carotid distending pressure (MCDP) (arterial pressure at carotid level minus NS pressure) was maintained at a 25-35% higher level than during eupneic isometric exercise over the last half of the NS period. In dynamic exercise, mean arterial pressure and MCDP started to increase after 3-5 s of apneic NS, whereas they were maintained during eupnea. One to three seconds later, HR started to drop markedly in apneic subjects, reaching values 20 beats/min lower than those in eupneic subjects at the end of the NS. We conclude that cardiovascular effects of apnea may appear after only 8 s of apnea in dynamic exercise and therefore could confound responses to NS.

Slowing of carotid-cardiac baroreflex with standing and with isometric and dynamic muscle activity

We hypothesized that the carotid-cardiac baroreflex becomes slowed in conditions with increased sympathetic activity. Changes in heart rate (HR) and blood pressure in response to 10-s trains of 50-mmHg pulses of neck suction (NS) were studied in six male subjects during supine rest, upright rest, isometric arm exercise at 30% of maximum voluntary contraction, and dynamic leg exercise at 100 W in the sitting position. Estimated mean carotid distending pressure increased by approximately 20 mmHg with 50-mmHg, QRS-triggered, pulsatile NS. Repeated NS sequences were performed in each condition. The amplitude of the bradycardic response was highly variable among the subjects and did not differ significantly between conditions, mean values ranging from 0.3 to 0.6 beats.min-1.mmHg-1. In supine rest, the full bradycardic response appeared within < 1 s, i.e., during or immediately after the R-R interval of the first NS pulse. In the other conditions it took significantly longer, 2-3 s or three to seven R-R intervals, for the full HR responses to develop. Our results support the notion that the carotid-cardiac baroreflex in humans becomes slowed under conditions of concurrent sympathetic stimulation.