Measures of reliability in sports medicine and science

Reliability refers to the reproducibility of values of a test, assay or other measurement in repeated trials on the same individuals. Better reliability implies better precision of single measurements and better tracking of changes in measurements in research or practical settings. The main measures of reliability are within-subject random variation, systematic change in the mean, and retest correlation. A simple, adaptable form of within-subject variation is the typical (standard) error of measurement: the standard deviation of an individual's repeated measurements. For many measurements in sports medicine and science, the typical error is best expressed as a coefficient of variation (percentage of the mean). A biased, more limited form of within-subject variation is the limits of agreement: the 95% likely range of change of an individual's measurements between 2 trials. Systematic changes in the mean of a measure between consecutive trials represent such effects as learning, motivation or fatigue; these changes need to be eliminated from estimates of within-subject variation. Retest correlation is difficult to interpret, mainly because its value is sensitive to the heterogeneity of the sample of participants. Uses of reliability include decision-making when monitoring individuals, comparison of tests or equipment, estimation of sample size in experiments and estimation of the magnitude of individual differences in the response to a treatment. Reasonable precision for estimates of reliability requires approximately 50 study participants and at least 3 trials. Studies aimed at assessing variation in reliability between tests or equipment require complex designs and analyses that researchers seldom perform correctly. A wider understanding of reliability and adoption of the typical error as the standard measure of reliability would improve the assessment of tests and equipment in our disciplines.

Transcranial DC stimulation (tDCS): a tool for double-blind sham-controlled clinical studies in brain stimulation

OBJECTIVE

Brain polarization in the form of transcranial direct current stimulation (tDCS), which influences motor function and learning processes, has been proposed as an adjuvant strategy to enhance training effects in Neurorehabilitation. Proper testing in Neurorehabilitation requires double-blind sham-controlled study designs. Here, we evaluated the effects of tDCS and sham stimulation (SHAM) on healthy subjects and stroke patients' self-report measures of attention, fatigue, duration of elicited sensations and discomfort.

METHODS

tDCS or SHAM was in all cases applied over the motor cortex. Attention, fatigue, and discomfort were self rated by study participants using visual analog scales. Duration of perceived sensations and the ability to distinguish tDCS from Sham sessions were determined. Investigators questioning the patients were blind to the intervention type.

RESULTS

tDCS and SHAM elicited comparably minimal discomfort and duration of sensations in the absence of differences in attention or fatigue, and could not be distinguished from SHAM by study participants nor investigators.

CONCLUSIONS

Successful blinding of subjects and investigators and ease of application simultaneously with training protocols supports the feasibility of using tDCS in double-blind, sham-controlled randomized trials in clinical Neurorehabilitation.

SIGNIFICANCE

tDCS could evolve into a useful tool, in addition to TMS, to modulate cortical activity in Neurorehabilitation.

Match performance of high-standard soccer players with special reference to development of fatigue

The aim of this study was to assess physical fitness, match performance and development of fatigue during competitive matches at two high standards of professional soccer. Computerized time-motion analyses were performed 2-7 times during the competitive season on 18 top-class and 24 moderate professional soccer players. In addition, the players performed the Yo-Yo intermittent recovery test. The top-class players performed 28 and 58% more (P < 0.05) high-intensity running and sprinting, respectively, than the moderate players (2.43 +/- 0.14 vs 1.90 +/- 0.12 km and 0.65 +/- 0.06 vs 0.41 +/- 0.03 km, respectively). The top-class players were better (11%; P < 0.05) on the Yo-Yo intermittent recovery test than the moderate players (2.26 +/- 0.08 vs 2.04 +/- 0.06 km, respectively). The amount of high-intensity running, independent of competitive standard and playing position, was lower (35-45%; P < 0.05) in the last than in the first 15 min of the game. After the 5-min period during which the amount of high-intensity running peaked, performance was reduced (P < 0.05) by 12% in the following 5 min compared with the game average. Substitute players (n = 13) covered 25% more (P < 0.05) ground during the final 15 min of high-intensity running than the other players. The coefficient of variation in high-intensity running was 9.2% between successive matches, whereas it was 24.8% between different stages of the season. Total distance covered and the distance covered in high-intensity running were higher (P < 0.05) for midfield players, full-backs and attackers than for defenders. Attackers and full-backs covered a greater (P < 0.05) distance in sprinting than midfield players and defenders. The midfield players and full-backs covered a greater (P < 0.05) distance than attackers and defenders in the Yo-Yo intermittent recovery test (2.23 +/- 0.10 and 2.21 +/- 0.04 vs 1.99 +/- 0.11 and 1.91 +/- 0.12 km, respectively). The results show that: (1) top-class soccer players performed more high-intensity running during a game and were better at the Yo-Yo test than moderate professional players; (2) fatigue occurred towards the end of matches as well as temporarily during the game, independently of competitive standard and of team position; (3) defenders covered a shorter distance in high-intensity running than players in other playing positions; (4) defenders and attackers had a poorer Yo-Yo intermittent recovery test performance than midfielders and full-backs; and (5) large seasonal changes were observed in physical performance during matches.

EULAR revised recommendations for the management of fibromyalgia

OBJECTIVE

The original European League Against Rheumatism recommendations for managing fibromyalgia assessed evidence up to 2005. The paucity of studies meant that most recommendations were 'expert opinion'.

METHODS

A multidisciplinary group from 12 countries assessed evidence with a focus on systematic reviews and meta-analyses concerned with pharmacological/non-pharmacological management for fibromyalgia. A review, in May 2015, identified eligible publications and key outcomes assessed were pain, fatigue, sleep and daily functioning. The Grading of Recommendations Assessment, Development and Evaluation system was used for making recommendations.

RESULTS

2979 titles were identified: from these 275 full papers were selected for review and 107 reviews (and/or meta-analyses) evaluated as eligible. Based on meta-analyses, the only 'strong for' therapy-based recommendation in the guidelines was exercise. Based on expert opinion, a graduated approach, the following four main stages are suggested underpinned by shared decision-making with patients. Initial management should involve patient education and focus on non-pharmacological therapies. In case of non-response, further therapies (all of which were evaluated as 'weak for' based on meta-analyses) should be tailored to the specific needs of the individual and may involve psychological therapies (for mood disorders and unhelpful coping strategies), pharmacotherapy (for severe pain or sleep disturbance) and/or a multimodal rehabilitation programme (for severe disability).

CONCLUSIONS

These recommendations are underpinned by high-quality reviews and meta-analyses. The size of effect for most treatments is relatively modest. We propose research priorities clarifying who will benefit from specific interventions, their effect in combination and organisation of healthcare systems to optimise outcome.

Neurobiology of muscle fatigue

Muscle fatigue encompasses a class of acute effects that impair motor performance. The mechanisms that can produce fatigue involve all elements of the motor system, from a failure of the formulation of the descending drive provided by suprasegmental centers to a reduction in the activity of the contractile proteins. We propose four themes that provide a basis for the systematic evaluation of the neural and neuromuscular fatigue mechanisms: 1) task dependency to identify the conditions that activate the various mechanisms; 2) force-fatigability relationship to explore the interaction between the mechanisms that results in a hyperbolic relationship between force and endurance time; 3) muscle wisdom to examine the association among a concurrent decline in force, relaxation rate, and motor neuron discharge that results in an optimization of force; and 4) sense of effort to determine the role of effort in the impairment of performance. On the basis of this perspective with an emphasis on neural mechanisms, we suggest a number of experiments to advance our understanding of the neurobiology of muscle fatigue.

Changes in muscle contractile properties and neural control during human muscular fatigue

The factors limiting force production and exercise endurance time have been briefly described, together with some of the changes occurring at various sites within the muscle and central nervous system. Evidence is presented that, in fatigue of sustained maximal voluntary contractions (MVC) executed by well-motivated subjects, the reduction in force generating capacity need not be due to a decline in central nervous system (CNS) motor drive or to failing neuromuscular transmission, but can be attributed solely to contractile failure of the muscles involved. However, despite this conclusion, both the integrated electromyogram (EMG) and the mean firing rate of individual motor units do decline progressively during sustained MVC. This, however, does not necessarily result in loss of force since the parallel slowing of muscle contractile speed reduces tetanic fusion frequency. It is suggested that the range of motoneuron firing rates elicited by voluntary effort is regulated and limited for each muscle to the minimum required for maximum force generation, thus preventing neuromuscular transmission failure and optimizing motor control. Such a CNS regulating mechanism would probably require some reflex feedback from the muscle.

Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia

Sleep apnea and associated daytime sleepiness and fatigue are common manifestations of mainly obese middle-aged men. The onset of sleep apnea peaks in middle age, and its morbid and mortal sequelae include complications from accidents and cardiovascular events. The pathophysiology of sleep apnea remains obscure. The purpose of this study was to test three separate, albeit closely related, hypotheses. 1) Does sleep apnea contribute to the previously reported changes of plasma cytokine (tumor necrosis factor-alpha and interleukin-6) and leptin levels independently of obesity? 2) Among obese patients, is it generalized or visceral obesity that predisposes to sleep apnea? 3) Is apnea a factor independent from obesity in the development of insulin resistance? Obese middle-aged men with sleep apnea were first compared with nonapneic age- and body mass index (BMI)-matched obese and age-matched lean men. All subjects were monitored in the sleep laboratory for 4 consecutive nights. We obtained simultaneous indexes of sleep, sleep stages, and sleep apnea, including apnea/hypopnea index and percent minimum oxygen saturation. The sleep apneic men had higher plasma concentrations of the adipose tissue-derived hormone, leptin, and of the inflammatory, fatigue-causing, and insulin resistance-producing cytokines tumor necrosis factor-alpha and interleukin-6 than nonapneic obese men, who had intermediate values, or lean men, who had the lowest values. Because these findings suggested that sleep apneics might have a higher degree of insulin resistance than the BMI-matched controls, we studied groups of sleep-apneic obese and age- and BMI-matched nonapneic controls in whom we obtained computed tomographic scan measures of total, sc, and visceral abdominal fat, and additional biochemical indexes of insulin resistance, including fasting plasma glucose and insulin. The sleep apnea patients had a significantly greater amount of visceral fat compared to obese controls (<0.05) and indexes of sleep disordered breathing were positively correlated with visceral fat, but not with BMI or total or sc fat. Furthermore, the biochemical data confirmed a higher degree of insulin resistance in the group of apneics than in BMI-matched nonapneic controls. We conclude that there is a strong independent association among sleep apnea, visceral obesity, insulin resistance and hypercytokinemia, which may contribute to the pathological manifestations and somatic sequelae of this condition.

Fatigue of long duration in human skeletal muscle after exercise

1. After severe muscular contraction in man recovery of force is largely complete in a few minutes, but is not wholly so for many hours. The long-lasting element of fatigue is found to occur primarily for low frequencies of stimulation (e.g. 20/sec), and is much less pronounced, or absent, at high frequencies (80/sec). The twitch force is an unreliable measure of the state of fatigue. 2. The long-lasting element of fatigue is not due to depletion of high-energy phosphate nor is it due to failure of electrical activity as recorded from surface electrodes. It is probably the result of an impairment of the process of excitation-contraction coupling. Its practical importance for man could be significant as an explanation of the subjective feelings of weakness following exercise.

Dynamical assessment of physiological systems and states using recurrence plot strategies

Physiological systems are best characterized as complex dynamical processes that are continuously subjected to and updated by nonlinear feedforward and feedback inputs. System outputs usually exhibit wide varieties of behaviors due to dynamical interactions between system components, external noise perturbations, and physiological state changes. Complicated interactions occur at a variety of hierarchial levels and involve a number of interacting variables, many of which are unavailable for experimental measurement. In this paper we illustrate how recurrence plots can take single physiological measurements, project them into multidimensional space by embedding procedures, and identify time correlations (recurrences) that are not apparent in the one-dimensional time series. We extend the original description of recurrence plots by computing an array of specific recurrence variables that quantify the deterministic structure and complexity of the plot. We then demonstrate how physiological states can be assessed by making repeated recurrence plot calculations within a window sliding down any physiological dynamic. Unlike other predominant time series techniques, recurrence plot analyses are not limited by data stationarity and size constraints. Pertinent physiological examples from respiratory and skeletal motor systems illustrate the utility of recurrence plots in the diagnosis of nonlinear systems. The methodology is fully applicable to any rhythmical system, whether it be mechanical, electrical, neural, hormonal, chemical, or even spacial.

Human circulatory and thermoregulatory adaptations with heat acclimation and exercise in a hot, dry environment

1. Heat acclimation was induced in eight subjects by asking them to exercise until exhaustion at 60% of maximum oxygen consumption rate (VO2) for 9-12 consecutive days at an ambient temperature of 40 degrees C, with 10% relative humidity (RH). Five control subjects exercised similarly in a cool environment, 20 degrees C, for 90 min for 9-12 days; of these, three were exposed to exercise at 40 degrees C on the first and last day. 2. Acclimation had occurred as seen by the increased average endurance from 48 min to 80 min, the lower rate of rise in the heart rate (HR) and core temperature and the increased sweating. 3. Cardiac output increased significantly from the first to the final heat exposure from 19.6 to 21.4 l min-1; this was possibly due to an increased plasma volume and stroke volume. 4. The mechanism for the increased plasma volume may be an isosmotic volume expansion caused by influx of protein to the vascular compartment, and a sodium retention induced by a significant increase in aldosterone. 5. The exhaustion coincided with, or was elicited when, core temperature reached 39.7 +/- 0.15 degrees C; with progressing acclimation processes it took progressively longer to reach this level. However, at this point we found no reduction in cardiac output, muscle (leg) blood flow, no changes in substrate utilization or availability, and no recognized accumulated 'fatigue' substances. 6. It is concluded that the high core temperature per se, and not circulatory failure, is the critical factor for the exhaustion during exercise in heat stress.

Sleep quality versus sleep quantity: relationships between sleep and measures of health, well-being and sleepiness in college students

Two studies assessed whether measures of health, well-being, and sleepiness are better related to sleep quality or sleep quantity. In both studies, subjects completed a 7-day sleep log followed by a battery of surveys pertaining to health, well-being, and sleepiness. In subjects sleeping an average of 7 hours a night, average sleep quality was better related to health, affect balance, satisfaction with life, and feelings of tension, depression, anger, fatigue, and confusion than average sleep quantity. In addition, average sleep quality was better related to sleepiness than sleep quantity. These results indicate that health care professionals should focus on sleep quality in addition to sleep quantity in their efforts to understand the role of sleep in daily life.

Fatigue and basal ganglia

Fatigue is a common symptom in neurology and occurs in the diseases of the central and peripheral nervous system. In order to understand the mechanism of fatigue, it is important to distinguish symptoms of peripheral neuromuscular fatigue from the symptoms of physical and mental fatigue characteristic of disorders like Parkinson's disease or multiple sclerosis. We have introduced and defined the concept of central fatigue for the latter disorders. We have further proposed, with supportive neuropathological data, that central fatigue may occur due to a failure in the integration of the limbic input and the motor functions within the basal ganglia affecting the striatal-thalamic-frontal cortical system.

Pregabalin for the treatment of fibromyalgia syndrome: Results of a randomized, double-blind, placebo-controlled trial

OBJECTIVE

Fibromyalgia syndrome (FMS) is characterized by widespread musculoskeletal pain and lowered pain threshold. Other prominent symptoms include disordered sleep and fatigue. FMS affects an estimated 2% of the population, predominantly women. This trial was designed to evaluate the efficacy and safety of pregabalin, a novel alpha(2)-delta ligand, for treatment of symptoms associated with FMS.

METHODS

This multicenter, double-blind, 8-week, randomized clinical trial compared the effects of placebo with those of 150, 300, and 450 mg/day pregabalin on pain, sleep, fatigue, and health-related quality of life in 529 patients with FMS. The primary outcome variable was the comparison of end point mean pain scores, derived from daily diary ratings of pain intensity, between each of the pregabalin treatment groups and the placebo group.

RESULTS

Pregabalin at 450 mg/day significantly reduced the average severity of pain in the primary analysis compared with placebo (-0.93 on a 0-10 scale) (P </= 0.001), and significantly more patients in this group had >/=50% improvement in pain at the end point (29%, versus 13% in the placebo group; P = 0.003). Pregabalin at 300 and 450 mg/day was associated with significant improvements in sleep quality, fatigue, and global measures of change. Pregabalin at 450 mg/day improved several domains of health-related quality of life. Dizziness and somnolence were the most frequent adverse events. Rates of discontinuation due to adverse events were similar across all 4 treatment groups.

CONCLUSION

Pregabalin at 450 mg/day was efficacious for the treatment of FMS, reducing symptoms of pain, disturbed sleep, and fatigue compared with placebo. Pregabalin was well tolerated and improved global measures and health-related quality of life.

Increased gait unsteadiness in community-dwelling elderly fallers

OBJECTIVE

To test the hypothesis that quantitative measures of gait unsteadiness are increased in community-dwelling elderly fallers.

STUDY DESIGN

Retrospective, case-control study.

SETTING

General community.

PARTICIPANTS

Thirty-five community-dwelling elderly subjects older than 70 years of age who were capable of ambulating independently for 6 minutes were categorized as fallers (age, 82.2 +/- 4.9 yrs [mean +/- SD]; n = 18) and nonfallers (age, 76.5 +/- 4.0 yrs; n = 17) based on history; 22 young (age, 24.6 +/- 1.9 yrs), healthy subjects also participated as a second reference group.

MAIN OUTCOME MEASURES

Stride-to-stride variability (standard deviation and coefficient of variation) of stride time, stance time, swing time, and percent stance time measured during a 6-minute walk.

RESULTS

All measures of gait variability were significantly greater in the elderly fallers compared with both the elderly nonfallers and the young subjects (p < .0002). In contrast, walking speed of the elderly fallers was similar to that of the nonfallers. There were little or no differences in the variability measures of the elderly nonfallers compared with the young subjects.

CONCLUSIONS

Stride-to-stride temporal variations of gait are relatively unchanged in community-dwelling elderly nonfallers, but are significantly increased in elderly fallers. Quantitative measurement of gait unsteadiness may be useful in assessing fall risk in the elderly.

Exercise, oxidative stress and hormesis

Physical inactivity leads to increased incidence of a variety of diseases and it can be regarded as one of the end points of the exercise-associated hormesis curve. On the other hand, regular exercise, with moderate intensity and duration, has a wide range of beneficial effects on the body including the fact that it improves cardio-vascular function, partly by a nitric oxide-mediated adaptation, and may reduce the incidence of Alzheimer's disease by enhanced concentration of neurotrophins and by the modulation of redox homeostasis. Mechanical damage-mediated adaptation results in increased muscle mass and increased resistance to stressors. Physical inactivity or strenuous exercise bouts increase the risk of infection, while moderate exercise up-regulates the immune system. Single bouts of exercise increases, and regular exercise decreases the oxidative challenge to the body, whereas excessive exercise and overtraining lead to damaging oxidative stress and thus are an indication of the other end point of the hormetic response. Based upon the genetic setup, regular moderate physical exercise/activity provides systemic beneficial effects, including improved physiological function, decreased incidence of disease and a higher quality of life.

Depression in patients with lung cancer: prevalence and risk factors derived from quality-of-life data

PURPOSE

To evaluate self-reported depression rates in patients with inoperable lung cancer and to explore demographic, clinical, and quality-of-life (QOL) factors associated with depression and thus identify patients at risk.

PATIENTS AND METHODS

Nine hundred eighty-seven patients from three palliative treatment trials conducted by the Medical Research Council Lung Cancer Working Party formed the study sample. 526 patients (53%) had poor prognosis small-cell lung cancer (SCLC) and 461 patients (47%) had good prognosis non-small-cell lung cancer (NSCLC). Hospital Anxiety and Depression Scale data and QOL items from the Rotterdam Symptom Checklist were analyzed, together with relevant demographic and clinical factors.

RESULTS

Depression was self-rated in 322 patients (33%) before treatment and persisted in more than 50% of patients. SCLC patients had a three-fold greater prevalence of case depression than those with NSCLC (25% v 9%; P <.0001). An increased rate for women was found for good performance status (PS) patients (PS of 0 or 1) but the sex difference reduced for poor PS patients (PS of 3 or 4) because of increased depression rates for men (chi(2) for trend, P <.0001). Multivariate analysis showed that functional impairment was the most important risk factor; depression increased by 41% for each increment on the impairment scale. Pretreatment physical symptom burden, fatigue, and clinician-rated PS were also independent predictors, but cell type was not.

CONCLUSION

Depression is common and persistent in lung cancer patients, especially those with more severe symptoms or functional limitations. Psychologic screening and appropriate intervention is an essential part of palliative care.

Rapid iterative negative geotaxis (RING): a new method for assessing age-related locomotor decline in Drosophila

Age-related behavioral declines are common manifestations of aging in animals. Negative geotaxis, an innate escape response during which flies ascend the wall of a cylinder after being tapped to its bottom, is one of the behaviors that senesces in Drosophila. Many laboratories, including ours, have used a variety of negative geotaxis assays based on the performance of single flies. To circumvent limitations of single-fly assays, we developed a new method for assessing negative geotaxis called rapid iterative negative geotaxis (RING). In RING assays, digital photography is used to document negative geotaxis in multiple groups of animals simultaneously. We show that performance in RING assays is not influenced by the density of flies being tested, the time of day, or repeated testing. We used the RING assay to demonstrate that negative geotaxis declines with the age of animals as previously shown in single fly studies and that senescence of negative geotaxis is sensitive to genetic background. Finally, we used RING assays to show that long-lived Indy and chico mutants exhibit delayed senescence of negative geotaxis. Our results demonstrate that RING is a powerful method for assessing negative geotaxis that should facilitate the search for manipulations that influence behavioral aging in Drosophila.

Possible mechanisms of central nervous system fatigue during exercise

Fatigue of voluntary muscular effort is a complex phenomenon. To date, relatively little attention has been placed on the role of the central nervous system (CNS) in fatigue during exercise despite the fact that the unwillingness to generate and maintain adequate CNS drive to the working muscle is the most likely explanation of fatigue for most people during normal activities. Several biological mechanisms have been proposed to explain CNS fatigue. Hypotheses have been developed for several neurotransmitters including serotonin (5-HT; 5-hydroxytryptamine), dopamine, and acetylcholine. The most prominent one involves an increase in 5-HT activity in various brain regions. Good evidence suggests that increases and decreases in brain 5-HT activity during prolonged exercise hasten and delay fatigue, respectively, and nutritional manipulations designed to attenuate brain 5-HT synthesis during prolonged exercise improve endurance performance. Other neuromodulators that may influence fatigue during exercise include cytokines and ammonia. Increases in several cytokines have been associated with reduced exercise tolerance associated with acute viral or bacterial infection. Accumulation of ammonia in the blood and brain during exercise could also negatively effect the CNS function and fatigue. Clearly fatigue during prolonged exercise is influenced by multiple CNS and peripheral factors. Further elucidation of how CNS influences affect fatigue is relevant for achieving optimal muscular performance in athletics as well as everyday life.

Contractile speed and EMG changes during fatigue of sustained maximal voluntary contractions

Measurements were made from the human adductor pollicis muscle of force, contractile speed, and electromyographic activity (EMG) before, during, and after maximal isometric voluntary contractions sustained for 60 s. The use of brief test periods of maximal nerve stimulation with single shocks or trains of shocks enabled various muscle mechanical properties to be studied throughout each contraction. Electrical activity was measured after rectification and smoothing of the surface potentials and also by counting the total number of potentials per unit time from a population of motor units using fine wire intramuscular electrodes. During a 60-s maximal voluntary contraction, the force fell by 30-50%. Throughout the experiment the voluntary force matched that produced by supramaximal tetanic nerve stimulation. This indicated that, with sufficient practice, full muscle activation could be maintained by voluntary effort. However, the amplitude of the smoothed, rectifed EMG and the rate of spike counts declined. Since no evidence for neuromuscular block was found, the decline in EMG and spike counts was attributed to a progressive reduction of the neural drive from the central nervous system, despite maintained maximum effort. After the prolonged voluntary contractions twitch duration was prolonged, mainly as a result of slowing in relaxation rate. Twitch summation in unfused tetani increased. Both the maximum rate of relaxation and the time course of force decay declined by 50-70%. Similar changes were seen in both voluntary contractions and in test periods of stimulation. The percentage change in muscle contractile speed measured by these parameters approximately equaled the percentage change in the surface EMG measured simultaneously. It is concluded that 1) during a 60-s sustained maximal voluntary contraction there is a progressive slowing of contraction speed such that the excitation rate required to give maximal force generation is reduced, 2) the simultaneous decline in EMG may be due to a continuous reduction in motoneuron discharge rate, and 3) the EMG decline may not necessarily contribute to force loss.

Increased intracortical remodeling following fatigue damage

We previously demonstrated that microcracks occurred in common with resorption spaces more often than expected by chance, and proposed that fatigue damage initiates remodeling events. However, it was possible that cracks accumulated at sites of preexisting resorption spaces and did not initiate new remodeling. The goal of this work was to determine whether osteonal remodeling follows the accumulation of microcracks, as expected if microcracks are responsible for initiation of bone remodeling, or if it precedes microdamage accumulation. A three-point bending load was applied to the left limb of 13 dogs for 10,000 cycles at 2 Hz with 2500 microstrain on the cranial radial surface. The right limb was loaded in the same manner eight days later, and the dogs sacrificed immediately after the second loading episode. A nonloaded groups (n = 7) was used as an external control. Radii were strained en bloc for microdamage; parameters related to bone resorption, microdamage accumulation, and the association of damage and resorption were collected. The data demonstrate a significant increase in new remodeling events subsequent to the generation of microdamage. This temporal relationship between microcracks and resorption spaces is inconsistent with the hypothesis that cracks localize at sites of preexisting resorption spaces. This demonstrates that bone remodeling occurs preferentially in fatigue-damaged regions, and supports a direct cause and effect relationship between the initiation of microdamage in bone and its repair.

Fatigue in soccer: A brief review

This review describes when fatigue may develop during soccer games and the potential physiological mechanisms that cause fatigue in soccer. According to time-motion analyses and performance measures during match-play, fatigue or reduced performance seems to occur at three different stages in the game: (1) after short-term intense periods in both halves; (2) in the initial phase of the second half; and (3) towards the end of the game. Temporary fatigue after periods of intense exercise in the game does not appear to be linked directly to muscle glycogen concentration, lactate accumulation, acidity or the breakdown of creatine phosphate. Instead, it may be related to disturbances in muscle ion homeostasis and an impaired excitation of the sarcolemma. Soccer players' ability to perform maximally is inhibited in the initial phase of the second half, which may be due to lower muscle temperatures compared with the end of the first half. Thus, when players perform low-intensity activities in the interval between the two halves, both muscle temperature and performance are preserved. Several studies have shown that fatigue sets in towards the end of a game, which may be caused by low glycogen concentrations in a considerable number of individual muscle fibres. In a hot and humid environment, dehydration and a reduced cerebral function may also contribute to the deterioration in performance. In conclusion, fatigue or impaired performance in soccer occurs during various phases in a game, and different physiological mechanisms appear to operate in different periods of a game.

A comparison of the reproducibility and the sensitivity to change of visual analogue scales, Borg scales, and Likert scales in normal subjects during submaximal exercise

OBJECTIVE

To assess which subjective scale, the visual analogue scale (VAS), the Borg CR10 (Borg) scale, or the Likert scale (LS), if any, is decidedly more reproducible and sensitive to change in the assessment of symptoms.

DESIGN

Prospective clinical study.

SETTING

Exercise laboratory.

PARTICIPANTS

Twenty-three physically active male subjects (mean +/- SD age of 30 +/- 4 years old) were recruited.

INTERVENTION

Each subject attended the exercise laboratory on four occasions at intervals of 1 week. Three subjective scales were used: (1) the VAS (continuous scale); (2) the Borg scale (12 fixed points); and (3) the Likert scale (LS; 5 fixed points). Four identical submaximal tests were given (2 min at 60% maximum oxygen uptake [VO(2)max] and 6 min at 70% VO(2)max). Two tests were undertaken to assess the reproducibility of scores that were obtained with each subjective scale. Two other tests were undertaken to assess the sensitivity of each scale to a change in symptom perception: a double-blind treatment with propranolol, 80 mg, (ie, active therapy; to increase the sensation of breathlessness and general fatigue during exercise) or matching placebo. The subjective scale scores were measured at 1 min 30 s, 5 min 30 s, and 7 min 15 s of exercise. Reproducibility was defined as the proportion of total variance (ie, between-subject plus within-subject variance) explained by the between-subject variance given as a percentage. Sensitivity was defined as the effect of the active drug therapy over the variation within subjects.

RESULTS

Overall, the VAS performed best in terms of reproducibility for breathlessness and general fatigue, with reproducibility coefficients as high as 78%. For sensitivity, the VAS was best for breathlessness (ratio, 2.7) and the Borg scale was most sensitive for general fatigue (ratio, 3.0). The relationships between the respective psychological and physiologic variables were reasonably stable throughout the testing procedure, with overall typical correlations of 0.73 to 0.82

CONCLUSION

This study suggests that subjective scales can reproducibly measure symptoms during steady-state exercise and can detect the effect of a drug intervention. The VAS and Borg scales appear to be the best subjective scales for this purpose.