Writing a case report for the American Journal of Physical Medicine and Rehabilitation and the European Journal of Physical and Rehabilitation Medicine.

Case reports (CR) have led to the description and discovery of new diseases, syndromes, therapeutic complications or side-effects, and previously unknown potential benefits of pharmacologic agents. CRs may also be used as an effective training strategy for novice authors to develop the skills needed for medical writing. Yet, too often, CRs do not follow standards for excellence in scientific writing. Therefore, in this article, the American Journal of Physical Medicine and Rehabilitation (AJPMR) and the European Journal of Physical and Rehabilitation Medicine (EJPRM) collaborate with the purpose of providing guidance to authors in selecting CRs that might be appropriate for publication. In addition, we discuss different aspects of the preparation of a well-written CR in accordance with the mission and editorial views of both journals.

Contractile properties of adjacent segments of single human muscle fibers.

A comparison of the contractile properties of adjacent segments of single human muscle fibers may help to explain the interaction among nuclear domains within the myofiber. Biopsy samples were obtained from the vastus lateralis muscle of 20 healthy untrained women (age 18-79 years). Single fibers (n = 38) were dissected and cut into halves (segments A and B). Segment diameter and depth were measured using an image analysis system. Maximal force (Po) was recorded during activation with calcium (pCa 4.5). Maximal unloaded shortening velocity (Vo) was calculated using the slack test. Myosin heavy chain (MyHC) expression was determined using sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE). A significant difference ( approximately 7%) in Po was seen between adjacent segments expressing type I MyHC that could not be attributed to differences in fiber size. Significant differences were observed in Vo even after adjusting for fiber type. A positive correlation was seen in Po (concordance coefficient Rho_C = 0.803) and Vo (Rho_C = 0.690) between segments, but concordance was less than perfect in both cases. Possible explanations for nonuniformity of contractile properties include random variations in physiological systems or variability of protein expression among nuclear domains.

Brace modification improves aerobic performance in Charcot-Marie-Tooth disease: a single-subject design.

OBJECTIVE: Ankle-foot orthoses (AFOs) can lower energy expenditure in patients with hemiplegia by 10%-13%. Review of the lower motor injury literature reveals insufficient physiologic evidence supporting the use or modification of AFOs in patients with lower motor neuron injury and, specifically, progressive conditions such as Charcot-Marie-Tooth disease. We sought to test the hypothesis that optimal AFOs would improve submaximal aerobic performance and submaximal perceived exertion, while producing no change in maximal aerobic capacity. DESIGN: In an individual with Charcot-Marie-Tooth disease, a single-subject design study was used. An A-B-A design was used, with "A" corresponding to use of the patient's old AFOs and "B" corresponding to the newly prescribed AFOs. The subject underwent treadmill exercise tolerance testing using a modified Balke protocol. Indirect calorimetry was used to measure oxygen consumption per unit time (VO2), and the Borg scale was used to measure perceived exertion. RESULTS: At the same submaximal exercise intensities, VO2, rate-pressure product, and perceived exertion were all reduced when using the modified AFOs. Additionally, these conditions allowed the subject to conduct the treadmill exercise test 20% longer. Maximal VO2 remained constant under all conditions. CONCLUSION: Optimizing the AFO prescription in a patient with Charcot-Marie-Tooth disease can enhance physiologic performance and perceived exertion at submaximal activity levels. Larger controlled trials are necessary to further demonstrate such benefits in patients with progressive neuropathy and other causes of lower motor neuron injury.

Age- and gender-related differences in maximum shortening velocity of skeletal muscle fibers.

OBJECTIVE: To determine age- and gender-related differences in maximum unloaded shortening velocity (Vo) of Type I and IIA single muscle fibers. Muscle fibers must have a broad range of contractile velocities to generate the full range of power required for varied activities. DESIGN: Percutaneous needle biopsies of the vastus lateralis were obtained from 31 healthy subjects (n = 7 young men [YM], n = 7 young women [YW], n = 12 older men [OM], n = 12 older women [OW]). The slack test was used to determine Vo of individual fibers; 916 muscle fibers were chemically skinned. Fiber type was determined by myosin heavy chain isoform identification. RESULTS: Among men, Vo (fiber lengths/sec) was reduced with age in Type IIA fibers (OM vs. YM: 1.78 vs. 2.14; P < 0.05) but unchanged in Type I fibers. Among women, Vo was reduced with age in Type I fibers (OW vs. YW: 0.70 vs. 0.75; P < 0.05) but not IIA. OW had a lower Vo than did OM in both fiber types (Type I: OW = 0.70, OM = 0.77; Type IIA: OW = 1.51, OM = 1.78; P < 0.05). YW did not differ from YM. CONCLUSIONS: Both age and gender affect Vo. Age- and gender-related differences in Vo may partially explain the impairments in muscle function that occur with aging and the greater impairment in muscle function observed in OW compared with that observed in OM.

Effects of testosterone and exercise on muscle leanness in eugonadal men with AIDS wasting.

Loss of lean body and muscle mass characterizes the acquired immunodeficiency syndrome (AIDS) wasting syndrome (AWS). Testosterone and exercise increase muscle mass in men with AWS, with unclear effects on muscle composition. We examined muscle composition in 54 eugonadal men with AWS who were randomized to 1) testosterone (200 mg im weekly) or placebo and simultaneously to 2) resistance training or no training in a 2 x 2 factorial design. At baseline and after 12 wk, we performed assessments of whole body composition by dual-energy X-ray absorptiometry and single-slice computed tomography for midthigh cross-sectional area and muscle composition. Leaner muscle has greater attenuation. Baseline muscle attenuation correlated inversely with whole body fat mass (r = -0.52, P = 0.0001). This relationship persisted in a model including age, body mass index, testosterone level, viral load, lean body mass, and thigh muscle cross-sectional area (P = 0.02). Testosterone (P = 0.03) and training (P = 0.03) increased muscle attenuation. These data demonstrate that thigh muscle attenuation by computed tomography varies inversely with whole body fat and increases with testosterone and training. Anabolic therapy in these patients increases muscle leanness.

Longitudinal muscle strength changes in older adults: influence of muscle mass, physical activity, and health.

The longitudinal changes in isokinetic strength of knee and elbow extensors and flexors, muscle mass, physical activity, and health were examined in 120 subjects initially 46 to 78 years old. Sixty-eight women and 52 men were reexamined after 9.7 +/- 1.1 years. The rates of decline in isokinetic strength averaged 14% per decade for knee extensors and 16% per decade for knee flexors in men and women. Women demonstrated slower rates of decline in elbow extensors and flexors (2% per decade) than men (12% per decade). Older subjects demonstrated a greater rate of decline in strength. In men, longitudinal rates of decline of leg muscle strength were approximately 60% greater than estimates from a cross-sectional analysis in the same population. The change in leg strength was directly related to the change in muscle mass in both men and women, and it was inversely related to the change in medication use in men. Physical activity declined yet was not directly associated with strength changes. Although muscle mass changes influenced the magnitude of the strength changes over time, strength declines in spite of muscle mass maintenance or even gain emphasize the need to explore the contribution of other cellular, neural, or metabolic mediators of strength changes.

Skeletal muscle fiber quality in older men and women.

Whole muscle strength and cross-sectional area (WMCSA), and contractile properties of chemically skinned segments from single fibers of the quadriceps were studied in 7 young men (YM, 36.5 +/- 3. 0 yr), 12 older men (OM, 74.4 +/- 5.9 yr), and 12 older women (OW, 72.1 +/- 4.3 yr). WMCSA was smaller in OM compared with YM (56.1 +/- 10.1 vs. 79.7 +/- 13.1 cm(2); P = 0.031) and in OW (44.9 +/- 7.5; P < 0.003) compared with OM. Age-related, but not sex-related, differences in strength were eliminated after adjusting for WMCSA. Maximal force was measured in 552 type I and 230 type IIA fibers. Fibers from YM (type I = 725 +/- 221; type IIA = 792 +/- 271 microN) were stronger (P < 0.001) than fibers from OM (I = 505 +/- 179; IIA = 577 +/- 262 microN) even after correcting for size. Type IIA fibers were stronger (P < 0.005) than type I fibers in YM and OM but not in OW (I = 472 +/- 154; IIA = 422 +/- 97 microN). Sex-related differences in type I and IIA fibers were dependent on fiber size. In conclusion, differences in WMCSA explain age-related differences in strength. An intrinsic defect in contractile proteins could explain weakness in single fibers from OM. Sex-related differences exist at the whole muscle and single fiber levels.

Muscle fatigue and muscle injury.

The purpose of this review is to acquaint the reader with the neurobiology of muscle fatigue. Muscle fatigue is a complex, multifactorial process. The authors have covered the chain of events bringing about skeletal muscle contraction and the manner in which fatigue may affect each step. Advances in technology continue to increase understanding of central fatigue. Many excellent studies of peripheral fatigue have been designed to delineate the mechanisms that influence the excitation-contraction coupling, energy supply, and force generation processes. Although much of this work has considered mechanisms in isolation, different mechanisms may be responsible under different conditions. Fatigue is a common complaint among patients with a variety of neuromuscular and metabolic diseases. Armed with an enhanced knowledge of the mechanisms of muscle fatigue, one can more fully recognize the signs and symptoms of metabolic disorders and neuromuscular diseases and use diagnostic testing. The clinician should anticipate the role of muscle fatigue in injury and focus on injury prevention strategies, especially during the restorative phase of rehabilitation. As a clinician-scientist concerned with optimizing patients' and athletes' performance, one must design ways to identify, measure, and treat muscle fatigue. Beyond illustrating what is currently known about muscle fatigue, the authors hope this review inspires the reader to solve problems of great clinical importance to patients and athletes alike.

Aging of skeletal muscle: a 12-yr longitudinal study.

The present study examines age-related changes in skeletal muscle size and function after 12 yr. Twelve healthy sedentary men were studied in 1985-86 (T1) and nine (initial mean age 65.4 +/- 4.2 yr) were reevaluated in 1997-98 (T2). Isokinetic muscle strength of the knee and elbow extensors and flexors showed losses (P < 0.05) ranging from 20 to 30% at slow and fast angular velocities. Computerized tomography (n = 7) showed reductions (P < 0.05) in the cross-sectional area (CSA) of the thigh (12.5%), all thigh muscles (14.7%), quadriceps femoris muscle (16.1%), and flexor muscles (14. 9%). Analysis of covariance showed that strength at T1 and changes in CSA were independent predictors of strength at T2. Muscle biopsies taken from vastus lateralis muscles (n = 6) showed a reduction in percentage of type I fibers (T1 = 60% vs. T2 = 42%) with no change in mean area in either fiber type. The capillary-to-fiber ratio was significantly lower at T2 (1.39 vs. 1. 08; P = 0.043). Our observations suggest that a quantitative loss in muscle CSA is a major contributor to the decrease in muscle strength seen with advancing age and, together with muscle strength at T1, accounts for 90% of the variability in strength at T2.

Contractile properties of single muscle fibers in myotonic dystrophy.

Muscle fiber contractile dysfunction in myotonic dystrophy (MD) is poorly understood. We biopsied the tibialis anterior of two symptomatic and three asymptomatic subjects (aged 21-31 years) with the MD mutation. Biopsies were freeze dried. A total of 103 single muscle fibers were activated with Ca(++), allowing maximal force measurements and specific force (SF) estimates. The slack test was performed to calculate maximum unloaded shortening velocity (V(o)). The myosin heavy chain composition of each fiber was determined using sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE). Type I and IIA fibers of all subjects had reduced SF when compared with healthy control subjects (P < 0.001). In addition, the type I fibers of symptomatic subjects generated less SF than those of asymptomatic subjects (P < 0.001). Type I fibers from asymptomatic and symptomatic subjects did not differ in V(o), but V(o) was lower than in control subjects (P < 0.001). There was no significant difference in V(o) of type IIA fibers from symptomatic, asymptomatic, and control subjects. These results indicate that the MD mutation leads to a diminished force-generating capacity of the myofilaments in both symptomatic and asymptomatic individuals. The results further suggest that reduction in force-generating capacity at the cellular level develops prior to clinical weakness.

Drink composition, voluntary drinking, and fluid balance in exercising, trained, heat-acclimatized boys.

This study examined the effects of beverage composition on the voluntary drinking pattern, body fluid balance, and thermoregulation of heat-acclimatized trained boys exercising intermittently in outdoor conditions (wet bulb globe temperature 30.4 +/- 1.0 degreesC). Twelve boys (age 13.4 +/- 0.4 yr) performed two 3-h sessions, each consisting of four 20-min cycling bouts at 60% maximal aerobic power alternating with 25-min rest. One of two beverages was assigned: unflavored water (W) or flavored water plus 6% carbohydrate and 18 mmol/l Na (CNa). Drinking was ad libitum. Total intake was higher (P < 0.05) during CNa (1,943 +/- 190 g) compared with W (1,470 +/- 143 g). Euhydration was maintained with CNa (+0.18% body wt), but a mild dehydration resulted with W (-0.94% body wt; P < 0.05). Sweat loss, much higher than previously published for children of similar age, was similar between conditions (CNa = 1,644.7 +/- 117.5; W = 1,750.2 +/- 152.7 g). The increase in rectal temperature (CNa = 0.86 +/- 0.3; W = 0.76 +/- 0.1 degreesC), heart rate, and all perceptual variables did not differ between conditions. In conclusion, a flavored carbohydrate-electrolyte drink prevents voluntary dehydration in trained heat-acclimatized boys exercising in a tropical climate despite their large sweat losses. Because hydration changes were minor, the thermoregulatory strain observed was similar between conditions.

Dietary and performance assessment of elite soccer players during a period of intense training.

This study examined the nutritional and performance status of elite soccer players during intense training. Eight male players (age 17+/-2 years) of the Puerto Rican Olympic Team recorded daily activities and food intake over 12 days. Daily energy expenditure was 3,833+/-571 (SD) kcal, and energy intake was 3,952+/-1,071 kcal, of which 53.2+/-6.2% (8.3 g x kg BW(-1)) was from carbohydrates (CHO), 32.4+/-4.0% from fat, and 14.4+/-2.3% from protein. With the exception of calcium, all micronutrients examined were in accordance with dietary guidelines. Body fat was 7.6+/-1.1% of body weight. Time to completion of three runs of the soccer-specific test was 37.65+/-0.62 s, and peak torques of the knee flexors and extensors at 60 degrees x s(-1) were 139+/-6 and 225+/-9 N x m, respectively. Players' absolute amounts of CHO seemed to be above the minimum recommended intake to maximize glycogen storage, but calcium intakes were below recommended. Their body fat was unremarkable, and they had a comparatively good capacity to endure repeated bouts of intense soccer-specific exercise and to exert force with their knee extensors and flexors.

Muscle strength and hormonal levels in adolescents: gender related differences.

The purpose of the present investigation was to study muscle strength in adolescents and its relationship to serum levels of testosterone and growth hormone in both genders. Thirty active adolescents (15 boys; age range 11 -12 y/o) participated in the first study. Isokinetic muscle strength of the dominant knee extensors (KE) was determined at 0, 12, 20, 30, 120, 180 and 240 deg/sec using a Cybex 340 dynamometer. The assessment of pubertal status was accomplished using the criteria of Tanner. Serum levels of total testosterone (T) and growth hormone (GH) were determined using radioimmunoassay techniques. Boys had higher (p< 0.001) T levels but no differences in muscle strength were detected between genders. Fifty-seven additional subjects representing three age groups (11-12 y/o, n=18; 13-14, n=21; 17-18, n=18) participated in the second study. A significant increase in peak torque (absolute and corrected for body weight) with age was observed in both genders. There were no significant gender differences in strength for the two youngest age groups, but boys were stronger than girls in the oldest age group (group 3). Testosterone and GH levels increased with age in boys but not in girls. Gender related differences in T were found in groups 2 and 3. A positive correlation (r=0,64 boys; r=0.46 girls) between testosterone levels and absolute muscle strength was seen in both genders. Our results suggest that increases in anabolic hormones precede muscle strength gains in adolescent males. In addition, gender related differences in muscle strength during adolescents cannot be explained solely on the basis of difference in body size or T levels.

Firing rate of the lower motoneuron and contractile properties of its muscle fibers after upper motoneuron lesion in man.

We studied motor unit (MU) firing rate and contractile properties and myosin isoform composition of single muscle fibers after upper motoneuron lesion. Single-MUs and surface electromyogram (EMG) were recorded during voluntary contractions and locomotion in the paretic (P) and nonparetic (NP) tibialis anterior (TA) of 15 hemiparetics. P TA low-threshold MUs fired within the lower end of their normal range. High-threshold MUs fired below their normal range or were not recruited. Surface EMG was abnormally low and high in the P TA and NP TA, respectively. On muscle cross sections stained with histochemical methods, type I fibers represented 99.4%, 74.3% and 66.6% of NP, P, and control TA, respectively. P TA fibers expressing type I myosin heavy chain (MyHC) were smaller, weaker, and slower. In conclusion, low MU firing rate and activity in the P TA was associated with slower type I MyHC fibers, while increased activity in NP TA resulted in homogenous expression of type I MyHC.

Contractile studies of single human skeletal muscle fibers: a comparison of different muscles, permeabilization procedures, and storage techniques.

The study of single muscle fibers has improved our understanding of muscle physiology and pathology. To compare three techniques for fiber preparation and storage, biopsies were obtained from the tibialis anterior and vastus lateralis muscles of a hemiparetic patient and a control subject. Single fibers were prepared with: (1) chemical skinning (CS) and storage at -20 degrees C; (2) chemical skinning followed by sucrose (SU) incubation and storage at -80 degrees C; or (3) freeze-drying (FD) and -80 degrees C storage. Cross-sectional area (CSA), resting, maximal (P0), and specific tension (P0/CSA), and maximum shortening velocity (V0) were determined in 189 cells. CSA was similar in all groups. Resting tension was higher and P0 and P0/CSA lower after FD. In general, V0 was the same in all groups. Our data suggest that CS and SU preserve the properties of single muscle fibers better than FD. SU may allow longer storage of fibers.