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A 46-year-old man with a history of well-controlled hypertension presented with a central retinal vein occlusion (CRVO) in his right eye, which was complicated by cystoid macular edema. When the patient noted new visual symptoms, he was also experiencing muscle aches and easy fatiguability. A standard hypercoagulability panel failed to identify an etiology for his CRVO. However, the patient underwent COVID-19 antibody testing, which returned positive. The patient received a series of aflibercept injections for his macular edema, and his vision improved. Further study is warranted to determine if there is any association between mild infection with COVID-19 and the development of CRVO.

Purpose of review Skeletal muscle dysfunction contributes to exercise intolerance, which manifests as dyspnea and fatiguability in patients with heart failure with preserved ejection fraction (HFpEF). This review aims to summarize the current understanding of skeletal muscle dysfunction in HFpEF. Recent findings Animal and human studies in HFpEF provide insights into the pathophysiological alterations in skeletal muscle structure and function with the identification of several molecular mechanisms. Exercise training and novel pharmacological therapies that target skeletal muscle are proposed as therapeutic interventions to treat HFpEF. Summary There is evidence that skeletal muscle dysfunction plays a pathophysiological role in HFpEF. However, precise mechanistic insights are needed to understand the contribution of skeletal muscle dysfunction in HFpEF.

Background: Acute fatigue is hypothesized to alter lower extremity injury risk profiles by affecting intrinsic risk factors (i.e. single leg postural control, hamstring strength). However, no systematic overview exists that merges the insights into prospective lower extremity injury risk profiling with the effect of acute fatigue on functional test performance. Objective: The objective of this review is to identify the influence of acute fatigue on prospectively determined modifiable intrinsic risk factors for lower extremity injuries. Design: Systematic review. Methods: PubMed (MEDLINE), Web of Science, PEDro, and Cochrane Library were searched until 29 May 2019. Studies were eligible when the study outcomes encompassed intrinsic modifiable risk factors for lower extremity injury, an acute fatigue intervention, and included healthy athletes or physically active people. Intrinsic modifiable risk factors were identified through recent systematic reviews and meta-analyses, and the referenced original research papers were used to determine outcome measures associated with increased injury risk. Results: Forty-three studies reported acute fatigue effects on modifiable risk factors, with eight studies matching all criteria for data-extraction. Acute fatigue can decrease single leg postural control, decrease ankle joint position sense, decrease isokinetic strength of hamstring and quadriceps muscles and can affect isokinetic hamstring:quadriceps ratios. Conclusion: Acute fatigue affects prospective intrinsic modifiable risk factors for lower extremity injury, indicating an altered injury risk profile for lateral ankle sprain, patellofemoral pain syndrome and hamstring injuries. Future research should allow for individual fatiguability as a relevant outcome, and merge insights from athlete-centred injury risk profiling and fatigue.

Background: Injury prevalence data, muscle strength, and fatiguability have shown differences between males and females. In addition, arm spatial orientation affects muscle activation and strength of the shoulder muscles, but little to no research has been conducted in relation to the shoulder rotator muscles comparing men and women. Therefore, the main aim of of this study was to perform a comparative investigation between two arm spatial orientations (45⁰ and 90⁰ of abduction in frontal plane) during a fatigue assessment of shoulder internal rotator (IR) and external rotator (ER) muscles. Secondly, the interaction of gender and dominance with muscular performance was assessed.Methods: Forty healthy sedentary participants, 20 males and 20 females took part in this study. Participants performed a fatigue resistance protocol consisting of 30 consecutive maximal concentric contractions of the IR and ER shoulder muscles in a supine position at a speed of 180⁰/s. The upper limb was abducted to an angle of 45⁰ or 90⁰ in frontal plane and each subject was tested on dominant and nom-dominant side, counterbalanced in order of administration. Performance measures of Induced Fatigue (IF), Cumulated Performance (C.Perf) and Best repetition (BR) were calculated and used for further analysis.Results: There was a significant difference in angle, with higher values observed in 90⁰ of abduction compared to 45⁰ of abduction for C.Perf by 6% and 7% for BR (P < 0.0005) in the ER. The dominant arm was significantly higher than the non-dominant arm for C.Perf with higher values of 9.7% at 90⁰ of abduction compared to 45⁰ of abduction (P = 0.017) and BR with higher values of 4.2% at 90⁰ of abduction compared to 45⁰ of abduction (P < 0.0005) in the ER in males. There was a significant difference in muscle group, with higher values observed in the IR for C.Perf (88.2%), BR (22.5%) and IF (36.9%); at 90⁰ of abduction compared to 45⁰ of abduction in males (P < 0.0005). Significantly higher values were observed for C.Perf in females between the dominant and non-dominant arm for the IR and ER (P < 0.0005). The females showed significantly lower values for C.Perf (47.74-55.10%) and BR (47.30-53.41%) in both muscle groups, both testing positions and in both limbs, when compared to males (P < 0.05)Discussion: It was established that an increase in the abduction angle will influence the strength of ER muscles in favour of the 90° angle without any differences observed in IR muscles. Males were found to produce approximately double the amount of work done compared to females, but the amount of induced fatigue was no different between both groups. Conclusion: Therefore, these findings are useful for clinicians throughout the monitoring of rehabilitation programs in sedentary individuals following shoulder injuries.

Background: An on body personal lift assist device (OBPLAD) is a non-motorized, passive device in which the elastic elements act as an external muscle power generator to assist lifting thereby offloading the trunk muscles. Though there is enough evidence for the use of OBPLAD generated through laboratory studies, we found a scarcity of evidence on the use of OBPLAD in real-life work settings, especially in the Indian population. This study investigates the effect of the Jaipur belt, an OBPLAD, on trunk muscle fatiguability while performing repetitive lifting task in manual material handlers. Methods:70 subjects engaged in manual material handling were recruited from industries in and around Mangalore, Karnataka in this non-randomized single group trial. Subjects were made to perform a repetitive lifting task over a period of 15 minutes with and without an OBPLAD. Electromyographic data were recorded from rectus abdominis, transverse abdominis, quadratus lumborum, and erector spinae from either side of the body, and the onset of fatigue was deduced from the changes in electromyographic parameters. Results: We found a delay in the onset of fatigue in all the muscle groups studied while the lift was performed wearing the Jaipur belt. However, the findings were statistically significant only for right erector spinae, right rectus abdominis, left transverse abdominis, and left quadratus lumborum. It was found also that number of repetitions as well as time for which a task would be sustained were both found to be significantly better wearing an OBPLAD.Conclusion: The findings of the study imply that the Jaipur belt could potentially delay the onset of fatigue in the trunk muscles while performing repetitive lifting task and hence, is proved to be useful in the prevention of fatigue-related musculoskeletal disorders of the lower back.CTRI Registration date: 10/02/2020 Trial registration number: CTRI/2020/02/023219

Introduction Respiratory muscle performance has been theorized to contribute to sleep quality in obese patients. However, the results from previous studies investigating are conflicting but have primarily utilized static measurements of respiratory muscle performance. We hypothesized that dynamic measurements of respiratory muscle performance obtained from the Test of Incremental Respiratory Endurance (TIRE) may elucidate significant differences in performance between obese individuals with good sleep quality and poor sleep quality. Subjects 30 anonymized medical records from patients enrolled in a bariatric rehabilitation program between June 2018 and May 2019. Methods A retrospective chart review was used to obtain the following data: Maximal Inspiratory Pressure (MIP), Sustained Maximal Inspiratory Pressure (SMIP), Inspiratory Duration (ID), Slope of the SMIP Plot (SMIP Slope), Pittsburgh Sleep Quality Index (PSQI), age, height, weight, and BMI. Patients were sorted into groups according to their PSQI total score (PS: poor sleep quality ≥ 5, and GS: good sleep quality l5). Independent T-Tests were used to compare means between groups. Results 15 patients had a PSQI total score of ≥ 5, and 15 patients had a PSQI total score l5. No significant differences between groups were observed for Age, Height, Weight, BMI, MIP, SMIP, and ID. A significant between groups difference was observed for SMIP Slope (PS: 11.17 ± 4.77; GS: 9.58 ± 2.3; p = 0.027). Conclusion Individuals with poorer sleep quality demonstrated a significantly higher slope of the SMIP plot reflecting a reduced ability of the respiratory muscles to sustain force output and greater fatiguability.

Introduction. What is well known: Myasthenia gravis presents with ocular, bulbar and proximal limb weakness. What is less known: Myasthenia gravis can rarely present with predominant distal weakness of hand muscles. Myasthenia gravis (MG) is an immune mediated, post-synaptic neuromuscular transmission disorder, presenting with predominant ocular, bulbar and/or proximal fluctuating weakness and fatiguability. Distal and asymmetric onset of symptoms in MG is rare and could lead to delay in diagnosis especially when fatiguability or fluctuation is not clearly reported as a prominent initial symptom - as seen in our patients. Results. We report 3 cases of distal MG who presented with predominant distal asymmetric hand weakness. Their clinically diagnoses for referral to the electrodiagnostic (EDx) laboratory were chronic inflammatory demyelinating polyneuropathy, C8T1 motor radiculopathy and multifocal motor neuropathy. It was in the EDx laboratory that the diagnosis of MG was suspected in these patients. Since the routine EDx tests were normal in all 3 patients - a repetitive nerve stimulation test (RNST) was done - which was positive in the affected muscles and hence a diagnosis of distal MG made (This is the protocol followed in our laboratory). These patients were then found to have high serum levels of antibodies to acetylcholine receptors - confirming the diagnosis of MG. RNST is not routinely done in all patients sent for electrodiagnostic testing and none of these patients had a reference for the same – however using a protocol based method of EDx testing, leading to the diagnosis of a treatable condition. Conclusion. Electrodiagnosticians need to be aware of this presentation of MG and follow protocols or else the diagnosis could be missed.

Background Hamstring injuries remain a major burden in football while the effective prevention exercise the Nordic Hamstring is poorly adopted, despite the added positive effects on performance. Better understanding of hamstring function during Nordic Hamstring compared to other exercises may provide better insight to the physiological adaptations of different types of hamstring curls. Purpose This cross-sectional study therefore aimed to compare the Nordic Hamstring curl with a conventional prone Leg Curl at different loads, and novel high velocity Hamstring Catches; in terms of peak normalized electromyographical activity (nEMG) and rate of electromyographic rise (RER) of Biceps Femoris long head, and angular velocity of the knee. Study design Cross-sectional study. Methods Out of 28 participants enrolled, the final sample included 23 recreationally active male participants who attended a session for determining RM (repetition maximum) to establish loading (8 and 16RM for Hamstring Catches, and 8, 16 and 24RM for Leg Curl) and to familiarize themselves with the three different exercises (Nordic Hamstring, Leg Curl and Hamstring Catch), and a testing session >4 days after during which EMG data were collected during 3 repetitions of each exercise performed in a random order. Results The Nordic Hamstring evoked higher RER (1091.8 nEMG/s) than Hamstring Catches (mean difference: 421 nEMG/s, p Conclusion The Nordic Hamstring displayed the highest level muscle activity and most explosive recruitment characteristics with early and high rate of electromyographic rise, compared to even high velocity exercises, thus providing a possible mechanism by which it may increase performance and reduce injuries. Levels of evidence 3 What is known about the subject Early phase force and muscle recruitment have been linked to both performance and hamstring-related inhibition and fatiguability. However, the potential for different hamstring exercises to elicit explosive recruitment is unknown. What this study adds to existing knowledge Early phase recruitment was higher and faster during the Nordic Hamstring exercise compared with conventional hamstring Leg Curl exercises with different loads and a high-velocity hamstring exercise. Clinical Relevance The surprisingly fast and explosive recruitment characteristics during the Nordic Hamstring exercise suggests the possibility that this exercise have the potential to improve the rate of force development and perhaps counter the effects of hamstring-related inhibition and fatigue.

A 54-year-old man presented with easy fatiguability, dyspnoea on exertion and dyspeptic symptoms. On evaluation, he was found to have an ulcero-proliferative growth in the gastric fundus, the biopsy of which was malignant melanoma of the stomach. Further evaluation with 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) scan showed operable disease with no focus of disease elsewhere. He was diagnosed as primary gastric melanoma and underwent radical total gastrectomy with adequate margins. His postoperative period was uneventful. Further adjuvant therapy was refused by the patient. At 6-month follow-up, an 18F-FDG PET-CT scan was done, which showed no evidence of disease. On follow-up at 1-year, he was alive and asymptomatic.

A 34-year-old woman was admitted with symptoms of easy fatiguability, decreased urine output and jaundice for 1 week. She had similar history of weakness and jaundice 3 months ago that lasted for a week for which she consumed herbal medicines. Laboratory evaluation revealed anaemia with

Exercise intolerance and early fatiguability are hallmark symptoms of chronic heart failure. While the malfunction of the heart is certainly the leading cause of chronic heart failure, the patho-physiological mechanisms of exercise intolerance in these patients are more complex, multifactorial and only partially understood. Some evidence points towards a potential role of an exaggerated afferent feedback from group III/IV muscle afferents in the genesis of these symptoms. Overactivity of feedback from these muscle afferents may cause exercise intolerance with a double action: by inducing cardiovascular dysregulation, by reducing motor output and by facilitating the development of central and peripheral fatigue during exercise. Importantly, physical inactivity appears to affect the progression of the syndrome negatively, while physical training can partially counteract this condition. In the present review, the role played by group III/IV afferent feedback in cardiovascular regulation during exercise and exercise-induced muscle fatigue of healthy people and their potential role in inducing exercise intolerance in chronic heart failure patients will be summarised.

Reduced muscle mass and increased fatiguability are major complications after spinal cord injury (SCI), and often hinder the rehabilitation efforts of patients. Such detriments to the musculoskeletal system, and the concomitant reduction in level of activity, contribute to secondary complications such as cardiovascular disease, diabetes, bladder dysfunction and liver damage. As a result of decreased weight-bearing capacity after SCI, muscles undergo morphological, metabolic, and contractile changes. Recent studies have shown that exercise after SCI decreases muscle wasting and reduces the burden of secondary complications. Here, we describe RNA sequencing data for detecting chronic transcriptomic changes in the rat soleus after SCI at two levels of injury severity, under conditions of restricted in-cage activity and two methods of applied exercise, swimming or shallow water walking. We demonstrate that the sequenced data are of good quality and show a high alignment rate to the Rattus norvegicus reference assembly (Rn6). The raw data, along with UCSC Genome Browser tracks created to facilitate exploration of gene expression, are available in the NCBI Gene Expression Omnibus (GEO; GSE129694).

Background: Impairment of peripheral skeletal muscle function is a common phenomenon in patients with cystic fibrosis (CF) in addition to great clinical connotations, such as lack of exercise tolerance and decrease of health-related quality of life. There is very limited data on the effects of maximal exercise on muscle fatiguability and exercise capacity in children with cystic fibrosis. Objectives: The aim of this study was to evaluate the effect of progressive maximal exercise training of the lower extremities on exercise capacity and muscle fatiguability in children with cystic fibrosis.Study design: Between June and September 2017, eighteen children aged 8-12 years were recruited in this study. This study had two groups of children; the CF group consisted of nine children (6 males and 3 females) with cystic fibrosis and the control group consisted of nine healthy age matched children (6 males and 3 females). The children underwent a progressive maximal cardiopulmonary exercise cycling test (CPET), muscle fatigue test, and magnetic resonance imaging (MRI) to measure a muscle cross-section area (CSA). Also, pulmonary functions were assessed.Results: The findings of this study showed that the CF children had less pulmonary functions, had a less exercise capacity, and had a higher breathing reserve index and oxygen desaturation when compared with healthy children (p0.05). Conclusion: This study indicates that progressive maximal exercise doesn’t affect muscle fatiguability, muscle cross-section area, and maximal voluntary contraction in CF children with moderate respiratory diseases but includes lower exercise capacity. CF children and healthy age matched children have similar responses to maximal exercise in muscle fatiguability, muscle cross-section area, and maximal voluntary contractions but lower exercise capacity in the CF group.Keywords: Cystic fibrosis, children, lower extremities, exercise capacity, muscle fatiguability.

A 32-year-old male presented with shortness of breath and easy fatiguability for the past six months. There was no history of chest pain, fever, or palpitations. His renal function parameters were ...

A 42-year-old man presented with easy fatiguability, pain and swelling in the upper limbs of 6-month duration associated with progressive difficulty in bearing weights ([figure 1][1]). Imaging revealed extensive ill-defined osteolytic lesions of both humerus which are permeative, with a wide zone of

Paralyzed muscle fatigues more quickly than intact muscle. The reason for this difference is currently unknown. This work will bridge this gap in knowledge by evaluating the predictive abilities of higher-resolution closed-form mathematical models of muscle force and fatigue. Knowledge garnered from this effort will suggest possible mechanisms for the differences in fatiguability of muscle in different states of health. The hypothesis to be tested is that the concept missing from present models, and thus the present understanding of the physiology, is the dynamic behavior of divalent calcium (Ca) during induced muscle contraction. If the behavior of Ca can be understood as a Riccati-Bass diffusion process, muscle force and low-frequency fatigue in paralyzed muscle can be more accurately predicted over the time course of response to neuromuscular electrical stimulation. The abilities of existing mathematical models to predict force and low-frequency fatigue are compared to the predictive abilities of new models that include the Riccati-Bass equation. There are several major findings of this study. First, it was found that the structure of the Conaway models better predicts force and low-frequency fatigue than do the Ding models. Second, the cross-bridge friction is the dominant process in generating force in fresh muscle at frequencies greater than 5 pps. Finally, the calcium leak current is dominant in low-frequency fatigue in paralyzed muscle. It is concluded that the process of muscle fatigue occurs as

A 57-year-old woman presented to the emergency department with melena, easy fatiguability and dizziness for 2 days. She did not have haematemesis, abdominal pain, ascites or jaundice. Her routine master health check-up done 4 years previously revealed a diagnosis of Bernard-Soulier syndrome (BSS

Non-compaction cardiomyopathy (NCC), also called spongiform cardiomyopathy, is a rare congenital cardiomyopathy that affects both children and adults. It results from the failure of myocardial development during embryogenesis. In this case report we present a 70 year old male patient presenting with history of dyspnea on exertion and easy fatiguability of 1 year duration. Echocardiography revealed a biventricular non compaction associated with a patent ductus arteriosus (PDA). Search through medline showed 8 case reports LV non-compaction associated with PDA in younger patients and this is the first case report of biventricular non compaction associated with PDA in an elderly patient. Key words: Cardiomyopathy, Heart Failure, Non Compaction, PDA, Spongiform.

This report describes the story of a young female, diagnosed with the rare combination dermatomyositis and myasthenia gravis (MG). The patient presented with progressive muscle weakness without typical skin manifestations of dermatomyositis, except for an early mechanic's hand. In addition, the patient had fatiguability and mild ptosis which raised the suspicion of MG which was later confirmed by the presence of anti-acetyl choline receptor antibodies and clinical response to pyridostigmine. On evaluation, she was found to be seropositive for Mi-2Beta antibody, which is a myositis-specific antigen for classical steroid responsive dermatomyositis. The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice based learning and improvement.

The ability to modulate the function of muscle is integral to an animal's ability to function effectively in the face of widely disparate challenges. This modulation of function can manifest through short-term changes in neuromuscular control, but also through long-term changes in force profiles, fatigability, and architecture. However, the relative extent to which shorter-term modulation and longer-term plasticity govern locomotor flexibility remains unclear. Here, we obtain simultaneously-recorded kinematic and muscle activity data of fin and body musculature of an amphibious fish, Polypterus senegalus. After examining swimming and walking behaviour in aquatically-raised individuals, we show that walking behaviour is characterized by greater absolute duration of muscle activity in most muscles when compared with swimming, but that the magnitude of recruitment during walking is only increased in the secondary bursts of fin muscle and in the primary burst of the mid-body point. This localized increase in intensity suggests that walking in P. senegalus is powered in a few key locations on the fish, contrasting with the more distributed, low intensity muscle force that characterizes the stroke cycle during swimming. Finally, the increased intensity in secondary, but not primary, bursts of the fin muscles when walking likely underscores the importance of antagonistic muscle activity to prevent fin collapse, add stabilization, and increase body support. Understanding the principles that underlie the flexibility of muscle function can provide key insights into the sources of animal functional and behavioural diversity.

Myasthenia gravis is an autoimmune disorder affecting the neuromuscular junction, resulting in muscle fatiguability and weakness. The pathological characteristics of the disorder include ocular weakness resulting in diplopia and/or ptosis. More generally, the disease can result in fluctuant weakness of skeletal muscle, predominantly affecting ocular, bulbar and respiratory muscles. Autoimmunity in this instance is mediated by IgG anti-acetylcholine receptor antibodies that results in an impaired structure of postsynaptic neurotransmission. Approximately 15% of patients with myasthenia gravis present with bulbar symptoms, of which isolated bulbar symptoms are seen only on occasion. As with our patient, this presentation is most commonly seen in men with late-onset myasthenia gravis. We present a case of an 83-year-old male who presented with a 1 year history of dysphagia for solids and fatigable dysarthria. Following a diagnosis of myasthenia gravis, he was initiated on corticosteroid treatment. He later descended into myasthenic crisis, requiring invasive ventilation measures due to a failure of both non-invasive ventilation and intravenous immunoglobulin G (IVIG) to achieve therapeutic goals. LEARNING POINTS Isolated bulbar symptoms in an elderly man warrants consideration of myasthenia gravis to be included in the differential diagnosis. There is possibly an increased risk of myasthenic crisis in late-onset isolated bulbar myasthenia gravis. Empirical treatment for myasthenia gravis must be administered within a hospital setting, paying attention to respiratory tract infection and corticosteroid treatment as triggers for myasthenic crisis.

Introduction/Hypothesis The purpose of this study is to determine the mid/long term shoulder function in patients with complete deltoid paralysis and intact rotator cuff. 27 patients with at least 2-years FU were included. Materials and methods Outcome measures included pain, range of motion (including the swallowtail test STT), deltoid extension lag test DELT and Bertelli test), subjective fatigability using the injured shoulder and postoperative modified Neer ratings. Results At an average 68 months FU, mean shoulder abduction was 131°, flexion 153°, external rotation with the arm at the side 58° and 58° with the arm abducted. All patients reported quick fatiguability with repetitive use of the injured arm which did not change over time. Average pain score was 2. Eighteen patients had positive STT and DELT tests and all patients had positive Bertelli test. Discussion This study demonstrates that patients with deltoid paralysis and intact rotator cuff do maintain most of their shoulder function and this is sustained over time. Level of evidence Level IV; prognostic Study: case series.

Pediatric neuromuscular junction disorders are less common in children compared to adults, but both autoimmune and inherited subtypes of this disease category occur in the pediatric age group. Neuroanatomically, these can either be classified into presynaptic, synaptic or postsynaptic disorders. Symptoms occur when there is a disruption in the normal synthesis, storage, or release of acetylcholine, the microanatomy of the synapse, the acetylcholinesterase enzyme, or the function of the acetylcholine receptor complex. The specific clinical manifestations are dependent on the pathophysiology and severity of the disorder. The hallmarks of neuromuscular junction disorders are weakness and fatiguability, especially with extraocular muscles and bulbar muscles. However, due to the rarity of the condition and the overlap of the major symptoms with other neuromuscular or metabolic disorders, making the diagnosis can be quite challenging, from first conception of the possibility to confirmatory testing, especially as several of the classic diagnostic tests have limitations with regard to sensitivity. It is also frequently difficult to differentiate these disorders from one another, especially in children. Electrodiagnostic studies can be a valuable tool in not only detecting the presence of a disorder involving the neuromuscular junction, but also differentiating the type of neuromuscular disorders using a combination of nerve conduction studies, repetitive stimulation studies, exercise testing and needle EMG. Single fiber EMG and stimulated single fiber EMG are techniques that are also valuable in these evaluations. The results can then aid the pediatric neurologist in selecting the appropriate serologies or genetic tests to help confirm a definitive diagnosis in these patients.

Examination of the oral cavity provides valuable clues to a large number of systemic disorders. Gum hypertrophy is usually associated with myelomonocytic and monocytic subtypes of acute myeloid leukaemia.1 Its occurrence in a case of acute promyelocytic leukaemia (APL) is unusual.1 We describe a 28-year-old man from India who presented to our hospital with a 2-week history of easy fatiguability and gum bleeding. Examination revealed pallor and marked gum hypertrophy (figure 1). Blood investigations showed haemoglobin 50 g/L, white cell count 5.4×109/L, differential counts 95% promyelocytes, 3% myelocytes, 1% metamyelocytes and 1% …

IntroductionFatigue is common in patients with primary mitochondrial disease (PMD). There has been little prospective research into sleep pathology in these patients and assessment of scontributory factors to fatigue.MethodsPatients with PMD were prospectively assessed with overnight polysomnography in addition to measures of fatigue, muscle fatiguability, disease severity, sleep propensity and depression.Results16 patients participated, 15 completing inpatient polysomnography. Obstructive sleep apnoea (OSA) was common (53%), affecting 5/9 females (56%) and 3/6 males (50%), although most cases were mild in severity. There was a trend to higher incidence of OSA in older patients but not other traditional risk factors, nor presence of myopathy. The Epworth Sleepiness Scale (ESS) was the best predictor of OSA, although not reaching significance.Fatigue was common, with 81% of patients having significant fatigue on the Fatigue Severity score and 69% on the Fatigue Impact Scale. The two scores correlated well (r =0.85, p 0.01).The mean 5 times sit to stand time of 16 seconds was significantly higher than community normals (p 0.04), demonstrating muscle fatiguability, not isolated to patients with myopathy.ConclusionOSA is common in patients with PMD, although mostly mild in severity. ESS likely remains a relevant tool in screening patients when considering overnight polysomnography to investigate fatigue in these patients. OSA does not explain the high prevalence of fatigue, with other factors including depressive symptoms, important considerations.

A 14-year-old boy of Asian origin presented with a history of bluish discolouration of the finger and toenail bed with associated mild fatiguability on exertion since early childhood. Clinical examination revealed bilaterally symmetric uniform central cyanosis with no associated clubbing. Cardiovascular and respiratory system examination was normal. Pulse oximetry revealed an oxygen saturation of 87% in all four limbs. Transthoracic and transoesophageal echocardiography showed no evidence of shunt lesions. In view of the past diagnosis of pulmonary arteriovenous fistulae made at 4 years of age, a repeat cardiac catheterisation study was done, which revealed no shunt at any level. Interestingly, arterial oxygen tension of the chocolate-brown blood was normal in all the samples, suggesting the possibility of methaemoglobinaemia. Co-oximetry revealed methaemoglobin levels of 36%, confirming the diagnosis. Secondary causes were ruled out. The family was counselled about the hereditary nature of the condition.

Background/aims: Biomechanical properties of the skin are evaluated in vivo by torsion or extension methods. We assessed their modifications as function of age, probe diameter and regional body site. Methods: For measuring skin extensibility (or traction), we used a non-invasive suction device on a total of 37 volunteers, consisting of (A) 14 younger women (30.1±7.6 years) and (B) 23 older women (60.2±6.5 years). Measurements were performed on three different areas with 4 different probe diameters. The parameters used were (UE) extensibility; (UV) plasticity; (UR) tonicity; (URUE) elasticity; the difference between the lowest point of the last curve (5th) and that of the 1st is the fatiguability. Concurrently, we measured on each volunteer the microdepressionary network (mDN) length. Results: Generally, tonicity, extensibility and elasticity decreased; fatiguability increased and plasticity stayed the same; all of these factors apply regardless of age. Results are more homogenous on the volar face of the forearm and with 2, 4 and 6 mm probe diameters. As a general trend, mDN length decreases with age. Conclusions: The knowledge of this variation is important in interpreting the results obtained after product application. Standardisation of measures with the 2-mm probe will allow product efficacy determination and the comparison of different products.

This systematic literature review aimed at examining the validity and applicability in everyday clinical rehabilitation practise of methods for the assessment of back muscle fatiguability in patients with chronic non-specific low back pain (CNSLBP).Extensive research was performed in MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, Physiotherapy Evidence Database (PEDro) and Cochrane Central Register of Controlled Trials (CENTRAL) databases from their inception to September 2014. Potentially relevant articles were also manually looked for in the reference lists of the identified publications. Studies examining lumbar muscle fatigue in people with CNSLBP were selected. Two reviewers independently selected the articles, carried out the study quality assessment and extracted the results. A modified Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) scale was used to evaluate the scientific rigour of the selected works.Twenty-four studies fulfilled the selection criteria and were included in the systematic review. We found conflicting data regarding the validity of methods used to examine back muscle fatigue. The Biering-Sorensen test, performed in conjunction with surface electromyography spectral analysis, turned out to be the most widely used and comparatively, the most optimal modality currently available to assess objective back muscle fatigue in daily clinical practise, even though critical limitations are discussed.Future research should address the identification of an advanced method for lower back fatigue assessment in patients with CNSLBP which, eventually, might provide physical therapists with an objective and reliable test usable in everyday clinical practise. Implications for Rehabilitation Despite its limitations, the Biering-Sorensen test is currently the most used, convenient and easily available fatiguing test for lumbar muscles. To increase validity and reliability of the Biering-Sorensen test, concomitant activation of synergistic muscles should be taken into account. Pooled mean frequency and half-width of the spectrum are currently the most valid electromyographic parameters to assess fatigue in chronic non-specific low back pain. Body mass index, grading of pain and level of disability of the study population should be reported to enhance research quality.

Recumbent cycling exercise achieved by functional electrical stimulation (FES) of the paralyzed leg muscles is effective for cardiopulmonary and musculoskeletal conditioning after spinal cord injury, but its full potential has not yet been realized. Mechanical power output and efficiency is very low and endurance is limited due to early onset of muscle fatigue. The aim of this work was to compare stochastic modulation of the inter-pulse interval (IPI) to constant-frequency stimulation during an isokinetic leg extension task similar to FES-cycling. Seven able-bodied subjects participated: both quadriceps muscles were stimulated (n = 14) with two activation patterns (P1-constant frequency, P2-stochastic IPI). There was significantly higher power output with P2 during the first 30 s (p = 0.0092), the last 30 s (p = 0.018) and overall (p = 0.0057), but there was no overall effect on fatiguability when stimulation frequency was randomly modulated., European Journal of Translational Myology, 26 (3), ISSN:2037-7452, ISSN:2037-7460

Introduction. Premenstrual syndrome presents with vague psychological, somatic, or biological symptoms. It may be seen more commonly in a specific profile of patients. We try to evaluate the patterns and predictors of premenstrual symptoms among females working in a tertiary care psychiatry hospital.Methodology. We recruited working females at a tertiary care psychiatry hospital in India, through purposive sampling, and assessed them cross-sectionally. Premenstrual Symptom Checklist was used to assess the frequency and distribution of premenstrual symptoms, which were correlated with various sociodemographic variables to evaluate the predictors for premenstrual symptoms.Results. 150 working females were included, belonging to different sociodemographic profile. Somatic symptoms (backache, joint and muscles pain, and fatiguability) were most commonly reported followed by psychological (irritability and losing temper easily) and biological symptoms (increased micturition). Premenstrual symptoms were seen more commonly in women with higher educational status and nursing profession and residing in nuclear families (p<0.05), while age and marital status did not correlate significantly.Discussion. Premenstrual symptoms are common and distressing, especially for working females. Somatic symptoms such as backache and joint pains predominate over psychobiological symptoms. Women with higher educational status and professions like nursing belonging to nuclear families are more prone to these symptoms. Attention needs to be given to premenstrual symptoms in such population of working females.

Background: Hoarseness is a quality of voice that is rough, grating, harsh, more or less discordant and lower than normal in pitch for the individual. Besides affecting useful communication leading to tremendous alterations in daily living, voice problem may also signify the presence of more serious medical illnesses; such as malignancy or airway compromise. Hence this study is undertaken to determine the relative incidence of cases presented at a tertiary hospital, to analyse the hoarseness population based on age, sex, occupation etc, to find out the pathogenesis of hoarseness in the cases and to postulate the risk factors implicated in each. Methods: Descriptive cross sectional study was conducted on patients with hoarseness reported at Government Medical College, Trivandrum for a period of twelve months. Detailed history regarding duration, onset, nature of hoarseness, aggravating and relieving factors, voice fatiguability, diurnal variation, associated symptoms and history of upper respiratory infection were taken. Results: Being the tertiary hospital, the incidence was noted to be 0.7%. Majority of patients are in 4th to 7th decades and the most commonly affected age group was 50-59 years. Male preponderance with 4:1 ratio was observed in which manual labourers constitute the single largest group. Smoking, alcohol intake and vocal abuse are found to be the major etiological factors. Majority of lesions were malignant in nature, commonest being Carcinoma Glottis. In benign lesions, majority was vocal cord polyp. Conclusions: Early detection of pathology and awareness is very important in the management of hoarseness.

Objective This study was aimed to evaluate the electrophysiologic findings in patients with untreated primary hypothyroidism. Methods Twelve patients with newly diagnosed primary hypothyroidism and 10 healthy control subjects were included in the study. Neuromuscular symptoms, and neurological examination and electrophysiological findings were obtained from the patient records. Results Four male and 8 female patients with a mean age of 52.8 ± 11.8 year was enrolled. Nine patients (75%) had complaints suggestive of muscle dysfunction including weakness (53%), fatiguability, muscle pain, stiffness, or cramps (42%). Only one patients (8.3%) had muscle complaints as the presenting symptom or the main reason for consulting a doctor. In this group, there were 2 cases (16.5%) with neuropathy, including 1 sensory and 1 sensorimotor, and 1 case (8.5%) with myopathy, and 5 of the cases (41.3%) with carpal tunnel syndrome. There was no significant relation between gender, duration of the disease, serum TSH levels, and the presence of clinical muscle weakness with the occurrence of neuropathy or myopathy. (P Conclusions In patients with untreated primary hypothyroidism, majority had the carpal tunnel syndrome. Neuropathy and myopathy were uncommon and rare findings, respectively. Key words Hypothyroidism, electromyography, neuropathy.

Introduction Miller Fisher syndrome (MFS) is a variant of Guillain–Barre syndrome (GBS). MFS is clinically defined by trias – ophthalmoplegia, ataxia, areflexia. Antibodies against ganglioside GQ1b are bound on the nodal and paranodal sections of oculomotor nerves, sensory nerves (including spinal ganglia) and cerebellum. Ophthalmoparesis is usually severe with prominent fatiguability. In these patients neuromuscular transmission disorders are suspected. Case report A 52-year man was admitted to neurological department for progressive external ophthalmoparesis with generalized ataxia. The neurological signs and symptoms developer during 5 days with preceding upper respiratory tract infection. The first diagnosis was MFS. There was very prominent especially oculomotor fatiguability with worsening during the day and after rehabilitation, that neuromuscular transmission was suspected too. Neurophysiological investigation Motor conduction studies (including F-waves) were normal, sensory conduction studies with very low amplitude of sensory nerve action potentials. H-reflex was not elicitable. Needle EMG of biceps brachii was normal (14 days after disease onset). Repetitive stimulation (3 Hz) with recording from trapezius with 7% decrement (4th response) and from nasalis 5.8%. Axonal stimulated SF EMG with recording by concentric needle electrode from frontalis muscle presented an increased jitter −32.91 μs and 9% blocking - with the stimulation rate 3 Hz. With stimulation rate 10 Hz the jitter decreased to 26.26 μs and without blocking, with 20 Hz stimulation rate was the jitter normal (21.83 μs) and without blocking. Other investigations GQ1b antibody level was prominent – 315.7% (norm – up to 9%), antibodies against acetylcholine receptors were not found. MR of brain and thorax were normal. The patient was treated with a series of plasma exchange. After 14 days he began to walk with crutches and ptosis and diplopia significantly decreased. 6 weeks later he was able to walk without support and oculomotor function normalized. Neurophysiological findings in MFS are discussed. Conclusion In our patient with MFS we diagnosed presynaptic type (axonal) disorder of neuromuscular transmission.

Background While many studies have been performed on the effects of exercise on Adolescent Idiopathic Scoliosis (AIS) little research has been done into the underlying muscle physiology. Studies have suggested a fibre type imbalance, however, the implications of this difference as reflected through fatiguability have not been studied. The slope of the median frequency of the surface electromyographic (EMG) signal is a useful tool in determining the fatigability of muscles.