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1.  Assessment of neuromuscular and haemodynamic activity in individuals with and without chronic low back pain 
Dynamic Medicine  2006;5:6.
Biering-Sørenson (1984) found that individuals with less lumbar extensor muscle endurance had an increased occurrence of first episode low back pain. As a result, back endurance tests have been recommended for inclusion in health assessment protocols. However, different studies have reported markedly different values for endurance times, leading some researchers to believe that the back is receiving support from the biceps femoris and gluteus maximus. Therefore, this study was designed to examine the haemodynamic and neuromuscular activity of the erector spinae, biceps femoris, and gluteus maximus musculature during the Biering-Sørenson Muscular Endurance Test (BSME).
Seventeen healthy individuals and 46 individuals with chronic low back pain performed the Biering-Sørenson Muscular Endurance Test while surface electromyography was used to quantify neuromuscular activity. Disposable silver-silver-chloride electrodes were placed in a bipolar arrangement over the right or left biceps femoris, gluteus maximus, and the lumbosacral paraspinal muscles at the level of L3. Near Infrared Spectroscopy was used simultaneously to measure tissue oxygenation and blood volume changes of the erector spinae and biceps femoris.
The healthy group displayed a significantly longer time to fatigue (Healthy: 168.5s, LBP: 111.1s; p ≤ 0.05). Significant differences were shown in the median frequency slope of the erector spinae between the two groups at 90–100% of the time to fatigue while no significant differences were noted in the haemodynamic data for the two groups.
Although the BSME has been recognized as a test for back endurance, individuals with chronic LBP appear to incorporate a strategy that may help support the back musculature by utilizing the biceps femoris and gluteus maximus to a greater degree than their healthy counterparts.
PMCID: PMC1489922  PMID: 16734915
2.  Contribution of Hamstring Fatigue to Quadriceps Inhibition Following Lumbar Extension Exercise 
The purpose of this study was to determine the contribution of hamstrings and quadriceps fatigue to quadriceps inhibition following lumbar extension exercise. Regression models were calculated consisting of the outcome variable: quadriceps inhibition and predictor variables: change in EMG median frequency in the quadriceps and hamstrings during lumbar fatiguing exercise. Twenty-five subjects with a history of low back pain were matched by gender, height and mass to 25 healthy controls. Subjects performed two sets of fatiguing isometric lumbar extension exercise until mild (set 1) and moderate (set 2) fatigue of the lumbar paraspinals. Quadriceps and hamstring EMG median frequency were measured while subjects performed fatiguing exercise. A burst of electrical stimuli was superimposed while subjects performed an isometric maximal quadriceps contraction to estimate quadriceps inhibition after each exercise set. Results indicate the change in hamstring median frequency explained variance in quadriceps inhibition following the exercise sets in the history of low back pain group only. Change in quadriceps median frequency explained variance in quadriceps inhibition following the first exercise set in the control group only. In conclusion, persons with a history of low back pain whose quadriceps become inhibited following lumbar paraspinal exercise may be adapting to the fatigue by using their hamstring muscles more than controls.
Key PointsA neuromuscular relationship between the lumbar paraspinals and quadriceps while performing lumbar extension exercise may be influenced by hamstring muscle fatigue.QI following lumbar extension exercise in persons with a history of LBP group may involve significant contribution from the hamstring muscle group.More hamstring muscle contribution may be a necessary adaptation in the history of LBP group due to weaker and more fatigable lumbar extensors.
PMCID: PMC3818676  PMID: 24198683
Superimposed burst technique; electromyography; spectral median frequency; correlation and regression; low back pain
3.  Neuromuscular Evaluation of Trunk-Training Exercises 
Journal of Athletic Training  2001;36(2):109-118.
To evaluate the neuromuscular activation profiles of trunk muscles in commonly used gymnastic strength exercises with a polymyographic set-up and to describe the training effects of each exercise.
Design and Setting:
Subjects performed 9 repetitions of each of 12 gymnastic exercises. Variations of 5 trunk flexions, 5 extensions, and 2 lateral-flexion movements were performed under standardized test conditions.
Ten healthy subjects (men and women) who were familiar with the exercises participated in the study.
We recorded surface electromyograms (EMGs) from the rectus abdominis, external oblique, rectus femoris, middle trapezius, erector spinae at T12 and L3, gluteus maximus, and semitendinosus and semimembranosus muscles. Recording of each repetition cycle was triggered by a flexible electronic goniometer attached to the trunk. The raw EMG signals were rectified, smoothed, amplitude normalized to maximal voluntary contraction (MVC), and averaged for the last 8 repetitions.
Pure spine-flexion exercises, such as a curl-up, produced sufficient and isolated activation (greater than 50% MVC) of the abdominal muscles. When flexion of the spine was combined with hip flexion (sit-up), the peak activation was increased. Lateral-flexion tasks targeted primarily the external oblique muscle, which demonstrated high activity in side-lying flexion tasks. Back- and hip-extension exercises, such as bridging and diagonal hip and shoulder extension, produced only moderate mean activities (less than 35% MVC) in the trunk-extensor muscles. Trunk-extension exercises with combined hip extension increased the EMG activity to 50% MVC but only at the end of the extension.
Individual responses to each exercise varied markedly, which complicated the classification of exercise effects. However, within the limitations of the study, we found that the chosen abdominal exercises provided an effective training stimulus for the trunk-flexor muscles, whereas in the back- and hip-extension exercises, the neuromuscular activation tended to be too low or unspecific to qualify as muscle-specific training.
PMCID: PMC155519  PMID: 12937449
electromyography; activation profiles; EMG normalization; EMG variability; movement standardization; back muscles; abdominal muscles; hip muscles; training effectiveness
4.  Assessment of the paraspinal muscles of subjects presenting an idiopathic scoliosis: an EMG pilot study 
It is known that the back muscles of scoliotic subjects present abnormalities in their fiber type composition. Some researchers have hypothesized that abnormal fiber composition can lead to paraspinal muscle dysfunction such as poor neuromuscular efficiency and muscle fatigue. EMG parameters were used to evaluate these impairments. The purpose of the present study was to examine the clinical potential of different EMG parameters such as amplitude (RMS) and median frequency (MF) of the power spectrum in order to assess the back muscles of patients presenting idiopathic scoliosis in terms of their neuromuscular efficiency and their muscular fatigue.
L5/S1 moments during isometric efforts in extension were measured in six subjects with idiopathic scoliosis and ten healthy controls. The subjects performed three 7 s ramp contractions ranging from 0 to 100% maximum voluntary contraction (MVC) and one 30 s sustained contraction at 75% MVC. Surface EMG activity was recorded bilaterally from the paraspinal muscles at L5, L3, L1 and T10. The slope of the EMG RMS/force (neuromuscular efficiency) and MF/force (muscle composition) relationships were computed during the ramp contractions while the slope of the EMG RMS/time and MF/time relationships (muscle fatigue) were computed during the sustained contraction. Comparisons were performed between the two groups and between the left and right sides for the EMG parameters.
No significant group or side differences between the slopes of the different measures used were found at the level of the apex (around T10) of the major curve of the spine. However, a significant side difference was seen at a lower level (L3, p = 0.01) for the MF/time parameter.
The EMG parameters used in this study could not discriminate between the back muscles of scoliotic subjects and those of control subject regarding fiber type composition, neuromuscular efficiency and muscle fatigue at the level of the apex. The results of this pilot study indicate that compensatory strategies are potentially seen at lower level of the spine with these EMG parameters.
PMCID: PMC1079862  PMID: 15760468
EMG; scoliosis; neuromuscular efficiency; muscle fatigue
5.  Effects of Pelvic Belt on Hip Extensor Muscle EMG Activity during Prone Hip Extension in Females with Chronic Low Back Pain 
Journal of Physical Therapy Science  2014;26(7):1023-1024.
[Purpose] This study assessed the effects of a pelvic belt (PB) on the electromyography (EMG) activity of the elector spinae (ES), gluteus maximus (GM), and biceps femoris (BF) in females with chronic low back pain (CLBP) during prone hip extension (PHE). [Subjects] Twenty female with CLBP were recruited. Surface EMG data were collected from the ES, GM, and BF muscles during a PHE task. [Results] The EMG activity in the ES bilaterally, and the right GM decreased significantly when a PB was applied compared with when a PB was not applied. [Conclusion] This suggests that a PB is effective for altering the activation pattern of the hip extensor muscles in females with CLBP during PHE.
PMCID: PMC4135188  PMID: 25140087
Chronic low back pain; Pelvic belt; Prone hip extension
6.  Trunk muscle fatigue during a lateral isometric hold test: what are we evaluating? 
Side bridge endurance protocols have been suggested to evaluate lateral trunk flexor and/or spine stabilizer muscles. To date, no study has investigated muscle recruitment and fatigability during these protocols. Therefore the purpose of our study was to quantify fatigue parameters in various trunk muscles during a modified side bridge endurance task (i.e. a lateral isometric hold test on a 45° roman chair apparatus) and determine which primary trunk muscles get fatigued during this task. It was hypothesized that the ipsilateral external oblique and lumbar erector spinae muscles will exhibit the highest fatigue indices.
Twenty-two healthy subjects participated in this study. The experimental session included left and right lateral isometric hold tasks preceded and followed by 3 maximal voluntary contractions in the same position. Surface electromyography (EMG) recordings were obtained bilaterally from the external oblique, rectus abdominis, and L2 and L5 erector spinae. Statistical analysis were conducted to compare the right and left maximal voluntary contractions (MVC), surface EMG activities, right vs. left holding times and decay rate of the median frequency as the percent change from the initial value (NMFslope).
No significant left and right lateral isometric hold tests differences were observed neither for holding times (97.2 ± 21.5 sec and 96.7 ± 24.9 sec respectively) nor for pre and post fatigue root mean square during MVCs. However, participants showed significant decreases of MVCs between pre and post fatigue measurements for both the left and right lateral isometric hold tests. Statistical analysis showed that a significantly NMFslope of the ipsilateral external oblique during both conditions, and a NMFslope of the contralateral L5 erector spinae during the left lateral isometric hold test were steeper than those of the other side’s respective muscles. Although some participants presented positive NMFslope for some muscles, each muscle presented a mean negative NMFslope significantly different from 0.
Although the fatigue indices suggest that the ipsilateral external oblique and contralateral L5 erector spinae show signs of muscle fatigue, this task seems to recruit a large group of trunk muscles. Clinicians should not view this task as evaluating specifically lateral trunk flexors, but rather as providing an indication of the general endurance and stabilisation capacity of the trunk.
PMCID: PMC3418569  PMID: 22515489
Side bridge test; Muscle fatigue; Trunk muscle; Functional testing
7.  The gait pattern is not impaired in subjects with external snapping hip: a comparative cross-sectional study 
Symptomatic external snapping hip is a painful condition, where pain in the trochantor region and limitations of daily activity dominate clinical findings. The aetiology of symptomatic external snapping hip is elusive, but previous studies have suggested that weakness of the hip abductors and an altered walking pattern may play a role in the development of symptomatic external snapping hip. The aim of this study was to compare the walking pattern and muscular activity of the hip muscles between subjects with symptomatic external snapping hip and healthy subjects.
Thirteen subjects with diagnosed symptomatic external snapping hip (age: 25.5 years) were matched with 13 healthy subjects (age: 25.6 years). Joint kinematics and kinetics of the lower extremity were quantified by the peak hip adduction angle; the average knee rotation range of motion (ROM) and the peak valgus knee angle after data recording using a Vicon 612 motion capture system. Muscle activity was recorded bilaterally using surface electromyography (sEMG) on five muscles: gluteus maximus, gluteus medius, tensor fascia latae, rectus femoris and biceps femoris. A paired t-test was used to evaluate differences between the two groups.
No significant differences were found between the groups concerning the peak hip adduction angle, the average knee rotation ROM, and the static valgus knee angle. No significant between-group differences were found concerning all other kinematics, kinetics or muscle activity. In subjects with symptomatic external snapping hip activity of the gluteus medius muscle during the acceptance phase of walking was 0.58 ± 0.19 whereas the activity was 0.68±0.07 in the asymptomatic group (p=0.115).
No significant differences in the walking pattern were found between subjects with symptomatic external snapping hip and healthy subjects. This suggest that subjects with symptomatic external snapping hip does not have an impaired gait pattern.
PMCID: PMC3724713  PMID: 23870630
Iliotibial band; Trochantor pain; Healthy subjects; Walking; Electromyography; EMG
8.  Effects of muscle fatigue on gait characteristics under single and dual-task conditions in young and older adults 
Muscle fatigue and dual-task walking (e.g., concurrent performance of a cognitive interference (CI) while walking) represent major fall risk factors in young and older adults. Thus, the objectives of this study were to examine the effects of muscle fatigue on gait characteristics under single and dual-task conditions in young and older adults and to determine the impact of muscle fatigue on dual-task costs while walking.
Thirty-two young (24.3 ± 1.4 yrs, n = 16) and old (71.9 ± 5.5 yrs, n = 16) healthy active adults participated in this study. Fatigue of the knee extensors/flexors was induced by isokinetic contractions. Subjects were tested pre and post fatigue, as well as after a 5 min rest. Tests included the assessment of gait velocity, stride length, and stride length variability during single (walking), and dual (CI+walking) task walking on an instrumented walkway. Dual-task costs while walking were additionally computed.
Fatigue resulted in significant decreases in single-task gait velocity and stride length in young adults, and in significant increases in dual-task gait velocity and stride length in older adults. Further, muscle fatigue did not affect dual-task costs during walking in young and older adults. Performance in the CI-task was improved in both age groups post-fatigue.
Strategic and/or physiologic rationale may account for the observed differences in young and older adults. In terms of strategic rationale, older adults may walk faster with longer strides in order to overcome the feeling of fatigue-induced physical discomfort as quickly as possible. Alternatively, older adults may have learned how to compensate for age-related and/or fatigue-induced muscle deficits during walking by increasing muscle power of synergistic muscle groups (e.g., hip flexors). Further, a practice and/or learning effect may have occurred from pre to post testing. Physiologic rationale may comprise motor unit remodeling in old age resulting in larger proportions of type I fibres and thus higher fatigue-resistance and/or increased muscle spindle sensitivity following fatigue leading to improved forward propulsion of the body. These findings are preliminary and have to be confirmed by future studies.
PMCID: PMC2993724  PMID: 21062458
9.  The neurophysiology of central and peripheral fatigue during sub-maximal lower limb isometric contractions 
Fatigue has been defined as an exercise-induced decline in force generation capacity because of changes at both the peripheral and central levels. Movement is preceded and accompanied by brain activities related to the preparation and execution of movement (movement related cortical potentials, MRCP), which have been correlated with the perception of effort (RPE). We combined force measurements, surface electromyography (sEMG), peripheral electrical stimulation (maximal twitch, MT) and MRCP analysis to further our understanding of the neural correlates of peripheral and central changes during a fatiguing task involving the lower limbs. Eighteen healthy volunteers performed 4 blocks of isometric knee extensions at 40% of the maximal voluntary contraction (MVC) for a total of 240 2-s contractions. At the baseline and after each block, we measured RPE, MT and MVC. We simultaneously recorded the force of the knee extensor muscles, root mean square (RMS) of the sEMG of the vastus lateralis muscle, and electroencephalography (EEG) from 64 channels. The MRCPs were extracted from the EEG recordings and averaged in the early (Block 1–2) and late (Block 3–4) blocks. Two cohorts were obtained by cluster analysis based on the RPE (i.e., perception of effort) and MT (i.e., peripheral fatigue). We observed a significant decline in both the MVC (−13%) and RMS (−25%) of the sEMG signal over the course of the task; thus, muscle fatigue had occurred in all of the participants regardless of the cohort. The MRCP amplitude was larger in the fatigued than the non-fatigued MT cohort in the supplementary and premotor areas, whereas the MRCP amplitude was larger in the fatigued than the non-fatigued RPE cohort in the aforementioned areas, and also in the primary motor and prefrontal cortices (PFC). The increase in the positive activity of the PFC, along with the perception of effort, represents a novel result, suggesting that it is modulated more by the perception of effort than peripheral fatigue.
PMCID: PMC3625743  PMID: 23596408
movement-related cortical potentials (MRCPs); rating of perceived efforts (RPE); isometric contraction; maximal voluntary contractions (MVC); maximal twitch (MT)
10.  Changes in the flexion relaxation response induced by lumbar muscle fatigue 
The flexion relaxation phenomenon (FRP) is an interesting model to study the modulation of lumbar stability. Previous investigations have explored the effect of load, angular velocity and posture on this particular response. However, the influence of muscular fatigue on FRP parameters has not been thoroughly examined. The objective of the study is to identify the effect of erector spinae (ES) muscle fatigue and spine loading on myoelectric silence onset and cessation in healthy individuals during a flexion-extension task.
Twenty healthy subjects participated in this study and performed blocks of 3 complete trunk flexions under 4 different experimental conditions: no fatigue/no load (1), no fatigue/load (2), fatigue/no load(3), and fatigue/load (4). Fatigue was induced according to the Sorenson protocol, and electromyographic (EMG) power spectral analysis confirmed that muscular fatigue was adequate in each subject. Trunk and pelvis angles and surface EMG of the ES L2 and L5 were recorded during a flexion-extension task. Trunk flexion angle corresponding to the onset and cessation of myoelectric silence was then compared across the different experimental conditions using 2 × 2 repeated-measures ANOVA.
Onset of myoelectric silence during the flexion motion appeared earlier after the fatigue task. Additionally, the cessation of myoelectric silence was observed later during the extension after the fatigue task. Statistical analysis also yielded a main effect of load, indicating a persistence of ES myoelectric activity in flexion during the load condition.
The results of this study suggest that the presence of fatigue of the ES muscles modifies the FRP. Superficial back muscle fatigue seems to induce a shift in load-sharing towards passive stabilizing structures. The loss of muscle contribution together with or without laxity in the viscoelastic tissues may have a substantial impact on post fatigue stability.
PMCID: PMC2259346  PMID: 18218087
11.  Effects of a Bridging Exercise with Hip Adduction on the EMG Activities of the Abdominal and Hip Extensor Muscles in Females 
Journal of Physical Therapy Science  2013;25(9):1147-1149.
[Purpose] This study compared the activities of the abdominal and hip extensor muscles between the bridging exercise (BE) and bridging exercise with hip adduction (BEHA) positions in women using electromyography (EMG). [Subjects] We recruited 14 healthy adult females with no history of low back pain. [Methods] The subjects performed bridging exercises with and without hip adduction. The EMG activities of the rectus abdominis (RA), external oblique (EO), internal oblique (IO), and gluteus maximus (GM) muscles were recorded. [Result] The EMG activities of all muscles were significantly increased during the BEHA compared to the BE. [Conclusion] The bridging exercise with hip adduction produced greater activation of the abdominal and hip extensor muscles.
PMCID: PMC3818763  PMID: 24259933
Bridging exercise; EMG; Hip adduction
12.  Myoelectrical Manifestation of Fatigue Less Prominent in Patients with Cancer Related Fatigue 
PLoS ONE  2013;8(12):e83636.
A lack of fatigue-related muscle contractile property changes at time of perceived physical exhaustion and greater central than peripheral fatigue detected by twitch interpolation technique have recently been reported in cancer survivors with fatigue symptoms. Based on these observations, it was hypothesized that compared to healthy people, myoelectrical manifestation of fatigue in the performing muscles would be less significant in these individuals while sustaining a prolonged motor task to self-perceived exhaustion (SPE) since their central fatigue was more prominent. The purpose of this study was to test this hypothesis by examining electromyographic (EMG) signal changes during fatiguing muscle performance.
Twelve individuals who had advanced solid cancer and cancer-related fatigue (CRF), and 12 age- and gender-matched healthy controls performed a sustained elbow flexion at 30% maximal voluntary contraction till SPE. Amplitude and mean power frequency (MPF) of EMG signals of the biceps brachii, brachioradialis, and triceps brachii muscles were evaluated when the individuals experienced minimal, moderate, and severe fatigue.
CRF patients perceived physical “exhaustion” significantly sooner than the controls. The myoelectrical manifestation of muscular fatigue assessed by EMG amplitude and MPF was less significant in CRF than controls. The lower MPF even at minimal fatigue stage in CRF may indicate pathophysiologic condition of the muscle.
CRF patients experience less myoelectrical manifestation of muscle fatigue than healthy individuals near the time of SPE. The data suggest that central nervous system fatigue plays a more important role in limiting endurance-type of motor performance in patients with CRF.
PMCID: PMC3877402  PMID: 24391800
13.  A comparison of pain level and entropy changes following core stability exercise intervention 
As reported in our previous studies, the complexity of physiologic time series is a sensitive measure of muscle fatigability. This study compared the differences between 2 different analyses following 4 weeks of core stability exercises (CSE) in subjects with and without chronic low back pain (LBP). We examined whether the observed Shannon (information) entropy, as compared with median frequency (MF), was able to differentiate fatigability of the thoracic and lumbar parts of the erector spinae (ES) muscles following the intervention.
In total, 32 subjects participated in this study. There were 13 subjects in the CSE intervention group (average age 50.4±9.1 years) and 19 subjects in the control group (average age 46.6±9.1 years). The CSE group performed the specific exercise intervention, but the control group was asked to maintain their current activity and/or exercise levels. The endurance of the back muscles was determined by using a modified version of the isometric fatigue test as originally introduced by Sorensen.
Pain level decreased significantly for all subjects (F=25.29, p=0.001), but there was no difference between groups (F=0.42, p=0.52). The MF was not different between groups following treatment (F=0.81, p=0.37). Although there was no entropy level changes following treatment (F=0.01, p=0.93), the interactions between muscles and groups following treatment were significant (F=7.25, p=0.01). The entropy level decreased in both thoracic ES muscles following intervention in the exercise group, while remaining the same in the control group.
Although the change in pain level was not different between groups, the Shannon entropy measure more sensitively differentiated the exercise intervention than did MF. In addition, the results also suggested that complexity is related to muscle fatigue, which corresponds to the values of entropy between groups. Further studies are needed to investigate the effectiveness of nonlinear time series of EMG data for fatigability.
PMCID: PMC3539569  PMID: 21709629
electromyography; low back pain; nonlinear time series; complexity; fatigue; core stability exercise; median frequency
14.  The Effects of Neuromuscular Fatigue on Task Performance During Repetitive Goal-Directed Movements 
Proper movement timing is essential to the successful execution of many motor tasks and may be adversely affected by muscle fatigue. This study quantified how muscle fatigue affected task performance during a repetitive upper extremity task. 14 healthy young adults pushed a low load back and forth along a low-friction horizontal track in time with a metronome until volitional exhaustion. Kinematic, force, and electromyography (EMG) data were measured continuously throughout the task. The first and last 3.5 minutes were analyzed to represent ‘early’ and ‘late’ fatigue. Means and standard deviations of movement distance, speed, and timing errors were computed. We also decomposed variations in movement distance and speed into deviations that directly affected achieving the task goal and those that did not, by identifying the goal equivalent manifold (GEM) of all valid solutions to this task. Detrended fluctuation analysis was used to quantify the temporal persistence in each time series. Principle components analysis provided a direct measure of alignment with the GEM. Median power frequencies of the EMG significantly decreased in 6 of the 9 muscles tested indicating that subjects did fatigue. However, there were no differences in the means or variability of movement distance, speed, or timing errors. Thus, subjects maintained overall performance despite fatigue. Subjects applied slightly higher peak handle forces when they were fatigued (p = 0.032). Muscle fatigue caused significant reductions in the temporal persistence of movement speed (p = 0.037) and timing errors (p = 0.046), indicating that subjects corrected errors more quickly when fatigued. Mean deviations and variability perpendicular to the GEM were much smaller than variability along the GEM (p < 0.001). Deviations perpendicular to the GEM were also corrected much more rapidly than those along the GEM (p < 0.001). Subjects aligned themselves very closely (< ±7°), but not exactly (p < 0.001), with the GEM. These measures were not significantly affected by muscle fatigue. Overall, these results indicated that subjects altered their biomechanical movement patterns in response to muscle fatigue, but did so in a way that specifically preserved the goal relevant features of task performance.
PMCID: PMC2825378  PMID: 18327575
Multi-joint movement; Redundancy; Muscle fatigue; Physical endurance; Motor control; Time factors
15.  Muscle Coactivation Before and After the Impact Phase of Running Following Isokinetic Fatigue 
Journal of Athletic Training  2011;46(1):11-19.
The effects of fatigue on impact loading during running are unclear, with some authors reporting increased impact forces and others reporting decreased forces.
To examine the effects of isokinetic fatigue on muscle cocontraction ratios about the knee and ankle during running.
Cross-sectional study.
Neuromechanics laboratory.
Patients or Other Participants:
Female middle-distance runners (age  =  21.3 ± 1.93 years) with at least 5 years of training experience.
Participants ran on the treadmill at 3.61 m/s before and immediately after the fatigue protocol, which consisted of consecutive, concentric knee extension-flexion at 120°/s until they could no longer produce 30% of the maximum knee-extension moment achieved in the familiarization session for 3 consecutive repetitions.
Main Outcome Measure(s):
Electromyographic (EMG) amplitude of the vastus medialis (VM), biceps femoris (BF), gastrocnemius (GAS), and tibialis anterior (TA) was recorded using surface electrodes. Agonist∶antagonist EMG ratios for the knee (VM∶BF) and ankle (GAS∶TA) were calculated for the preactivation (PR), initial loading response (LR1), and late loading response (LR2) phases of running. Hip-, knee-, and ankle-joint angular displacements at initial foot contact were obtained from 3-dimensional kinematic tracings.
Fatigue did not alter the VM∶BF EMG ratio during the PR phase (P > .05), but it increased the ratio during the LR1 phase (P < .05). The GAS∶TA EMG ratio increased during the LR1 phase after fatigue (P < .05) but remained unchanged during the PR and LR2 phrases (P > .05).
The increased agonist EMG activation, coupled with reduced antagonist EMG activation after impact, indicates that the acute decrease in muscle strength capacity of the knee extensors and flexors results in altered muscle-activation patterns about the knee and ankle before and after foot impact.
PMCID: PMC3017483  PMID: 21214346
biomechanics; muscle fatigue; joint stability
16.  Posterior muscle chain activity during various extension exercises: an observational study 
Back extension exercises are often used in the rehabilitation of low back pain. However, at present it is not clear how the posterior muscles are recruited during different types of extension exercises. Therefore, the present study will evaluate the myoelectric activity of thoracic, lumbar and hip extensor muscles during different extension exercises in healthy persons. Based on these physiological observations we will make recommendations regarding the use of extensions exercises in clinical practice.
Fourteen healthy subjects performed four standardized extension exercises (dynamic trunk extension, dynamic-static trunk extension, dynamic leg extension, dynamic-static leg extension) in randomized order at an intensity of 60% of 1-RM (one repetition maximum). Surface EMG signals of Latissimus dorsi (LD), Longissimus thoracis pars thoracic (LTT) and lumborum (LTL), Iliocostalis lumborum pars thoracic (ILT) and lumborum (ILL), lumbar Multifidus (LM) and Gluteus Maximus (GM) were measured during the various exercises. Subsequently, EMG root mean square values were calculated and compared between trunk and leg extension exercises, as well as between a dynamic and dynamic-static performance using mixed model analysis. During the dynamic exercises a 2 second concentric contraction was followed by a 2 second eccentric contraction, whereas in the dynamic-static performance, a 5 second isometric interval was added in between the concentric and eccentric contraction phase.
In general, the muscles of the posterior chain were recruited on a higher level during trunk extension (mean ± SD, 56.6 ± 30.8%MVC) compared to leg extension (47.4 ± 30.3%MVC) (p ≤ 0.001). No significant differences were found in mean muscle activity between dynamic and dynamic-static performances (p = 0.053). The thoracic muscles (LTT and ILT) were recruited more during trunk extension (64.9 ± 27.1%MVC) than during leg extension (54.2 ± 22.1%MVC) (p = 0.045) without significant differences in activity between both muscles (p = 0.138). There was no significant differences in thoracic muscle usage between the dynamic or dynamic-static performance of the extension exercises (p = 0.574).
Lumbar muscle activity (LTT, ILL, LM) was higher during trunk extension (70.6 ± 22.2%MVC) compared to leg extension (61.7 ± 27.0%MVC) (p = 0.047). No differences in myoelectric activity between the lumbar muscles could be demonstrated during the extension exercises (p = 0.574). During each exercise the LD (19.2 ± 13.9%MVC) and GM (28.2 ± 14.6%MVC) were recruited significantly less than the thoracic and lumbar muscles.
The recruitment of the posterior muscle chain during different types of extension exercises was influenced by the moving body part, but not by the type of contraction. All muscle groups were activated at a higher degree during trunk extension compared to leg extension. Based on the recruitment level of the different muscles, all exercises can be used to improve the endurance capacity of thoracic muscles, however for improvement of lumbar muscle endurance leg extension exercises seem to be more appropriate. To train the endurance capacity of the LD and GM extension exercises are not appropriate.
PMCID: PMC3716991  PMID: 23834759
Trunk extensor muscles; Multifidus; Posterior muscle chain; Extension exercise; Electromyography; Spine
17.  Effects of Quadriceps Muscle Fatigue on Stiff-Knee Gait in Patients with Hemiparesis 
PLoS ONE  2014;9(4):e94138.
The relationship between neuromuscular fatigue and locomotion has never been investigated in hemiparetic patients despite the fact that, in the clinical context, patients report to be more spastic or stiffer after walking a long distance or after a rehabilitation session. The aim of this study was to evaluate the effects of quadriceps muscle fatigue on the biomechanical gait parameters of patients with a stiff-knee gait (SKG). Thirteen patients and eleven healthy controls performed one gait analysis before a protocol of isokinetic quadriceps fatigue and two after (immediately after and after 10 minutes of rest). Spatiotemporal parameters, sagittal knee and hip kinematics, rectus femoris (RF) and vastus lateralis (VL) kinematics and electromyographic (EMG) activity were analyzed. The results showed that quadriceps muscle weakness, produced by repetitive concentric contractions of the knee extensors, induced an improvement of spatiotemporal parameters for patients and healthy subjects. For the patient group, the increase in gait velocity and step length was associated with i) an increase of sagittal hip and knee flexion during the swing phase, ii) an increase of the maximal normalized length of the RF and VL and of the maximal VL lengthening velocity during the pre-swing and swing phases, and iii) a decrease in EMG activity of the RF muscle during the initial pre-swing phase and during the latter 2/3 of the initial swing phase. These results suggest that quadriceps fatigue did not alter the gait of patients with hemiparesis walking with a SKG and that neuromuscular fatigue may play the same functional role as an anti-spastic treatment such as botulinum toxin-A injection. Strength training of knee extensors, although commonly performed in rehabilitation, does not seem to be a priority to improve gait of these patients.
PMCID: PMC3981762  PMID: 24718087
18.  Changes in the flexion-relaxation response induced by hip extensor and erector spinae muscle fatigue 
The flexion-relaxation phenomenon (FRP) is defined by reduced lumbar erector spinae (ES) muscle myoelectric activity during full trunk flexion. The objectives of this study were to quantify the effect of hip and back extensor muscle fatigue on FRP parameters and lumbopelvic kinematics.
Twenty-seven healthy adults performed flexion-extension tasks under 4 different experimental conditions: no fatigue/no load, no fatigue/load, fatigue/no load, and fatigue/load. Total flexion angle corresponding to the onset and cessation of myoelectric silence, hip flexion angle, lumbar flexion angle and maximal trunk flexion angle were compared across different experimental conditions by 2 × 2 (Load × Fatigue) repeated-measures ANOVA.
The angle corresponding to the ES onset of myoelectric silence was reduced after the fatigue task, and loading the spine decreased the lumbar contribution to motion compared to the hip during both flexion and extension. A relative increment of lumbar spine motion compared to pelvic motion was also observed in fatigue conditions.
Previous results suggested that ES muscles, in a state of fatigue, are unable to provide sufficient segmental stabilization. The present findings indicate that, changes in lumbar-stabilizing mechanisms in the presence of muscle fatigue seem to be caused by modulation of lumbopelvic kinematics.
PMCID: PMC2896348  PMID: 20525336
19.  Strength and Fatigability of the Dominant and Nondominant Hip Abductors 
Journal of Athletic Training  2005;40(3):203-206.
Context: Contralateral muscular imbalances have been suggested to increase the risk of lower extremity injury. Previous groups have assessed strength of the quadriceps and hamstring muscle groups; however, no previous authors have compared bilateral hip-abductor muscular performance.
Objective: To examine the strength and fatigability of the hip abductors in the dominant and nondominant legs.
Design: Single-group, repeated-measures design.
Setting: Musculoskeletal laboratory.
Patients or Other Participants: Forty-two healthy subjects (23 males, 19 females; age = 24.3 ± 2.7 years, height = 173.4 ± 9.8 cm, mass = 73.7 ± 11.6 kg).
Intervention(s): Subjects performed three 5-second maximal voluntary isometric contraction (MVIC) trials of the hip abductors with the dominant and nondominant legs. Following the maximal strength trials, subjects performed a submaximal (50% of MVIC) 30-second fatigue trial with each leg.
Main Outcome Measure(s): Peak torque (PT) was recorded from each MVIC trial. Surface electromyography was used to record muscle activity during the fatigue trials. Power spectral analysis was used to determine the median frequency of each 0.512-second portion of the fatigue trials. Median frequencies were plotted against time, and linear regression was used to determine the median frequency slope (MFslope). Data were analyzed using 2-tailed, paired t tests.
Results: Hip-abduction PT of the dominant leg (81.0 ± 23.7 Nm) was significantly larger than that of the nondominant leg (76.1 ± 9.9 Nm, P = 0.02). There was no difference in MFslope between the dominant (−0.37 ± 0.29) and nondominant limbs (−0.35 ± 0.34, P = 0.84). The PT and MFslope were not significantly correlated (r = −0.07, P = 0.53).
Conclusions: Hip-abduction strength differences exist between the dominant and nondominant legs. Measures of strength and fatigability were poorly related; therefore, clinicians may opt to assess hip strength and fatigability independent of each another.
PMCID: PMC1250264  PMID: 16284642
footedness; gluteus medius; electromyography; median frequency
20.  The Effects of Grade and Speed on Leg Muscle Activations during Walking 
Gait & posture  2011;35(1):143-147.
Compared to level walking, additional muscle actions are required to raise and lower the center of mass during uphill and downhill walking, respectively. However, it remains unclear which muscle recruitment strategies are employed at typical grades when walking over a range of speeds. Based on previous reports, we hypothesized that, across a range of walking speeds, hip, knee, and ankle extensor muscle activations increase with steeper uphill grade, but only knee extensor muscle activations increase with steeper downhill grade. We also hypothesized that these changes in muscle activations with grade become more pronounced with faster walking speed. To test these hypotheses, ten young adult subjects (5M/5F) walked on a standard treadmill at seven grades (0, ±3, ±6, and ±9°) and three speeds (0.75, 1.25, and 1.75 m·s−1). We quantified the stance phase electromyographic activities of the gluteus maximus (GMAX), biceps femoris (BF), rectus femoris (RF), vastus medialis (VM), medial gastrocnemius (MG), and soleus (SOL) muscles. On average, compared to level walking, hip (BF: 635%, GMAX: 345%), knee (RF: 165%, VM: 366%), and ankle (MG: 175%, SOL: 136%) extensor muscle activities increased to walk up 9°, but only knee (RF: 310%, VM: 246%) extensor muscle activities increased to walk down 9°. Further, these changes in muscle activations with grade became greater with faster walking speed. We conclude that people employ distinct uphill (hip, knee, and ankle extensors) and downhill (knee extensors) muscle recruitment strategies generally across walking speeds and progressively with steeper grade.
PMCID: PMC3262943  PMID: 21962846
Uphill; Downhill; EMG; Electromyography; Muscle Activity
21.  The effect of continuous ultrasound on chronic non-specific low back pain: a single blind placebo-controlled randomized trial 
Non-specific chronic low back pain (NSCLBP) is one of the most common musculoskeletal disorders around the world including Iran. One of the most widely used modalities in the field of physiotherapy is therapeutic ultrasound (US). Despite its common use, there is still inconclusive evidence to support its effectiveness in patients with NSCLBP. The objective of this study was to evaluate the effect of continuous US compared with placebo US additional to exercise therapy for patients with NSCLBP.
In this single blind placebo controlled study, 50 patients with NSCLBP were randomized into two treatment groups: 1) continuous US (1 MHz &1.5 W/cm2) plus exercise 2) placebo US plus exercise. Patients received treatments for 4 weeks, 10 treatment sessions, 3 times per week, every other day. Treatment effects were assessed in terms of primary outcome measures: 1) functional disability, measured by Functional Rating Index, and 2) global pain, measured by a visual analog scale. Secondary outcome measures were lumbar flexion and extension range of motion (ROM), endurance time and rate of decline in median frequency of electromyography spectrum during a Biering Sorensen test. All outcome variables were measured before, after treatment, and after one-month follow-up. An intention to treat analysis was performed. Main effects of Time and Group as well as their interaction effect on outcome measures were investigated using repeated measure ANOVA.
Analysis showed that both groups had improved regarding function (FRI) and global pain (VAS) (P < .001). Lumbar ROM as well as holding time during the Sorensen test and median frequency slope of all measured paravertebral muscles did not change significantly in either group (P > .05). Improvement in function and lumbar ROM as well as endurance time were significantly greater in the group receiving continuous US (P < .05).
The study showed that adding continuous US to a semi supervised exercise program significantly improved function, lumbar ROM and endurance time. Further studies including a third group of only exercise and no US can establish the possible effects of placebo US.
Trial registration
PMCID: PMC3537701  PMID: 23031570
Low back pain; Ultrasound; Functional disability; Pain; Muscle endurance; Range of motion
22.  Hip flexor muscle fatigue in patients with symptomatic femoroacetabular impingement 
International Orthopaedics  2011;36(5):967-973.
Patients with symptomatic femoroacetabular impingement (FAI) have considerable hip muscle weakness, in particular, hip flexion and hip adduction. In addition, they experience disabilities while performing prolonged dynamic tasks. It was therefore postulated that, besides hip flexor muscle weakness, patients with symptomatic FAI would show greater hip flexor fatigue compared with healthy controls.
Hip flexor fatigue was evaluated in two different experiments. Fifteen patients with symptomatic FAI and 15 age-matched healthy controls were tested in each experiment. In the first one, changes in hip flexor torque fluctuations and electromyographic (EMG) activity were measured during a sustained submaximal isometric contraction. In the second experiment, hip flexor torque decline was measured during a series of 20 maximal dynamic contractions.
Patients with FAI exhibited hip flexor weakness under both isometric (P = 0.02) and isokinetic conditions (P = 0.03). Fatigue-induced changes in isometric hip flexor torque fluctuations, EMG root mean square and median frequency did not differ significantly between patients and controls (P > 0.05). Similarly, isokinetic hip flexor torque decline was comparable in patients with FAI and controls (P > 0.05).
None of the hip flexor fatigue outcomes considered here differed between patients with symptomatic FAI and controls. Therefore, the disabilities that patients experience while performing prolonged dynamic tasks do not seem to be caused by exaggerated hip flexor muscle fatigue.
PMCID: PMC3337110  PMID: 22038443
Medicine & Public Health; Orthopedics
23.  Abnormal coactivation of knee and ankle extensors is related to changes in heteronymous spinal pathways after stroke 
Abnormal coactivation of leg extensors is often observed on the paretic side of stroke patients while they attempt to move. The mechanisms underlying this coactivation are not well understood. This study (1) compares the coactivation of leg extensors during static contractions in stroke and healthy individuals, and (2) assesses whether this coactivation is related to changes in intersegmental pathways between quadriceps and soleus (Sol) muscles after stroke.
Thirteen stroke patients and ten healthy individuals participated in the study. Levels of coactivation of knee extensors and ankle extensors were measured in sitting position, during two tasks: maximal isometric voluntary contractions in knee extension and in plantarflexion. The early facilitation and later inhibition of soleus voluntary EMG evoked by femoral nerve stimulation were assessed in the paretic leg of stroke participants and in one leg of healthy participants.
Coactivation levels of ankle extensors (mean ± SEM: 56 ± 7% of Sol EMG max) and of knee extensors (52 ± 10% of vastus lateralis (VL) EMG max) during the knee extension and the ankle extension tasks respectively were significantly higher in the paretic leg of stroke participants than in healthy participants (26 ± 5% of Sol EMG max and 10 ± 3% of VL EMG max, respectively). Early heteronymous facilitation of Sol voluntary EMG in stroke participants (340 ± 62% of Sol unconditioned EMG) was significantly higher than in healthy participants (98 ± 34%). The later inhibition observed in all control participants was decreased in the paretic leg. Levels of coactivation of ankle extensors during the knee extension task were significantly correlated with both the increased facilitation (Pearson r = 0.59) and the reduced inhibition (r = 0.56) in the paretic leg. Measures of motor impairment were more consistently correlated with the levels of coactivation of biarticular muscles than those of monoarticular muscles.
These results suggest that the heteronymous pathways linking quadriceps to soleus may participate in the abnormal coactivation of knee and ankle extensors on the paretic side of stroke patients. The motor impairment of the paretic leg is strongly associated with the abnormal coactivation of biarticular muscles.
PMCID: PMC3159134  PMID: 21806839
Hemiparesis; Extension synergy; Sensory afferents; Isometric strength; Spinal Circuits; Propriospinal
24.  The potential use of spectral electromyographic fatigue as a screening and outcome monitoring tool of sarcopenic back muscle alterations 
To examine whether or not median frequency surface electromyographic (MF-EMG) back muscle fatigue monitoring would be able to identify alterations in back muscle function in elderly muscles, if a protocol was used that allowed optimum standardization of the processes underlying electromyographic fatigue, and whether these tests were reliable from day to day.
A total of 42 older (21 females; 67 (±10.5) years old) and 44 younger persons (19 females; 33 (±10) years) performed maximum isometric back extensions which were followed by one 30 s lasting 80% submaximum extension. Participants were seated on a dynamometer with their trunks 30° anteflexed, and they repeated all tests after 1-2 days and 6 weeks. SEMG was recorded bilaterally from the L1 (iliocostalis lumborum), L2 (longissimus), and L5 (multifidus) recording sites. Outcome variables included maximum back extension torque, initial MF-EMG (IMF-EMG), MF-EMG slope declines, and individual MF-EMG muscular imbalance scores. Two-factorial ANOVAs served to examine the age and gender-specific effects, and models from Generalizability Theory (G-Theory) were used for assessing retest-reliability.
Maximum back extension moment was non-significantly smaller in elders. IMF-EMG was overall higher in elders, with significant differences at the L5 recordings sites. In the elderly, MF-EMG fatigue declines were significantly smaller in L5, in the recording with the most negative slope, or if the slope of all electrodes was considered. Retest reliability was unanimous in young and older persons. ICC-type measurements from G-Theory of both the IMF and the fatigue slopes ranged from 0.7 to 0.85. Absolute SEM values were found clinically acceptable for the IMF-EMG, but relatively high for the fatigue slope declines.
The MF-EMG fatigue method is able to elucidate alterations of aging back muscles. This method, thus, might be suggested as a potential biomarker to objectively identify persons at risk for sarcopenia. Considering the clinical relevance of the IMF-EMG relative to the MF-EMG slope declines, spectral EMG may also be used as an outcome monitoring tool in elderly populations.
PMCID: PMC4105890  PMID: 24985941
Back muscles; Fatigue; Electromyography; Sarcopenia; Power spectrum analysis
25.  Low frequency fatigue in human quadriceps is fatigue dependent and not task dependent 
It is well accepted that a low intensity/long duration isometric contraction induces more low frequency fatigue (LFF) compared to a high-intensity/short-duration contraction. However, previous reports examined the intensity/duration of the contraction but did not control the level of fatigue when concluding fatigue is task dependent. The purpose of this study was to determine whether a long duration/low intensity fatiguing contraction would induce greater LFF than a short duration/high-intensity contraction when the quadriceps muscle was fatigued to similar levels. Eighteen healthy male subjects performed quadriceps contractions sustained at 35% and 65% of maximal voluntary contraction (MVC) on separate days, until the tasks induced a similar amount of fatigue (force generating capacity = 45% MVC). Double pulse torque to single pulse torque ratio (D/S ratio) was obtained before, immediately and 5 min after fatigue along with the electromyographic (EMG) signal from vastus medialis (VM) and rectus femoris (RF). The D/S ratio significantly (p < 0.05) increased by 8.7 ± 8.5% (mean ± SD) and 10.2 ± 9.2% after 35% and 65% tasks, respectively, and remained elevated 5 min into recovery; however, there was no significant difference in ratio between the two sessions immediately or 5 min post-fatigue (p > 0.05) even though the endurance time for the 35% fatigue task (124 ± 39.68 s) was significantly longer (p = 0.05) than that of the 65% task (63 ± 17.73 s). EMG amplitude and median power frequency (MPF) analysis also did not reveal any significant differences between these two sessions after fatigue. These findings indicate that LFF fatigue is fatigue dependent as well as task intensity/duration dependent. These findings assist us in understanding task dependency and muscle fatigue.
PMCID: PMC2963071  PMID: 17157533
Task dependency; Equivalent fatigue; Double/single ratio; Excitation–contraction coupling; Electrical stimulation

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