Fatigue analysis of human reinnervated muscle after microsurgical nerve repair

The reinnervated elbow flexors, biceps, and brachialis muscles were compared with the elbow flexors on the healthy opposite side in terms of muscle strength and fatigue in 10 patients who sustained sequelae of a unilateral posttraumatic brachial plexus palsy. The patients had recovered an active elbow flexion against resistance after microsurgical nerve repair. The patients were reviewed with an average postoperative followup of 12 years (range, 7.5-16 years). Despite a statistically significant difference in maximum isometric force, this study showed that after peripheral nerve repair, a partially reinnervated muscle has the same characteristics of fatigue and endurance as a normally innervated muscle, if these muscles exert the same percentage of their own maximum force.     

Muscle strength in healthy people and in patients suffering from recent-onset inflammatory arthritis

Neuromuscular function was compared among 20 patients with relatively recent onset (symptomatic period 17 +/- 24 months) rheumatoid arthritis (RA) (experimental group; EG), and 20 age- and sex-matched healthy people (control group; CG). The comparison was repeated after a period of 6 months, when 16 patients had carried out progressive strength training. At baseline maximal grip strength and maximal dynamic unilateral strength of the knee extensors in the EG were significantly (P < 0.05) lower in comparison to the CG. The groups did not differ from each other in maximal isometric strength of the trunk flexors and extensors or the knee extensors. The 6-month dynamic strength training in the EG resulted in significant increases in maximal dynamic strength of the knee extensors (P < 0.001), in isometric grip strength (P < 0.001) and in isometric strength of the trunk flexors (P < 0.05) and extensors (P < 0.05) to the level of the healthy controls. Only minor changes took place in explosive strength and maximal isometric strength of the knee extensors. Erythrocyte sedimentation rate (P < 0.001), Ritchie's articular index (P < 0.01) and modified health assessment questionnaire (P < 0.01) improved significantly during the training period. The results suggest that inflammatory arthritis decreases dynamic and/or isometric muscle strength in selected muscle groups of the body already in the early stages of disease. However, progressive dynamic strength training rapidly increases the neuromuscular performance capacity of the patients even to the level of healthy people without detrimental effects on disease activity.     

Effect of N-acylethanolamines with different acyl-chains on DPPC multilamellar liposomes

Relationships between lower extremity strength and stride characteristics were studied in 24 patients with post-polio syndrome. Maximum isometric torques were measured in the ankle plantar flexors, hip and knee extensors, and hip abductors. Gait velocity, stride length, and cadence were recorded during free and fast walking. Step-wise regression analysis was performed to determine which muscle groups best predicted ambulatory function. Plantar flexion torque was the best predictor of velocity (r = .55 free walking and r = .76 fast) and cadence (r = .46 free and r = .58 fast). The combination of plantar flexion and hip abduction torques was the best predictor of fast stride length (r = .78). These findings emphasize the important role of the plantar flexor muscles in gait. Knee extension torque was the poorest predictor for each of the gait parameters. Several patients demonstrated gait deviations that minimized the penalty of quadriceps weakness. Without a contracture or an orthosis, however, no adequate substitution exists for weak plantar flexion.     

Therapeutic intervention and signaling

To examine the effects of rapid dehydration on isometric muscular strength and endurance, seven men were tested at baseline (control) and after a dehydration (dHST) and a euhydration (eHST) heat stress trial. The dHST consisted of intermittent sauna exposure until 4% of body mass was lost, whereas the eHST consisted of intermittent sauna exposure (same duration as dHST) with water replacement. Peak torque was determined for the knee extensors and elbow flexors during three isometric maximal voluntary contractions. Time to fatigue was determined by holding a maximal voluntary contraction until torque dropped below 50% peak torque for 5 s. Strength and endurance were assessed 3.5 h after the HSTs (no food or water intake). Body mass was decreased 3.8+/-0.4% post dHST and 0.4+/-0.3% post eHST. Plasma volume was decreased 7.5+/-4.6% and 5.7+/-4.4%, 60 and 120 min post dHST, respectively. A small (1.6 mEq x L[-1]) but significant increase was found for serum Na+ concentration 60 min post dHST but had returned to predehydration level 120 min post dHST. Serum K+ and myoglobin concentrations were not affected by HSTs. Peak torque was not different (P > 0.05) among control, dHST, and eHST for the knee extensors (Mean (Nm)+/-SD, 285+/-79, 311+/-113, and 297+/-79) and elbow flexors (79+/-12, 83+/-15, and 80+/-12). Time to fatigue was not different (P > 0.05) among control, dHST and eHST for the knee extensors (Mean (s)+/-SD. 42.4+/-11.5, 45.3+/-7.6, and 41.8+/-6.0) and elbow flexors (48.2+/-8.9, 44.0+/-9.4, and 46.0+/-6.4). These results provide evidence that isometric strength and endurance are unaffected 3.5 h after dehydration of approximately 4% body mass.     

Experiments in coding clinical information: an analysis of clinicians using a computerized coding tool

In 50 congenital clubfeet (in 28 children aged 62-126 months) operated on with subtalar release from dorsolateral and posteromedial approach isometric strength of flexors, extensors, pronators and supinators was assessed with tensometry. All the muscular groups showed decreased momentum if compared to normal foot. The smallest deficit was observed in plantar flexors. Better results were accompanied by greater muscular strength, but statistically significant relation existed between strength of dorsal flexors and the quality of result. Postoperative calcaneus position did not influence the strength of dorsal or plantar flexors of the foot. Additional lengthening of FHL and FDL decreased the strength of plantar flexion.     

Functional analysis of patients who have had a modified Van Nes rotationplasty

Electromyographic analysis of gait in eight patients who had had a modified Van Nes rotationplasty was performed to compare the activity of the flexors and extensors of the ankle on the side of the operation with that of the flexors and extensors of the knee on the normal, contralateral side. The resemblance in the activity of the extensors was more pronounced than that of the flexors. In three patients, the angle of flexion of the knee throughout the gait cycle was the same on the side of the rotationplasty as on the normal side. There was more symmetry in the swing phase than has been reported for patients who have had an above-the-knee amputation. The strength of the dorsiflexors of the ankle on the side of the rotationplasty was 68 percent and that of the flexors was 71 per cent when compared with that of the muscles of the normal ankle.     

Gender differences in strength and muscle fiber characteristics

Strength and muscle characteristics were examined in biceps brachii and vastus lateralis of eight men and eight women. Measurements included motor unit number, size and activation and voluntary strength of the elbow flexors and knee extensors. Fiber areas and type were determined from needle biopsies and muscle areas by computerized tomographical scanning. The women were approximately 52% and 66% as strong as the men in the upper and lower body respectively. The men were also stronger relative to lean body mass. A significant correlation was found between strength and muscle cross-sectional area (CSA; P < or = 0.05). The women had 45, 41, 30 and 25% smaller muscle CSAs for the biceps brachii, total elbow flexors, vastus lateralis and total knee extensors respectively. The men had significantly larger type I fiber areas (4597 vs 3483 microns2) and mean fiber areas (6632 vs 3963 microns2) than the women in biceps brachii and significantly larger type II fiber areas (7700 vs 4040 microns2) and mean fiber areas (7070 vs 4290 microns2) in vastus lateralis. No significant gender difference was found in the strength to CSA ratio for elbow flexion or knee extension, in biceps fiber number (180,620 in men vs 156,872 in women), muscle area to fiber area ratio in the vastus lateralis 451,468 vs 465,007) or any motor unit characteristics. Data suggest that the greater strength of the men was due primarily to larger fibers. The greater gender difference in upper body strength can probably be attributed to the fact that women tend to have a lower proportion of their lean tissue distributed in the upper body.(ABSTRACT TRUNCATED AT 250 WORDS)     

Peripheral and respiratory muscles in chronic heart failure

It is well-established that in patients with congestive heart failure (CHF), exercise is limited by fatigue and shortness of breath. The poor correlation between the fatigue and indices of central haemodynamic function might indicate that peripheral muscle alterations contribute to impaired exercise capacity. Intrinsic abnormalities of the skeletal muscles have been suggested as a possible explanation. Since the shortness of breath correlates poorly with changes in lung function, changes in the respiratory muscles have been investigated. Studies have demonstrated diaphragmatic myopathy and atrophy similar, in part, to the changes in peripheral skeletal muscles. In CHF, type I (slow twitch) fibre atrophy is seen in respiratory as well as in peripheral muscles. The mechanism of these alterations remains to be elucidated. Studies into the mechanism of muscle dysfunction in congestive heart failure are relevant to the prospect of treatment of the changes in peripheral and respiratory muscles.     

Gender differences in isometric contractile properties and fatigability in elderly human muscle

This study had two purposes: to compare the isometric contractile characteristics and fatigability in the elbow flexors (EF) and ankle dorsiflexors (DF) in older males and females (60-80 years), and to determine the effects of almost 2 years of twice weekly dynamic weight-lifting training on these properties One hundred nine male and female subjects completed the 22-month intervention, 54 in the exercise group and 55 in the control group. Isometric contractile properties and fatigue characteristics were assessed at baseline, 10 months, and 22 months. At baseline, males were significantly stronger (p < .05) than females in evoked twitch torque (Pt) and maximal voluntary strength (MVC) in both EF and DF. Females exhibited significantly less fatigue (expressed either absolutely or relatively) than males in both Pt and MVC during a 3-min protocol of intermittent MVCs (5 s contraction; 2 s rest). There were no significant effects of the 22 months of dynamic training on either the isometric contractile properties or the fatigue characteristics, suggesting a very strong and persistent specificity of training effect.     

Leptin is an endogenous protective protein against the toxicity exerted by tumor necrosis factor

Decrements in muscle strength as a result of prolonged bed rest are well defined, but little is known about potential countermeasures for preventing loss of strength under this condition. The purpose of this study was to determine whether testosterone administration would preserve protein balance and muscle strength during prolonged bed rest. Ten healthy men (age, 36 +/- 2 yr; height, 177.2 +/- 3.4 cm; weight, 80.5 +/- 3.9 kg; mean +/- SE) were admitted to our in-patient metabolic unit. After a 1-week ambulatory run-in period, each subject was confined to bed for 28 days at 6 degree head-down tilt while receiving a daily oral dose of T3 (50 microg/day). During the bed rest/T3 period, six of the men were randomized to receive testosterone enanthate by i.m. injection (T; 200 mg/week) while four received placebo in a double blind fashion. Nitrogen balance was determined throughout, and whole body [13C]leucine kinetics were assessed at baseline and on day 26 of bed rest. Before bed rest and on the third day of reambulation, the muscle strength of the knee extensors and flexors and shoulder extensors and flexors was determined at 60 degrees/s on a Cybex isokinetic dynamometer. Despite improved [13C]leucine kinetics and maintenance of nitrogen balance and lean body mass in T-treated subjects, little preservation of muscle strength, particularly in the knee extensors, was noted. Muscle strength [reported as the best work repetition in foot-pounds (FtLb)] for right knee extensors declined (P = 0.011) similarly in both groups; from 165 +/- 15 to 126 +/- 18 FtLb in T-treated men and from 179 +/- 22 to 149 +/- 13 FtLb in placebo-treated men. Overall, there was less of a decline in extension and flexion strength of the shoulder compared to the knee, with no benefit from T. These results suggest that in the absence of daily ambulatory activity, T administration will not increase or, in the case of this bed rest model, preserve muscle strength.     

A comparison of the contractile properties of the muscles of the lower extremities in man

The physiological features of two antagonistic muscle groups, the dorsiflexors and plantar flexors of the ankle, have been compared in 11 healthy subjects aged 15-17 years (+/- SE; 16 +/- 1.2 years). Contractile properties of plantar flexors of the foot, namely of tibialis anterior (TA) and extensors triceps surae (TS) have been estimated by mechanical parameters of voluntary and electrically evoked contractions. All test subjects exhibited tolerance to supramaximal force of electric stimulation of n. tibialis and n. peroneus profundus at a frequency of 150 impulses.s-1 (for TS) and 150 impulses.s-1 and 250 impulses.s-1 (for TA). TA displayed high velocity and force-velocity properties (p < 0.05-0.001); TS had high force parameters (p < 0.05-0.01). The magnitude of force deficiency observed during voluntary contraction of these muscles is lower in TA and higher in TS (p < 0.05). The results permit supposing that differences in contractile properties of the muscles under study depend on a various specific contribution of peripheral and CNS factors.     

Genetic association of apolipoprotein E with age-related macular degeneration

Several investigators have studied the deficit in maximal voluntary force that is said to occur when bilateral muscle groups contract simultaneously. A true bilateral deficit (BLD) would suggest a significant limitation of neuromuscular control; however, some of the data from studies in the literature are equivocal. Our purpose was to determine whether there is a BLD in the knee extensors of untrained young male subjects during isometric contractions and whether this deficit is associated with a decreased activation of the quadriceps, increased activation of the antagonist muscle, or an alteration in motor unit firing rates. Twenty subjects performed unilateral (UL) and bilateral (BL) isometric knee extensions at 25, 50, 75, and 100% maximal voluntary contraction. Total UL and BL force (delta 3%) and maximal rate of force generation (delta 2.5%) were not significantly different. Total UL and BL maximal vastus lateralis electromyographic activity (EMG; 2.7 +/- 0.28 vs. 2.6 +/- 0.24 mV) and coactivation (0.17 +/- 0.02 vs. 0.20 +/- 0.02 mV) were also not different. Similarly, the ratio of force to EMG during submaximal UL and BL contractions was not different. Analysis of force production by each leg in UL and BL conditions showed no differences in force, rate of force generation, EMG, motor unit firing rates, and coactivation. Finally, assessment of quadriceps activity with the twitch interpolation technique indicated no differences in the degree of voluntary muscle activation (UL: 93.6 +/- 2.51 Hz, BL: 90.1 +/- 2.43 Hz). These results provide no evidence of a significant limitation in neuromuscular control between BL and UL isometric contractions of the knee extensor muscles in young male subjects.     

Strength gains without muscle injury after strength training in patients with postpolio muscular atrophy

We evaluated changes in the dynamic and isometric strength in the newly weakened quadriceps muscles and asymptomatic triceps muscles of 6 patients with postpolio muscular atrophy (PPMA) after 10 weeks of progressive resistance strength training. Alterations in muscle size were determined with magnetic resonance imaging. Serum creatine kinase levels were measured throughout training, and histological signs of muscle injury and changes in muscle fiber size and types were assessed with muscle biopsies before and after training. Exercise training led to an increase in dynamic strength of 41% and 61% for the two knee extensor tests, and 54% and 71% for the two elbow extensor tests. Up to 20% of the improvement was maintained 5 months after cessation of training. Isometric strength, whole muscle cross-sectional areas of quadriceps and triceps muscles, and serum muscle enzymes did not change. No destructive histopathological changes were noted in the repeat muscle biopsies, and no consistent changes in muscle fiber size or fiber type percentages were observed. These results demonstrate that a supervised resistance training program can lead to significant gains in dynamic strength of both symptomatic and asymptomatic muscles of PPMA patients without serological or histological evidence of muscular damage.     

Quadriceps strength and fatigue assessed by magnetic stimulation of the femoral nerve in man

There is no nonvolitional method of assessing quadriceps strength which both supramaximally activates the muscle and is acceptable to subjects. In 10 normal subjects and 10 patients with suspected muscle weakness we used magnetic stimulation of the femoral nerve to elicit an isometric twitch and measured twitch tension (TwQ), surface electromyogram in addition to the maximum voluntary contraction force (MVC). Supramaximality was achieved in all subjects at a mean of 83% of maximum stimulator output. When supramaximal, TwQ was reproducible (mean coefficient of variation 3.6%, range 0.7-10.9) and correlated well with MVC (r2 = 0.83, P<0.001). In 7 normal subjects we measured TwQ before and after a fatiguing protocol; after 20 min TwQ was a mean of 55% (range 29-77%) of baseline and remained substantially reduced at 90 min. Magnetic femoral nerve stimulation is a painless, supramaximal method of assessing quadriceps strength and fatigue which is likely to be of value in clinical and physiological studies.     

Skeletal muscle function and its relation to exercise tolerance in chronic heart failure

OBJECTIVES: This study sought to define the relation between muscle function and bulk in chronic heart failure (HF) and to explore the association between muscle function and bulk and exercise capacity. BACKGROUND: Skeletal muscle abnormalities have been postulated as determinants of exercise capacity in chronic HF. Previously, muscle function in chronic HF has been evaluated in relatively small numbers of patients and with variable results, with little account being taken of the effects of muscle wasting. METHODS: One hundred male patients with chronic HF and 31 healthy male control subjects were studied. They were matched for age (59.0 +/- 1.0 vs. 58.7 +/- 1.7 years [mean +/- SEM]) and body mass index (26.6 +/- 0.4 vs. 26.3 +/- 0.7 kg/m2). We assessed maximal treadmill oxygen consumption (VO2), quadriceps maximal isometric strength, fatigue (20-min protocol, expressed in baseline maximal strength) and computed tomographic cross-sectional area (CSA) at midthigh. RESULTS: Peak VO2 was lower in patients (18.0 +/- 0.6 vs. 33.3 +/- 1.4 ml/min per kg, p < 0.0001), although both groups achieved a similar respiratory exchange ratio at peak exercise (1.15 +/- 0.01 vs. 1.19 +/- 0.03, p = 0.13). Quadriceps (582 vs. 652 cm2, p < 0.05) and total leg muscle CSA (1,153 vs. 1,304 cm2, p < 0.005) were lower in patients with chronic HF. Patients were weaker than control subjects (357 +/- 12 vs. 434 +/- 18 N, p < 0.005) and also exhibited greater fatigue at 20 min (79.1% vs. 92.1% of baseline value, p < 0.0001). After correcting strength for quadriceps CSA, significant differences persisted (5.9 +/- 0.2 vs. 7.0 +/- 0.3 N/cm2, p < 0.005), indicating reduced strength per unit muscle. In patients, but not control subjects, muscle CSA significantly correlated with peak absolute VO2 (R = 0.66, p < 0.0001) and is an independent predictor of peak absolute VO2. CONCLUSIONS: Patients with chronic HF have reduced quadriceps maximal isometric strength. This weakness occurs as a result of both quantitative and qualitative abnormalities of the muscle. With increasing exercise limitation there is increasing muscle weakness. This progressive weakness occurs predominantly as a result of loss of quadriceps bulk. In patients, this muscular atrophy becomes a major determinant of exercise capacity.     

Effects of hip center location on the moment-generating capacity of the muscles

We have developed a three-dimensional biomechanical model of the human lower extremity to study how the location of the hip center affects the moment-generating capacity of four muscle groups: the hip abductors, adductors, flexors, and extensors. The model computes the maximum isometric force and the resulting joint moments that each of 25 muscle-tendon complexes develops at any body position. Abduction, adduction, flexion, and extension moments calculated with the model correspond closely with isometric joint moments measured during maximum voluntary contractions. We used the model to determine (1) the hip center locations that maximize and minimize the moment-generating capacity of each muscle group and (2) the effects of superior-inferior, anterior-posterior, and medial-lateral displacement of the hip center on the moment arms, maximum isometric muscle forces, and maximum isometric moments generated by each muscle group. We found that superior-inferior displacement of the hip center has the greatest effect on the force- and moment-generating capacity of the muscles. A 2 cm superior displacement decreases abduction force (44%), moment arm (12%), and moment (49%), while a 2 cm inferior displacement increases abduction force (20%), moment arm (7%) and moment (26%). Similarly, a 2 cm superior displacement decreases flexion force (27%), moment arm (6%), and moment (22%), while inferior displacement increases all three variables. Anterior-posterior displacement alters the moment-generating capacity of the flexors and extensors considerably, primarily due to moment arm changes. Medial-lateral displacement has a large effect on the moment-generating capacity of the adductors only. A 2 cm medial displacement decreases adduction moment arm (20%), force (26%) and moment (40%). These results demonstrate that the force- and moment-generating capacities of the muscles are sensitive to the location of the hip center.     

Large index-fingertip forces are produced by subject-independent patterns of muscle excitation

Are fingertip forces produced by subject-independent patterns of muscle excitation? If so, understanding the mechanical basis underlying these muscle coordination strategies would greatly assist surgeons in evaluating options for restoring grasping. With the finger in neutral ad- abduction and flexed 45 degrees at the MCP and PIP, and 10 degrees at DIP joints, eight subjects attempted to produce maximal voluntary forces in four orthogonal directions perpendicular to the distal phalanx (palmar, dorsal, lateral and medial) and in one direction collinear with it (distal). Forces were directed within 4.7 +/- 2.2 degrees (mean +/- S.D.) of target and their magnitudes clustered into three distinct levels (p < 0.05; post hoc pairwise RMANOVA). Palmar (27.9 +/- 4.1 N), distal (24.3 +/- 8.3 N) and medial (22.9 +/- 7.8 N) forces were highest, lateral (14.7 +/- 4.8 N) was intermediate, and dorsal (7.5 +/- 1.5 N) was lowest. Normalized fine-wire EMGs from all seven muscles revealed distinct muscle excitation groups for palmar, dorsal and distal forces (p < 0.05; post hoc pairwise RMANOVA). Palmar force used flexors, extensors and dorsal interosseous; dorsal force used all muscles; distal force used all muscles except for extensors; medial and lateral forces used all muscles including significant co-excitation of interossei. The excitation strategies predicted to achieve maximal force by a 3-D computer model (four pinjoints, inextensible tendons, extensor mechanism and isometric force models for all seven muscles) reproduced the observed use of extensors and absence of palmar interosseous to produce palmar force (to regulate net joint flexion torques), the absence of extensors for distal force, and the use of intrinsics (strong MCP flexors) for dorsal force. The model could not predict the interossei co-excitation seen for medial and lateral forces, which may be a strategy to prevent MCP joint damage. The model predicts distal force to be most sensitive to dorsal interosseous strength, and palmar and distal forces to be very sensitive to MCP and PIP flexor moment arms, and dorsal force to be sensitive to the moment arm of and the tension allocation to the PIP extensor tendon of the extensor mechanism.     

Effects of detraining subsequent to strength training on neuromuscular function in patients with inflammatory arthritis

The effects of detraining subsequent to strength training on neuromuscular function were examined in 39 recent-onset rheumatoid arthritis (RA) patients. Eighteen age- and sex-matched healthy people (H) served as controls. Patients were randomly allocated either to the experimental group (PE), who carried out progressive strength training for 6 months, or to the control group (PC), who maintained only their habitual physical activities. After 6 months, PE returned to their earlier physical activities and strength training was terminated. At baseline, the maximal strength of the trunk extensors (not significant), grip strength and maximal dynamic strength and the shape of the force-time curve of the knee extensors were lower in PE and PC (P < 0.05-0.001) than in H. Strength training in PE led to remarkable increases (P < 0.05-0.001) in the maximal strength of all muscle groups without changes in the shape of the force-time curve. The increases in muscle strength in PE obtained by strength training were lost to a great degree during the detraining period for the isometric trunk extension (P < 0.01) and flexion (P < 0.01) strength and for the dynamic knee extension strength (P < 0.05), but not for the grip strength. In PC, trunk extension and flexion strength decreased significantly throughout the study period. At the post-test, all the strength values in both patient groups were much lower than in H. RA is a chronic disease which seems to need continuous physical exercise with sufficient intensity to minimize/prevent the loss of muscle strength and functional capacity.     

Lipopolysaccharides and beta-glucuronidase activity in choledochal bile in relation to choledocholithiasis

OBJECTIVE: To investigate whether localised skeletal muscle training, which does not have a great influence on the heart, improves abnormalities of calf muscle metabolism in patients with chronic heart failure. METHODS: Seven cardiac patients in New York Heart Association class II and III undertook a random order crossover trial. Training consisted of unilateral calf plantar flexion exercise. Before and after training, the patients' metabolic responses were examined during the calf exercise test with phosphorus-31 nuclear magnetic resonance spectroscopy (31P-MRS) and calf blood flow with plethysmography. The new Borg scale was employed as a subjective fatigue scale. RESULTS: In a constant load exercise test (70% of maximum load achieved during the incremental exercise), standardised phosphocreatine and intracellular pH decreased less after training (p < 0.05, repeated measures analysis of variance). The new Borg scale improved significantly after training (p < 0.05). Blood flow did not change significantly in either test. CONCLUSIONS: In patients with chronic heart failure, localised calf skeletal muscle training improved oxidative capacity without changes in calf blood flow. This training also improved the subjective fatigue scale. This training method may therefore alleviate leg fatigue experienced in daily activities.     

Muscle inactivation: assessment of interpolated twitch technique

The validity, reliability, and protocol for the interpolated twitch technique (ITT) were investigated with isometric plantar flexor and leg extension contractions. Estimates of muscle inactivation were attempted by comparing a variety of superimposed with potentiated evoked torques with submaximal and maximal voluntary contraction (MVC) torques or forces. The use of nerve and surface stimulation to elicit ITT was reliable, except for problems in maintaining maximal stimulation with nerve stimulation at 20 degrees plantar flexion and during leg extension. The interpolated twitch ratio-force relationship was best described by a shallow hyperbolic curve resulting in insignificant MVC prediction errors with second-order polynomials (1.1-6.9%). The prediction error under 40% MVC was approximately double that over 60% MVC, contributing to poor estimations of MVC in non-weight-bearing postimmobilized ankle fracture patients. There was no significant difference in the ITT sensitivity when twitches, doublets, or quintuplets were used. The ITT was valid and reliable when high-intensity contractions were analyzed with a second-order polynomial.