Canine X-linked muscular dystrophy studied with in vivo phosphorus magnetic resonance spectroscopy.

Duchenne muscular dystrophy (DMD) is an X-linked disease characterized by progressive muscle weakness and degeneration. Dystrophin is the product of the missing gene in this disorder. However, the cause of the dystrophic process is not understood. Transient muscle injury is normally seen after muscle exercise, and may be a necessary process in muscle growth and preservation. We, therefore, chose to evaluate the role of exercise in Duchenne dystrophy by studying the canine X-linked animal model (CXMD). These dogs also lack dystrophin and have clinical signs similar to humans. Exercise was initiated by electrical stimulation, and muscle metabolism was monitored with phosphorus magnetic resonance spectroscopy (P-MRS). Dogs with CXMD had abnormal muscle pathology and markedly elevated serum CK. The inorganic phosphate (Pi) to phosphocreatine (PCr) ratio was increased in CXMD dogs at rest compared with normal dogs (Pi/(Pi + PCr) = 0.166 +/- 0.054 for CXMD and 0.073 +/- 0.017 for normals, mean +/- SE). No changes in resting ATP, pH, phosphomonoesters (PME), and phosphodiesters (PDE) were seen. The mean Pi/(Pi + PCr) and pH values during stimulation were normal in the CXMD dogs. Two to three days after electrical stimulation, resting Pi/(Pi + PCr) ratios were significantly increased in the CXMD dogs (0.127 +/- 0.029 compared with 0.172 +/- 0.054, mean +/- SD). Normal dogs showed no increase in Pi/(Pi + PCr) following stimulation. There was a 50-fold greater increase in serum CK in CXMD compared with normal dogs following exercise. These results indicate greater muscle injury in CXMD muscle, and suggest that in the absence of dystrophin, exercise-induced muscle injury may play a role in the dystrophic process.     

In vivo determination of altered hemoglobin saturation in dogs with M-type phosphofructokinase deficiency.

Muscle-type phosphofructokinase (M-PFK) deficiency causes an exertional myopathy and chronic hemolysis in affected humans and dogs, the only animal model available. Deficient individuals have impaired glycolytic metabolism, impaired oxidative metabolism, and increased hemoglobin-oxygen (HbO2) affinity as a result of low 2,3-diphosphoglycerate (2,3-DPG) levels. The purpose of this study was to determine if PFK-deficient muscle has abnormal oxygen saturation during exercise. Oxygen saturation of hemoglobin/myoglobin was measured noninvasively in skeletal muscle during progressive muscle activation using near-infrared spectroscopy (NIRS). Muscle metabolites were also measured using magnetic resonance spectroscopy (MRS). PFK-deficient and normal dogs were anesthetized and the cranial tibial muscles stimulated for 6 min at each of four different rates (1, 2, 4, and 8 Hz). With increasing stimulation, muscles from normal dogs showed progressive decrease in hemoglobin saturation. In contrast, PFK-deficient dogs exhibited either an increase in hemoglobin saturation or an initial decrease with no further change. PFK-deficient muscles accumulated 11.1 +/- 3.5 mmol/L of sugar phosphate which was not seen in normal muscle and had higher calculated [ADP] levels at each stimulation level, indicating impaired oxidative metabolism. These findings are consistent with the hypothesis that these animals have impaired oxidative metabolism and impaired muscle O2 extraction from hemoglobin due to increased HbO2 affinity. NIRS appears to be a useful noninvasive method of monitoring tissue oxygen saturation in normal or disease conditions.     

Muscle fatigue unrelated to phosphocreatine and pH: an "in vivo" 31-P NMR spectroscopy study

Metabolic events were followed by 31-P NMR spectroscopy during mechanical exhaustion of directly stimulated rat gastrocnemius. During mechanical fatigue, phosphocreatine (PCr) and pH first declined but although stimulation continued high values were recovered without mechanical recovery. Total recovery was only observed after cessation of stimulation. Partial mechanical recovery was elicited by lowering stimulation rhythm; it was accompanied by decrease in PCr to a steady-state level without pH alteration. When exhaustive exercise was induced immediately after nonexhaustive exercise, failure of mechanical function occurred without decrease in pH. Major findings were: first, during exhaustive stimulations, the greater the muscle fatigue, and the higher the PCr level at the end of stimulation. Secondly, PCr and force levels did not depend on preceding levels of PCr and pH. Thirdly, acidosis was observed transiently during the first minutes of the first exercise period. These findings strongly suggested that electrical events and/or excitation-contraction (EC) coupling play a crucial role in this type of fatigue.     

Forearm P-31 nuclear magnetic resonance spectroscopy studies in oculopharyngeal muscular dystrophy.

Five siblings with autosomal dominant oculopharyngeal muscular dystrophy (OPMD) underwent P-31 Nuclear Magnetic Resonance Spectroscopy studies of forearm flexor muscles. Mean values of PCr/(PCr+Pi) in the patients were reduced (p = 0.01) and pH elevated (p = 0.02) in resting muscle when compared to controls. During exercise PCr/PCr+Pi) fell quickly to values less than controls (p less than 0.0001) despite submaximal exercise output and developed exercise-induced acidosis which exceeded that of controls (p = 0.05). Acidosis recovered slowly despite relatively normal recovery of PCr/(PCr+Pi) following exercise. Within the patient group, however, one member had normal resting, exercise and recovery values. The studies suggest that OPMD is a more widespread disorder of striated muscle than clinically appreciated. The pattern of findings observed in OPMD differs from those identified in denervation, disuse and mitochondrial myopathy.     

Caffeine impairs intramuscular energy balance in patients susceptible to malignant hyperthermia

Malignant hyperthermia (MH) is a metabolic myopathy with an abnormal release of calcium by the sarcoplasmic reticulum (SR), triggered by volatile anesthetics and succinylcholine. Similarly, caffeine enhances Ca(2+)release by the SR in vitro. In a prospective, randomized study, high-energy phosphates were studied by intramuscular 31-phosphorus magnetic resonance spectroscopy ((31)P-MRS) in 10 MH-susceptible (MHS) and 7 MH-nonsusceptible (MHN) subjects before and after injection of 0.5 ml caffeine (20 mM). Intramuscular energy balance, measured by the ratios of P(i)/PCr and P(i)/gamma-ATP, did not differ between MHS and MHN patients before and after intramuscular caffeine injection. However, within each group, P(i)/PCr and P(i)/gamma-ATP increased significantly only in the MHS group. Intramuscular caffeine injection seemed to impair the metabolic balance in MHS individuals. This may reflect a local calcium overload leading to consumption of high-energy phosphates and increase of inorganic phosphate. Intramuscular stimulation by caffeine and (31)P-MRS may provide a valuable tool to investigate MH-related metabolic disturbances.     

Effects of exercise on muscle activation and metabolism in multiple sclerosis

We investigated the role of metabolism in muscle fatigue during voluntary exercise in persons with mild multiple sclerosis (MS). Six MS and 8 healthy control subjects performed intermittent, progressive, isometric contractions of the ankle dorsiflexors, during which we measured maximum voluntary force (MVC), inorganic phosphate (Pi), phosphocreatine (PCr), and pH. During exercise. MVC fell sooner in MS, but by the end of exercise the relative decrease in MVC was similar in both groups. In contrast, at the end of exercise Pi/PCr increased to 1.86 ± 0.22 in controls but to only 0.66 ± 0.04 in MS (P < 0.01); likewise, pH was 6.75±0.04 in controls and unchanged (7.06 ± 0.04) in MS (P <0.01). The smaller metabolic change at the same relative exercise intensity suggests a failure of muscle activation that is present even in mild MS. Neurophsyiologic measures of activation indicated some central activation failure and no neuromuscular junction impairment in MS, and suggested that activation failure beyond the muscle membrane(excitation–contraction coupling) may be important in MS. We conclude that metabolic factors do not play a significant role in the development of muscle fatigue during voluntary exercise in mild MS. © 1994 John Wiley & Sons, Inc.     

A 31P-NMR study of muscle exercise metabolism in mdx mice: evidence for abnormal pH regulation.

We have studied exercise metabolism in vivo in the mdx mouse model of Duchenne muscular dystrophy with 31P-nuclear magnetic resonance spectroscopy. Intracellular pH, ratios of phosphocreatine (PCr) to ATP and PCr to inorganic phosphate (P(i)) expressed as PCr/ATP and PCr/(PCr+P(i)) as well as tension generated at the Achilles tendon were measured during sciatic nerve stimulation. Tension was similar between the mdx and control strain C57Bl/10ScSn at 10 Hz stimulation but slightly higher than the control at 100 Hz. The PCr/ATP and PCr/(PCr+P(i)) ratios were significantly reduced in mdx vs. control muscle during exercise. Although resting muscle pH in mdx mice is more alkaline than normal muscle, the pH of mdx muscle during exercise is reduced relative to controls, as is the rate of pH recovery. Total lactate is not elevated in the cells and so it is argued that there is a reduction in the capacity to export proton equivalents in muscles of mdx mice which could be caused by an elevation in intracellular sodium. This provides more evidence of impaired ionic regulation in dystrophic muscle and could be used as an index for the evaluation in vivo of therapeutic interventions such as myoblast transfer or gene replacement therapy.     

Postexercise phosphocreatine resynthesis is slowed in multiple sclerosis

To determine whether skeletal muscle oxidative metabolism is impaired in multiple sclerosis (MS), ³¹ phosphorus magnetic resonance spectroscopy was used to measure the rate of intramuscular phosphocreatine (PCr) resynthesis following exercise in MS and controls. Thirteen MS patients underwent intermittent isometric tetanic contractions of the dorsiflexor muscles elicited by stimulation of the peroneal nerve. Eight healthy control subjects performed voluntary isometric exercise of the same muscles. During exercise, there were no differences between groups in the fall of either PCr or pH. However, the half-time (T-_1/2) of PCr recovery following exercise was significantly longer in MS (2.3 ± 0.3 min) compared to controls (1.2 ± 0.1 min, P < 0.02). These data provide evidence of slowed PCr resynthesis following exercise in MS, which indicates impaired oxidative capacity in the skeletal muscle of this group. This finding suggests that intramuscular changes consistent with deconditioning may be important in the altered muscle function of persons with MS. © 1994 John Wiley & Sons, Inc.     

In vivo phosphorus nuclear magnetic resonance (31P-NMR) study of dystrophic hamster muscle

Skeletal muscle bioenergetics of dystrophic hamsters (DH) were studied by in vivo 31P-NMR in order to evaluate possible metabolic impairment. 31P-NMR data were obtained during rest, during muscle work that was induced by nerve stimulation at 3 frequencies (0.2, 0.4 and 1.0 Hz) and during postexercise recovery. At rest, phosphocreatine-to-inorganic phosphate ratio (PCr/Pi) was significantly (P less than 0.02) lower in adult DH (5.3 +/- 1.1; +/- 2 SD) compared with control hamsters (6.55 +/- 0.5). An increased PCr depletion was found in DH muscle during nerve stimulation and the steady-state PCr/Pi was significantly (P less than 0.05) lower at 0.4 and 1.0 Hz. Slow PCr/Pi recovery was observed in DH (0.5 +/- 0.2 units per min compared with 1.42 +/- 0.28 for control, +/- 2 SD, P less than 0.02). These findings suggest a significant in vivo mitochondrial malfunction in DH muscle that may result from either mitochondrial abnormalities or cardiac insufficiency or a combination of both.     

Actions of phosphomonoesters on CA1 hippocampal neurons as revealed by a combined electrophysiological and nuclear magnetic resonance study.

Phosphomonoesters (PMEs), precursors of membrane phospholipids, are found in high levels in the developing brain and Alzheimer's disease brain. The present study details the neurophysiological and metabolic effects of acute PME elevation on the Fisher 344 rat in vitro hippocampal slice. Two abundant PMEs, phosphoethanolamine (PE) and L-phosphoserine (PS), reliably altered properties of synaptic transmission at the Schaffer collateral/commissural-CA1 cell synapse. Specifically, PE reversibly depressed the amplitude of population EPSPs at millimolar concentrations but had no effect at micromolar concentrations. PS had biphasic effects on population EPSPs, inducing first a reduction followed by an enhancement of response amplitude. In contrast to PE, the effects of PS were not reversible; population EPSPs were augmented during the wash of PS, and the CA3 region generated evoked (but not spontaneous) epileptiform discharges. 31P nuclear magnetic resonance spectroscopy revealed enhanced slice uptake of PS compared to PE. There was no significant effect of PE on slice high-energy phosphates but incubation with PS significantly lowered slice phosphocreatine (PCr) and ATP concentrations. These observations indicate that the slice uptake of PS could be energy requiring and the enhanced response amplitude observed at 5 mM PS also could produce a drain on high-energy phosphates. Possible modes of PME action on hippocampal physiology are discussed.     

In vivo 31P NMR profiles of Alzheimer's disease and multiple subcortical infarct dementia

We used in vivo phosphorus 31 nuclear magnetic resonance (31P NMR) spectroscopy to study regional high-energy phosphate and phospholipid metabolism in brains of patients with dementia associated with probable Alzheimer's disease (AD) and multiple subcortical cerebral infarctions (MSID). The MSID patients demonstrated elevations of the phosphocreatine (PCr)/inorganic orthophosphate (Pi) ratio in both the temporoparietal and frontal regions. Phosphomonoesters (PME) and the ratio of PME to phosphodiesters were elevated in the temporoparietal region of AD. Pi was also elevated in the frontal and temporoparietal regions of AD. Findings from 31P NMR were accurate in distinguishing MSID from AD. Values of PCr/Pi accurately classified 100% of the MSID patients and 92% of AD. Pi and PME, considered jointly, also accurately classified all MSID and all but 1 AD. Findings from in vivo 31P NMR spectroscopy appear to yield metabolic profiles useful in distinguishing AD from MSID.     

Effects of fatiguing exercise on high-energy phosphates, force, and EMG: evidence for three phases of recovery

Experiments were designed to evaluate the relative contribution of impulse propagation failure, high-energy phosphate depletion, lowered pH, and impaired excitation-contraction coupling to human muscle fatigue and recovery. 31P nuclear magnetic resonance spectroscopy measurements were made on adductor pollicis muscle, together with simultaneous measurements of M-wave, force, and rectified integrated EMG (RIEMG). During fatigue, maximum voluntary contraction force (MVC) fell by 90%, pH fell from 7.1 to 6.4, and phosphocreatine was almost totally depleted. Neuromuscular efficiency (NME = force/RIEMG) was reduced to 40% of control at the end of the fatiguing contraction, and the M wave was reduced in amplitude and prolonged in duration. Following exercise, the M wave returned to normal within 4 minutes. pH, high-energy phosphates, and MVC recovered within 20 minutes. By contrast, neuromuscular efficiency did not recover within 60 minutes. These findings indicate three different components of fatigue. The first is reflected by the altered M wave and indicates impaired muscle membrane excitation and impulse propagation. The second, associated with reduced MVC, correlates with the metabolic state of the muscle (PCr and pH). The third, indicated by reduced NME, is independent of changes in high-energy phosphates and pH and is probably due to impaired excitation-contraction coupling.     

Metabolic and nonmetabolic components of fatigue monitored with 31P-NMR

The goal of this study was to determine the roles of metabolic and nonmetabolic factors in muscle fatigue. Rat gastrocnemius muscles were fatigued by stimulation of the nerve (n = 6) or muscle (n = 4, after 2 days of denervation). ³¹Phosphorus nuclear magnetic resonance spectroscopy was used to measure levels of intracellular inorganic phosphate (Pi) and hydrogen ions (H⁺) (which are thought to inhibit contraction) and the high-energy phosphates, phosphocreatine (PCr), and ATP. For both indirect and direct stimulation, with fatigue to ≈60% initial tetanic force, [Pi] increased from ≈3.5 mmol/L to ≈20 mmol/L and [PCr] decreased from ≈27 mmol/L to ≈9 mmol/L. However, with continued fatigue to 25–35% initial tetanic force, neither [Pi] or [PCr] changed further. [ATP] and pH changed only slightly during fatigue. The results are consistent with early fatigue arising from metabolic inhibition of contraction; but later fatigue arising independent of metabolites, due to impaired activation beyond the neuromuscular junction. © 1994 John Wiley & Sons, Inc.     

Motor-evoked potentials in response to fatiguing grip exercise in multiple sclerosis patients.

OBJECTIVE: This study examined central and peripheral effects of fatiguing exercise (3 min maximal grip) in healthy controls (n=10) and multiple sclerosis (MS) subjects with weakness, MS-W (n=16) and normal motor function, MS-NM (n=16) in the studied extremity.Method: Transcranial magnetic stimulation (TMS) was used to assess resting and facilitated motor-evoked potentials (MEPs) of abductor pollicus brevis (APB) and flexor carpi radialis (FCR) muscles before and after fatiguing exercise. Exercise-induced depletion and recovery of phosphocreatine (PCr) were measured using (31)P magnetic resonance spectroscopy ((31)PMRS) in FCR. RESULTS AND CONCLUSION: MS subjects demonstrated significantly lower peak force and a faster decline in force than controls. Contralateral muscle activation (hand grip) before the fatigue protocol resulted in significantly increased MEP amplitudes in all groups. Contralateral hand grip following fatiguing exercise resulted in significantly higher MEP amplitudes in controls and MS-NM subjects, but not MS-W subjects. Fatiguing exercise resulted in prolonged central motor conduction time (CMCT) in MS subjects, but not controls. No group differences in PCr depletion or resynthesis were observed. All groups demonstrated significant post-exercise depression (PED) of MEP amplitude that persisted beyond the time course of PCr recovery, indicating fatigue was central in origin. MS subjects were less able than controls to increase cortical excitability using contralateral muscle activation following fatiguing exercise, possibly indicating impaired conduction in the corpus callosum.     

Unique aspects of human newborn cerebral metabolism evaluated with phosphorus nuclear magnetic resonance spectroscopy

In vivo phosphorus nuclear magnetic resonance spectroscopy (31P NMR) was used to evaluate the pattern of phosphate compounds in seven newborn babies (mean gestational age, 32 weeks; birth weight, 1,430 gm; age, 37 days) with a history of perinatal asphyxia. Spectra were collected in a 1.9 Tesla superconductive magnet with surface coil techniques. The spectra had characteristic peaks for phosphorylated monoesters (PME), inorganic phosphate (Pi), phosphodiesters (PD), phosphocreatine (PCr), and ATP. In contrast to cortical spectra from mature animals, these newborn infant 31P NMR spectra were dominated by a large PME peak and had small PCr, Pi, and PD peaks. Intracellular pH, as measured from the chemical shift of the Pi peak relative to the PCr peak, was 7.1 +/- 0.1 (SD). We studied one infant postmortem, and a large PME peak was present in his spectrum. The presence of PME 3 hours after death strongly suggests that it is not a sugar phosphate. In NMR spectroscopy, compounds are identified by their chemical shift relative to a known standard (PCr); the chemical shift of the PME peak was 6.5 ppm, suggesting that it is a mixture of phosphoryl ethanolamine and phosphoryl choline. The PCr/Pi ratio (1.3 +/- 0.7) and the PCr/ATP ratio (0.7 +/- 0.4) were lower in these babies than in mature animals (greater than 2 and greater than 1.4, respectively); the PME/PD ratio (1.2 +/- 0.6), however, was much greater in the infants (mature animals, less than 0.2). These findings suggest that there are unique aspects of human newborn cerebral metabolites and bioenergetic reserve.     

Aerobic exercise and muscle metabolism in patients with mitochondrial myopathy

Exercise therapy improves mitochondrial function in patients with mitochondrial myopathy (MM). We undertook this study to determine the metabolic abnormalities that are improved by exercise therapy. This study identified metabolic pathology using (31)P-magnetic resonance spectroscopy and magnetic resonance imaging (MRI) in a group of patients with MM compared to a control group matched for age, gender, and physical activity. We also observed the effect of exercise therapy for 12 weeks on muscle metabolism and physical function in the MM group. During muscle activity, there was impaired responsiveness of the mitochondria to changes in cytosolic adenosine diphosphate concentration, increased dependence on anaerobic energy pathways, and an adaptive increase in proton efflux in patients with MM. Following exercise therapy, mitochondrial function and muscle mass improved without any change in proton efflux rate. These metabolic findings were accompanied by improvements in functional ability. We conclude that there are significant metabolic differences between patients with MM and a control population, independent of age, gender, and physical activity. Exercise therapy can assist in improving mitochondrial function in MM patients.     

<Superscript>31</Superscript>P-MRS of skeletal muscle is not a sensitive diagnostic test for mitochondrial myopathy

Clinical phenotypes of persons with mitochondrial DNA (mtDNA) mutations vary considerably. Therefore, diagnosing mitochondrial myopathy (MM) patients can be challenging and warrants diagnostic guidelines. (31)phosphorous magnetic resonance spectroscopy ((31)P-MRS) have been included as a minor diagnostic criterion for MM but the diagnostic strength of this test has not been compared with that of other commonly used diagnostic procedures for MM. To investigate this, we studied seven patients with single, large-scale deletions-, nine with point mutations of mtDNA and 14 healthy subjects, who were investigated for the following: 1) (31)P-MRS of lower arm and leg muscles before and after exercise, 2) resting and peak-exercise induced increases of plasma lactate, 3) muscle morphology and -mitochondrial enzyme activity, 4) maximal oxygen uptake (VO(2max)), 5) venous oxygen desaturation during handgrip exercise and 6) a neurological examination. All MM patients had clinical symptoms of MM, > 2% ragged red fibers in muscle, and impaired oxygen desaturation during handgrip. Fourteen of 16 patients had impaired VO(2max), 10/16 had elevated resting plasma lactate, and 10/11 that were investigated had impaired citrate synthase-corrected complex I activity. Resting PCr/P(i) ratio and leg P(i) recovery were lower in MM patients vs. healthy subjects. PCr and ATP production after exercise were similar in patients and healthy subjects. Although the specificity for MM of some (31)P-MRS variables was as high as 100%, the sensitivity was low (0-63%) and the diagnostic strength of (31)P-MRS was inferior to the other diagnostic tests for MM. Thus, (31)P-MRS should not be a routine test for MM, but may be an important research tool.     

Exercise fuel mobilization in mitochondrial myopathy: A metabolic dilemma

In mitochondrial myopathy, severely impaired muscle oxidative capacity poses a dilemma for metabolic regulation in exercise. We inquired whether fuel mobilization during exercise in mitochondrial myopathy is adjusted to the reduced capacity to oxidize substrate, or if fuel is mobilized in excess of oxidative capacity. Hormonal and metabolic responses to 20 minutes of cycle exercise were studied in 4 patients with mitochondrial myopathy working at near maximal effort and in 4 healthy matched controls. On 2 separate days, controls were studied at the same absolute (A) workload (9 ± 3 W) and the same relative (R) workload (77 ± 9 W) as performed by the patients. During exercise, average glucose production was higher in patients (28 ± 5 μmol min^?1 kg^?1) than in controls at both workloads (A, 12 ± 1; R, 18 ± 2 μmol min^?1 kg^?1). Exercise-induced increases in plasma glucose, growth hormone, epinephrine, norepinephrine, corticotropin, and lactate, and decreases in plasma insulin and pH were also larger in patients compared with findings in controls at both workloads. In conclusion, mitochondrial myopathies are associated with excessive neuroendocrine responses and mobilization of glucose during exercise. These responses augment ATP synthesis but result in proressive accumulation of nonoxidized substrates. Apparently, substrate mobilization and neuroendocrine responses in exercise are linked to oxidative demand rather than to oxidative capacity in working muscle.     

Neurochemical investigation of the schizophrenic brain by in vivo phosphorus magnetic resonance spectroscopy.

Abnormal phospholipid metabolisms may play important roles in the pathophysiology of schizophrenia. Phosphorus magnetic resonance spectroscopy (31P-MRS) offers a new method for studying phosphorus-related metabolism in vivo. A decrease in the level of phosphomonoesters (PME) and an increase in the level of phosphodiesters (PDE) has been demonstrated in the prefrontal lobe of neuroleptic-naive schizophrenic patients. Most of the studies in medicated schizophrenic patients have shown decreased PME and/or increased PDE. The decreased PME in the frontal lobe appears to be associated with negative symptoms and poor working memory performance. 1H-decoupled 31P-MRS revealed a reduction in the phosphocholine element of PME and an elevation in the mobile phospholipids of PDE in the prefrontal region of medicated schizophrenic patients. PDE were elevated in the temporal lobes of neuroleptic-naive schizophrenic patients, and this increase was partially normalized by haloperidol administration. Data about the temporal lobes of medicated schizophrenic patients have not been consistent. Except for the reduction in the adenosine triphosphate (ATP) in the basal ganglia and the correlation between the increase in the frontal lobe phosphocreatine (PCr) and negative symptomatology, data related to changes in high-energy phosphates are contradictory. No consensus on the effect of neuroleptics on phosphorus metabolites has been achieved. Methodological problems inherent in 31P-MRS may have contributed to the confusion in understanding available data. Future directions of MRS studies are suggested in the last section of the paper.     

Muscle energy metabolism in McArdle's syndrome by in vivo phosphorus magnetic resonance spectroscopy

Five patients with McArdle's syndrome were examined by phosphorus magnetic resonance spectroscopy (31P-NMR). Adenosine triphosphate (ATP) levels at rest were reduced by 22%, but did not fall further during exercise or contracture. The slope of work rate versus inorganic phosphate/phosphocreatine (Pi/PCr) was 42 +/- 8 joules/min/Pi/PCr in three patients without muscle wasting, compared with 13 and 16 in patients with atrophy (normal, 30 to 50 joules/min/Pi/PCr). Recovery from exercise showed similar rates in patients (postischemic exercise 1.03 +/- 0.17, post-aerobic 1.63 +/- 0.17 PCr/Pi units per minute) and controls (1.0 +/- 0.2 and 1.8 +/- 0.2, respectively) independent of intracellular pH. Infusion of glucose improved exercise kinetics by 163 to 190%, but an oral load of protein had no effect. We conclude that (1) muscle mitochondria operate normally in vivo in this glycogenolytic disorder, suggesting a sufficient alternate fuel supply. (2) Blood-borne glucose may serve as one alternate fuel for the "second wind" phenomenon. (3) ATP control mechanisms are altered only at rest. (4) Recovery from exercise is relatively pH-independent.