January 2014 References  Devin J. Starlanyl   for http://www.sover.net/~devstar

Ablin JN, Clauw DJ, Lyden AK et al. 2013.  Effects of sleep restriction and exercise deprivation on somatic symptoms and mood in healthy adults.  Clin Exp Rheumatol. 31(6 Suppl 79):53-59.

“This study supports previous research suggesting that both sleep and exercise are critical in 'preventing' somatic symptoms among some individuals. Furthermore, to our knowledge, this is the first time there is data to suggest that women are much more sensitive to decrements in routine sleep and exercise than are men.”

Afari N, Ahumada SM, Wright LJ et al. 2013. Psychological Trauma and Functional Somatic Syndromes: A Systematic Review and Meta-Analysis. Psychosom Med. [Dec 12 Epub ahead of print.] “Findings highlight the limitations of the existing literature and emphasize the importance of conducting prospective studies, further examining the potential similarities and differences of these conditions and pursuing hypothesis-driven studies of the mechanisms underlying the link between trauma, PTSD, and functional somatic syndromes.”  [If the authors really want to understand the meaningful connections, they need to include myofascial trigger points. DJS] 

Bisdorff A. 2014.  Migraine and dizziness.  Curr Opin Neurol. 27(1):105-110. “The further refinement and wider acceptance of the diagnostic entity of vestibular migraine is an important development as it is one the most common vestibular disorders. But the relationship between migraine and vestibular dysfunction is complex and has many aspects beyond vestibular migraine.”

Castori M. 2012. Ehlers-Danlos syndrome, hypermobility type: an underdiagnosed hereditary connective tissue disorder with mucocutaneous, articular, and systemic manifestations.  ISRN Dermatol [Nov 22 Epub ahead of print.]  EDS, hypermobility type, is a common and often missed hereditary condition.   It may have relatively few skin and joint manifestations, and may be missed among common co-existing conditions such as fibromyalgia, carpal tunnel syndrome, chronic low back pain, or chronic regional pain syndrome.  When there is hyperextensible or smooth, velvety skin and generalized joint hypermobility, EDS should be among the interactive diagnoses considered.  [Many of the common co-morbidities mentioned commonly have co-existing myofascial trigger points as well, and EDS is certainly an initiating and perpetuating factor for trigger points.  DJS]

Castori M. 2013. Joint hypermobility syndrome (a.k.a. Ehlers-Danlos Syndrome, Hypermobility Type): an updated critique. G Ital Dermatol Venereol. 148(1):13-36.  This review covers every system that could be affected in this common, underdiagnosed and often missed condition, as well as management strategies.

Castori M, Morino S, Celletti C et al. 2013. Am J Med Genet A. 161(12):2989-3004.  This paper focuses on fatigue and headache in EDS (Ehlers-Danlos Syndrome) hypermobility type, and its co-existence with chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and similar conditions.

Chalaye P, Lafrenaye S, Goffaux P et al. 2013. The role of cardiovascular activity in fibromyalgia and conditioned pain modulation. Pain. [Dec 14 Epub ahead of print.] “Patients with FM had higher heart rate than HS at baseline and during CPT. Higher heart rate was related with higher pain intensity during the CPT (cold presser test). Blood pressure increments during CPT were weaker in the FM group. CPM (conditioned pain modulation) was less effective in FM patients than HS. Importantly, systolic blood pressure responses during CPT were positively related to CPM effectiveness, suggesting that reduced blood pressure response during the conditioning stimulus could be involved in CPM dysfunction in the FM group. Higher heart rate could be implicated in the greater sensitivity to cold pain in FM. Patients with FM have reduced blood pressure response to a painful CPT Reduced cardiovascular reactivity to pain could have important involvement in diminished endogenous pain inhibition efficacy and FM pathophysiology.”   

Chang YP, Compton P. 2013. Management of chronic pain with chronic opioid therapy in patients with substance use disorders. Addict Sci Clin Pract. 8(1):21. “Substance use disorders (SUDs), whether active or in remission, are often encountered in patients with chronic nonmalignant pain. Clinicians are challenged when managing chronic pain while facing substance abuse issues during the course of chronic opioid therapy (COT). Further, the interrelated behavioral symptomatology of addiction and chronic pain suggests that if one disorder is untreated, effective treatment of the other in not possible. Incomplete understanding of the overlapping presentations of the two disorders, coupled with insufficient management of both conditions, leads to undertreated pain and premature discharge of SUD patients from pain treatment. In order to achieve pain relief and optimal functionality, both conditions need to be carefully managed. This paper reviews the prevalence of SUDs in chronic pain patents; the overlapping presentation of the two disorders; risk factors and stratification for addiction; identification of addiction in the chronic pain population; and suggestions for treating patients with COT, with an emphasis on relapse prevention. With appropriate assessment and treatment, COT for chronic pain patients with a history of SUD can be successful, leading to improved functionality and quality of life.”

Chen Q, Basford J, An KN. 2008. Ability of magnetic resonance elastography to assess taut bands. Clin Biomech (Bristol, Avon) 23(5):623-629. “This study suggests that magnetic resonance elastography may have a potential for objectively characterizing myofascial taut bands that have been up to now detectable only by the clinician’s fingers.”

Desmeules J, Chabert J, Rebsamen M et al. 2013. Central Pain Sensitization, COMT Val158Met Polymorphism, and Emotional Factors in Fibromyalgia. J Pain. [Oct 20 Epub ahead of print.]  “Neurobiological evidence points to altered central nervous system processing of nociceptive stimuli in fibromyalgia. Enzymes like catechol-O-methyl-transferase (COMT) are involved in the elimination of catecholamines playing a possible role in central sensitization and pain. We used quantitative sensory testing to evidence central sensitization in fibromyalgia patients and test whether COMTVal158Met polymorphism, associated with a reduction in enzyme activity, plays a role in sensitized patients. Pain evaluation and quantitative sensory testing were performed including the spinal nociceptive flexion reflex, a physiologic correlate for the evaluation of central nociceptive pathways.”  The study found: “The association between COMT p.Val158Met polymorphism and central sensitization in fibromyalgia is essential as it refers to the severity of central sensitization and may be a risk factor for treatment outcome.”

de Tommaso M, Nolano M, Iannone F et al. 2013. Update on laser-evoked potential findings in fibromyalgia patients in light of clinical and skin biopsy features. J Neurol. [Dec 24 Epub ahead of print.]  “In fibromyalgia (FM), reduced habituation of laser-evoked potentials (LEPs) suggests a dysfunction of pain processing at a central level. In this study, we aimed to further examine the nociceptive pathways at the peripheral to the central level in a large group of FM patients by means of LEPs and skin biopsy, in light of healthy controls findings and main clinical features. One hundred and ninety-nine FM patients and 109 age- and sex-matched controls were submitted to LEPs by the dorsum of the right hand and the skin over the right chest and knee tender point stimulation. Skin biopsy was performed in 21 randomly selected FM patients and 60 age- and sex-matched controls. The mean N2-P2 amplitude was reduced in the whole FM group, with normal or even increased values in patients with migraine as comorbidity and reduced values in other patients including those presenting with distal sensory deficits. All patients had reduced N2-P2 habituation in respect to controls. In the FM group, LEPs habituation was correlated with pain at tender points and bad quality of life. Epidermal fiber density was significantly reduced in FM patients versus controls, and correlated with N2-P2 amplitude by the hand and chest tender-point stimulation. Dysfunction in the nociceptive system at both the central and peripheral levels may concur to explain phenotypical eterogeneity and clinical symptom complexity in fibromyalgia.”

Domire ZJ, McCullough MD, Chen Q et al. 2009. Feasibility of using magnetic resonance elastography to study the effect of aging on shear modulus of skeletal muscle. J Appl Biomech. 25(1):93-93.  Stiffening of muscles is commonly associated with aging.  MRE might be a promising way to study age-related changes in muscle tissue and to evaluate treatments.

Fitzcharles MA, Shir Y Ablin JN et al. 2013. Classification and Clinical Diagnosis of Fibromyalgia Syndrome: Recommendations of Recent Evidence-Based Interdisciplinary Guidelines. Evid Based Complement Alternat Med. 2013:528952. “Guidelines from three continents showed remarkable consistency regarding the clinical concept of FMS, acknowledging that FMS is neither a distinct rheumatic nor mental disorder, but rather a cluster of symptoms, not explained by another somatic disease. While FMS remains an integral part of rheumatology, it is not an exclusive rheumatic condition and spans a broad range of medical disciplines.”

Ge HY, Monterde S, Graven-Nielsen T et al. 2013. Latent Myofascial Trigger Points Are Associated With an Increased Intramuscular Electromyographic Activity During Synergistic Muscle Activation.  J Pain. [Nov 2 Epub ahead of print.] “This study provides evidence that latent MTPs are associated with increased intramuscular, but not surface, EMG amplitude of synergist activation. The increased amplitude of synergistic muscle activation may result in incoherent muscle activation pattern of synergists inducing spatial development of new MTPs and the progress to active MTPs.”

Gerwin RD. 2013. Chronic Pain Perspectives: Diagnosing fibromyalgia and myofascial pain syndrome: A guide. J Fam Pract. 62(12 Suppl 1):S19-25. “The instruments and physical exam techniques described here will help you to diagnose these 2 common soft-tissue pain conditions.”

Handa T, Fukuda K, Ichinohe T. 2013. Effect of Combination of Trigger Point Injection and Stellate Ganglion Block on Non-odontogenic Mandibular Molar Pain Referred from Masseter Muscle: A Case Report. Bull Tokyo Dent Coll. 54(3):171-175. “We report a case of myofascial pain syndrome (MPS), manifested as nonodontogenic mandibular molar pain referred from the masseter muscle, relieved by a combination of trigger point injection (TPI) and stellate ganglion block (SGB). The patient was a 32-year-old woman who had experienced cold hypersensitivity in the right third mandibular molar 2 months prior to visiting our department. Subsequently, she had visited a family dentist and undergone pulpectomy under local anesthesia. She eventually visited our clinic because there was no marked change in her symptoms. On the first visit, no tooth abnormality was found and the patient was neither anxious nor depressive. Tender points were found in the right masseter and temporal muscles during muscle palpation. Referred pain radiating to the right mandibular molars was observed when pressure was applied to the central portion of the right masseter muscle. As a result, we diagnosed MPS based on evidence of nonodontogenic tooth pain caused by referred pain from the masseter muscle. We performed TPI with 2% lidocaine hydrochloride to the tender point in the masseter muscle. Although the visual analog scale (VAS) pain score dropped from 97 to 36, complete pain relief was not achieved. The TPI was effective for approximately 7 hrs, after which severe throbbing pain returned. The sustained nature of the tooth pain suggested that it was sympathetic nerve-dependent. Subsequently, we performed SGB, resulting in a reduction in the VAS pain score from 90 to 32. Therefore, we performed another TPI and the VAS pain score dropped to 0. We continued SGB and TPI for the next 3 days and the symptoms disappeared. Thus, a combination of TPI and SGB controlled MPS manifested as masseter muscle-mediated nonodontogenic tooth pain.”

Ickmans K, Meeus M, De Kooning M et al. 2013. Recovery of upper limb muscle function in chronic fatigue syndrome with and without fibromyalgia. Eur J Clin Invest. [Nov 11 Epub ahead of print.] “This study reveals, for the first time, delayed recovery of upper limb muscle function in CFS+FM, but not in CFS-only patients. The results underline that CFS is a heterogeneous disorder suggesting that reducing the heterogeneity of the disorder in future research is important to make progress towards a better understanding and uncovering of mechanisms regarding the nature of divers impairments in these patients.”

Joergensen TS, Henriksen M, Danneskiold-Samsoe B et al. 2013. Experimental knee pain evokes spreading hyperalgesia and facilitated temporal summation of pain.  Pain Med 14(6):874-883.  Why hypertonic saline was injected into the infrapatellar knee pad in healthy individuals, hyperalgesia and facilitated temporal summation (wind-up) resulted.  When isotonic saline was injected into the same area of each patient on the other knee, no changes were noted.  “Acute knee joint pain leads to hyperalgesia and facilitated temporal summation in the infrapatellar fat pad and in muscles located distant to the injection site, in subjects with no history of knee pain.” 

Juuso P, Soderberg S, Olsson M et al. 2013. The significance of FM associations for women with FM.  Disabil Rehabil. [Dec 18 Epub ahead of print.]  “Living with fibromyalgia (FM) means living with a long-term pain syndrome that is invisible to others. Support and understanding from others seem to be important to managing the affected daily life….The findings show that women experienced associations for people with FM as important as they gave access to contacts with others with similar experiences. Their need of togetherness was fulfilled at the association and they described being strengthened by the support received. Because of the lack of information and knowledge about FM, the association was described as an important venue for getting and mediating information about the illness. ….At the association the women seem to be empowered, which increases their ability to manage their daily lives despite the limitations imposed by FM. Healthcare personnel could not satisfy the women's needs and to manage to support women with FM. There is a need for communication based on a shared understanding between the women and healthcare personnel. Implications for Rehabilitation This study highlighted the need for communication based on a shared understanding between people with chronic illness and healthcare personnel to support and strengthen women with FM in their daily lives. The FM associations meet the needs for togetherness, confirmation, and information that the women with FM in this study described and healthcare personnel could not satisfy. Healthcare personnel can learn from FM associations how to empower women with FM in their everyday lives.”

Koca I, Tutoglu A, Boyaci A et al. 2013. A comparison of the effectiveness of low-, moderate- and high-dose ultrasound therapy applied in the treatment of myofascial pain syndrome. Mod Rheumatol. [Dec 11 Epub ahead of print.] “This study aimed to compare and evaluate the effects of ultrasound (US) treatment applied at low-, medium- and high-power-pain threshold (HPPT) doses to trigger points in the treatment of myofascial pain syndrome (MPS). Methods: The study comprised 61 (40 female and 21 male) patients diagnosed with MPS, aged between 18 and 60 years. The patients were randomly allocated to three groups for the US application at different dosages. Group I patients received treatment of medium-dose US (1.5 Watt/cm2), Group II received HPPT US, and Group III received low-dose US (0.5 W/cm2). The patients were evaluated pre-treatment and 3 weeks after treatment in respect of visual analogue scale (VAS) scores, number of trigger points (NTP), pressure pain threshold (PPT), Range of Tragus-Acromioclavicular joint (RT-AJ) and neck pain disability scores (NPDS). Results: A significant improvement was determined after treatment in all scores except PPT in Group I, in all scores in Group II, and only in the VAS score in Group III. When the groups were compared post-treatment in respect of improvement in NTP, VAS, RT-AJ and NPDS scores, Group II showed significant superiority over Group I, and Group I was determined to have significant superiority over Group III in respect of VAS, RT-AJ and NPDS scores (p < 0.05).… In the treatment of MPS, US therapy at HPPT dose can be considered as an alternative therapy method, which is more economical and more effective than low-dose and conventional US therapy.”

Kole AK, Roy R, Kole DC. 2013. Musculoskeletal and rheumatological disorders in HIV infection: Experience in a tertiary referral center. Indian J Sex Transm Dis. 34(2):107-112.

“Musculoskeletal involvement was common in HIV patients causing increased morbidity, so early detection and timely intervention is essential to improve quality of life.”

Lai HH, Gardner V, Ness TJ et al. 2013. Segmental Hyperalgesia to Mechanical Stimulus in Interstitial Cystitis/Bladder Pain Syndrome - Evidence of Central Sensitization. J Urol. [Dec 5 Epub ahead of print.] “Female subjects with IC/BPS showed segmental hyperalgesia to mechanical pressure stimulation in the suprapubic area (T10-T12). This segmental hyperalgesia may be explained in part by spinal central sensitization.”

La Rubia M, Rus A, Molina F et al.  2013. Is fibromyalgia-related oxidative stress implicated in the decline of physical and mental health status? Clin Exp Rheumatol. 31(6 Suppl 79):121-127.  “These findings reveal an imbalance between oxidants and antioxidants in FM patients. The lower antioxidant enzyme activities may lead to oxidative stress through the oxidation of DNA and proteins, which may affect the health status of FM patients.”


Madeleine P, Vangsgaard S, Hviid Andersen J et al. 2013. Computer work and self-reported variables on anthropometrics, computer usage, work ability, productivity, pain and physical activity. BMC Musculoskel Disord 14:226. “The differences in pain characteristics, i.e., higher intensity, longer duration and more pain locations as well as poorer work ability reported by women workers relate to their higher risk of contracting WMSD (work-related musculoskeletal disorders). Overall, this investigation confirmed the complex interplay between anthropometrics, work ability, productivity, and pain perception among computer workers.”

Maher RM, Hayes DM, Shinohara, M. 2013. Quantification of dry needling and posture effects on myofascial trigger points using ultrasound shear-wave elastography. Arch Phys Med Rehabil. 94(11):2146-2150. “The shear modulus measured with ultrasound SWE (shear-wave elastography) reduced after DN (dry needling) and in the prone position compared with sitting, in agreement with reductions in palpable stiffness. These findings suggest that DN and posture have significant effects on the shear modulus of MTrPs, and that shear modulus measurement with ultrasound SWE may be sensitive enough to detect these effects.”

McAllister SJ, Vincent A, Hassett AL et al. 2013. Psychological Resilience, Affective Mechanisms and Symptom Burden in a Tertiary-care Sample of Patients with Fibromyalgia. Stress Health. [Dec 26 Epub ahead of print.]  “Our results suggest that improving affect through resiliency training could be studied as a modality for improving fibromyalgia symptom burden.”

Offenbaecher M, Kohls N, Toussaint LL et al. 2013. Spiritual needs in patients suffering from fibromyalgia. Evid Based Complement Alternat Med. [Nov 20 Epub ahead of print.] “Using a set of standardized questionnaires (i.e., Spiritual Needs Questionnaire, Fibromyalgia Impact Questionnaire, SF-36's Quality of Life, Brief Multidimensional Life Satisfaction Scale, etc.), we enrolled 141 patients (95% women, mean age 58 ± 10 years). Here, needs for inner peace and giving/generativity scored the highest, while existential needs and religious needs scored lowest. Particularly inner peace needs and existential needs correlated with different domains of reduced mental health, particularly with anxiety, the intention to escape from illness, and psychosocial restrictions. Thirty-eight percent of the patients stated needs to be forgiven and nearly half to forgive someone from their past life. Therefore, the specific spiritual needs of patients with chronic diseases should be addressed in clinical care in order to identify potential therapeutic avenues to support and stabilize their psychoemotional situation.”

Okumus M, Koybası M, Tuncay F et al. 2013. Fibromyalgia syndrome: is it related to vitamin D deficiency in premenopausal female patients?  Pain Manag Nurs. 14(4):e156-163. “In conclusion, the results of this study indicate that deficiency of vitamin D is not more common in premenopausal female patients with FM than in control subjects without FM. However, the association between pain and vitamin D levels in FM patients emphasizes that hypovitaminosis of vitamin D in the FM syndrome may have an augmenting impact on pain intensity and functional status. Future studies are needed to show the effect of vitamin D supplementation in the reduction of pain intensity and disability in patients suffering from this chronic condition.”         

Park JM, Kim CK, Lee HC et al. 2013. Antiallodynic effects of vitamin C and vitamin E in chronic post-ischemia pain rat model. Korean J Anesthesiol. 65(5):442-448.  The authors of this study in rats concluded:  “The reduced phosphorylated NR1 and ERK levels indicate that vitamins C and E inhibit the modulation of spinal cord neuropathic pain processing. Co-administration of vitamins C and E had a greater antiallodynic effect.”

Pasisson TS, Graven-Neilsen T. 2012. Experimental pelvic pain facilitates pain provocation tests and causes regional hyperalgesia. Pain. 153(11):2233-2240.  This study showed that an extra-articular sacroiliac joint structure (the long posterior sacroiliac ligament) can hold pain receptors that can cause referred pain and regional hyperalgesia that is sensitive to manual pain provocation testing.

Prados G, Miro E, Martínez MP et al. 2013. Fibromyalgia: gender differences and sleep-disordered breathing. Clin Exp Rheumatol. 31(6 Suppl 79):102-110. “Alterations in sleep respiratory patterns were more highly prevalent in male than in female FM patients. More so in male FM patients, the alterations in sleep patterns, non-refreshing sleep, and other FM-related symptoms observed in this population might be part of a primary sleep-disordered breathing.”

Riley JL 3rd, Cruz-Almeida Y, King CD et al. 2013. Age and race effects on pain sensitivity and modulation among middle-aged and older adults. J Pain. [Nov 13 Epub ahead of print.] “This study tested the effects of aging and race on responses to noxious stimuli using a wide range of stimulus modalities. The participants were 53 non-Hispanic Blacks and 138 non-Hispanic White adults, ages 45 to 76. The participants completed a single 3-hour sensory testing session where responses to thermal, mechanical, and cold stimuli were assessed. The results suggest that there are selected age differences, with the older group less sensitive to warm and painful heat stimuli than middle-aged participants, particularly at the knee. This site effect supports the hypothesis that the greatest decrement in pain sensitivity associated with aging occurs in the lower extremities. In addition, there were several instances where age and race effects were compounded, resulting in greater race differences in pain sensitivity among the older participants. Overall, the data suggest that previously reported race differences in pain sensitivity emerged in our older samples, and this study contributes new findings in that these differences may increase with age in non-Hispanic Blacks for temporal summation and both heat and cold immersion tolerance. We have added to the aging and pain literature by reporting several small to moderate differences in responses to heat stimuli between middle and older age adults.”

Sido B, Dumoulin FL, Homann J et al. 2013. [Surgical interventions in patients with mast cell activation disease: Aspects relevant for surgery using the example of a cholecystectomy.]  Chirurg. [Dec 15 Epub ahead of print.] [Article in German] “Systemic mast cell activation disease (MCAD) is characterized by an increased and unregulated release of mast cell mediators which can evoke a multifaceted clinical picture often resembling irritable bowel syndrome or fibromyalgia. Because of the considerable prevalence (~ 17 %) of MCAD surgeons are frequently unwittingly confronted with MCAD patients in whom unexpected intraoperative and postoperative complications may occur. Therefore, knowledge of the particular requirements is of relevance for surgical treatment of MCAD patients….Due to the high prevalence of MCAD in the general population it can be assumed that the frequency in the surgical patient population is similar. If a patient has MCAD, specific characteristics should be taken into account in the surgical procedure to avoid increased operative and complication risks resulting from MCAD.”

Smith PF, Zheng Y. 2013. From ear to uncertainty: vestibular contributions to cognitive function. Front Integr Neurosci. 7:84. “In addition to the deficits in the vestibulo-ocular and vestibulo-spinal reflexes that occur following vestibular dysfunction, there is substantial evidence that vestibular loss also causes cognitive disorders, some of which may be due to the reflexive deficits and some of which are related to the role that ascending vestibular pathways to the limbic system and neocortex play in spatial orientation. In this review we summarize the evidence that vestibular loss causes cognitive disorders, especially spatial memory deficits, in animals and humans and critically evaluate the evidence that these deficits are not due to hearing loss, problems with motor control, oscillopsia or anxiety and depression. We review the evidence that vestibular lesions affect head direction and place cells as well as the emerging evidence that artificial activation of the vestibular system, using galvanic vestibular stimulation (GVS), can modulate cognitive function.”

Staud R, Weyl EE, Bartley E et al. 2013. Analgesic and anti-hyperalgesic effects of muscle injections with lidocaine or saline in patients with fibromyalgia syndrome.  Eur J Pain. [Nov 5 Epub ahead of print.] “These results suggest that muscle injections can reliably reduce clinical FM pain, and that peripheral impulse input is required for the maintenance of mechanical and heat hyperalgesia of patients with FM. Whereas the effects of muscle injections on hyperalgesia were greater for lidocaine than saline, the effects on clinical pain were similar for both injectates.” [Treating co-existing trigger points with injection therapy, in FM patients, can significantly reduce their pain. DJS]

Stejskal V, Ockert K, Bjørklund G. 2013. Metal-induced inflammation triggers fibromyalgia in metal-allergic patients. Neuro Endocrinol Lett. 34(6):559-565. “Fifteen female FM patients were included in the study. Metal allergy was measured by a lymphocyte transformation test, MELISA®….All FM patients tested positive to at least one of the metals tested. The most frequent reactions were to nickel, followed by inorganic mercury, cadmium and lead. Some healthy controls responded to inorganic mercury in vitro but most of the tests were negative. Objective examination 5 years later showed that half of the patients no longer fulfilled the FM diagnosis, 20% had improved and the remaining 30% still had FM. All patients reported subjective health improvement.”

Wang YH, Yin MJ, Fan ZZ et al. 2013. Hyperexcitability to electrical stimulation and accelerated muscle fatigability of taut bands in rats. Acupunct Med. [Dec 6 Epub ahead of print.] The taut bands associated with myofascial trigger points were, in this study, more excitable to electrical stimulation in rats, and significantly less resistant to fatigue than healthy muscle fibers.

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