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PubMed2002

Muscle strength before and mortality after a bone fracture in older people.

We studied whether muscle strength measured before a bone fracture predicts mortality following the fracture. The participants were a sub-cohort of 82 people of a total of 493 Evergreen project participants initially aged 75- and 80 years, who had participated in knee extension strength tests as part of the baseline examinations, and who subsequently suffered at least one bone fracture. Maximal isometric knee extension strength was measured at baseline using an adjustable dynamometer chair. Fracture surveillance was carried out from patient records for 5 years, and mortality surveillance from population register for 10 years after baseline examinations. Average time till a fracture occurred after the baseline was 878 days (SD 576). Subsequent to the fracture, 32 deaths occurred. Using gender-specific cut-offs, three equal distribution-based groups were formed. A gradient risk of mortality was found according to baseline strength. The crude mortality rate per 1000 person-months was 15.2 in the lowest 4.9 in the middle and 1.7 in the highest third of baseline knee extension strength. The adjusted relative risk (RR) of death was 4.40 (95% confidence interval, CI 1.40-13.80) in the lowest and 2.39 (95% CI 0.68-8.4) in the middle tertile vs the highest tertile of muscle strength. Poor muscle strength measured before a fracture occurred was a powerful predictor of increased mortality after the fracture. Poor muscle strength may be a good indicator of overall vulnerability and frailty in old age, and strength testing could be helpful in targeting older people for preventive interventions.

Aged↗
PubMed2005

Reliability and validity of static knee strength measurements obtained with a chair-fixed dynamometer in subjects with hip or knee arthroplasty.

OBJECTIVES: To evaluate the reliability (intertrial, interevaluator) and the concurrent validity of strength measurements obtained with a chair-fixed dynamometer and to recommend a clinical protocol that minimizes standard error of measurement (SEM). DESIGN: Within-session repeated measures of maximal static strength of knee flexors and extensors at 30 degrees and 60 degrees of flexion on the chair-fixed and Cybex dynamometers. SETTING: Ambulatory physiotherapy department of a rehabilitation hospital. PARTICIPANTS: Convenience sample of 50 subjects with total hip (n=25) or knee (n=25) arthroplasty. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Reliability was quantified by indices of dependability and corresponding SEMs estimated with the generalizability theory, whereas coefficients of correlation were used to assess the validity. RESULTS: Indices of dependability confirmed excellent intertrial (0.98-1.00) and a very good interevaluator (.92-.99) reliability for the strength measures obtained for different movements and positions. An average of 3 trials minimized the magnitude of the SEMs (>2 Nm for all measurements). When comparing the strength values obtained with the Cybex dynamometer to those measured with the chair-fixed dynamometer, strongest relations were attained when the tested knee was positioned at 60 degrees compared with 30 degrees for subjects with a total knee (.78-.92 vs .87-.93) or hip (.73-.85 vs .86-.91) arthroplasty. CONCLUSIONS: A clinical protocol averaging 3 trials with the knee positioned at 60 degrees after a familiarization period, both for knee flexors and extensors, performed by a trained therapist is recommended to minimize measurement errors on strength values measured with the chair-fixed dynamometer.

Aged↗
PubMed1993

Relationship between quadriceps strength and bone mineral density of the proximal tibia and distal forearm in women.

It is well known that there is a relationship between muscle strength and bone density, but it is uncertain whether this relationship is site specific. The aim of this study was to assess the relationship of quadriceps strength to site-specific bone mineral density (BMD) of the tibia and to BMD of the forearm. In 66 healthy women, aged 21-78 years, BMD was measured in the proximal tibia and the distal forearm by dual-photon absorptiometry. Isometric and isokinetic strength of the quadriceps was measured using an isokinetic dynamometer (Cybex II). Highly significant correlations between BMD of the proximal tibia and quadriceps strength were found (RS ranging from 0.79 to 0.84, p < 0.0001). Also, BMD of the distal forearm was correlated with quadriceps strength (RS ranging from 0.59 to 0.62, p < 0.0001). In a stepwise multiple regression analysis, quadriceps strength was a better predictor of tibial BMD than age, body height, or weight. However, age, height, and weight were more predictive of forearm BMD than quadriceps strength. When studying the pre- and postmenopausal women separately, quadriceps strength was correlated with BMD of the proximal tibia but not to forearm BMD. In conclusion, the study provides support for a site-specific relationship between muscle and bone.

Absorptiometry, Photon↗
PubMed2000

Relationship between quadriceps strength and rate of loading during gait in women.

One function of skeletal muscle is to serve as the body's shock absorbers and thus dampen rates of loading during activity. The aim of this cross-sectional study was to determine the significance of muscle strength on rates of loading during gait. Thirty-seven women (mean age: 34.5 +/- 8.2 years) were solicited by advertisement and placed into one of two groups-strength-trained or sedentary-on the basis of training history. They walked (10 trials) over a 10-m walkway at a controlled speed of 1.22-1.35 m/s while the rate of loading was sampled with a 1,000-Hz force platform. Quadriceps and hamstring strength was measured at 90 degrees/s with an isokinetic dynamometer. Statistical analyses (p < 0.05) included descriptive statistics and unpaired t tests for comparison between groups. The women in the sedentary group weighed more and had significantly less concentric and eccentric strength of the quadriceps and hamstrings relative to body weight than did those in the strength-trained group. In addition, they demonstrated significantly higher rates of loading (2.21 +/- 0.15 compared with 1.75 +/- 0.08%wt/ms) than those in the strength-trained group.

Adult↗
PubMed2004

Effects of functional electrostimulation on pain, muscular strength, and functional capacity in patients with osteoarthritis of the knee.

BACKGROUND: Osteoarthritis (OA) of the knee is a common cause of chronic disability in patients with quadriceps muscle weakness. Beneficial effects have been proposed for functional electrostimulation (FES) and exercise at the muscle level. OBJECTIVES: The objective of the study was to begin to compare the effects of both therapeutic modalities on quadriceps muscle strength, pain, and functional capacity in patients with OA of the knee and to prove whether the combination of these modalities provides greater benefits than the use of each therapeutic modality alone. METHODS: This pilot study included 37 patients with OA of the knee who were assessed at baseline and at 8 weeks, accounting for the following variables: body mass index, knee pain (measured using a VAS), WOMAC, quadriceps strength (measured using a dynamometer) and 6-minute walk test. Patients were randomized into 3 groups: (A) 8 patients who received FES 3 times per week; (B) 10 patients recruited into a twice-a-week physical training program; and (C) 8 patients under combined therapy; 29.7% of patients were lost to follow-up due to noncompliance with the treatment plan, leaving a total of 26 patients at 8 weeks. RESULTS: Pain and WOMAC improved in all 3 groups; strength improved significantly in the exercise-only group; the FES + exercise combination improved strength significantly when compared with the individual therapeutic procedures. CONCLUSIONS: FES merits a larger placebo-controlled study as it may prove to be useful patients with OA of the knee; the combination with exercise was helpful in improving muscle strength. This technique may be considered in patients who are unable to carry out physical activity due to health problems or in those who are not interested in physical activity.

Journal Article↗
PubMed2001

Markers of inflammation and myofibrillar proteins following eccentric exercise in humans.

The purpose of this study was to examine the time-course and relationships of technetium-99m (99mTc) neutrophils in muscle, interleukin-6 (IL-6), myosin heavy chain fragments (MHC), eccentric torque, and delayed onset muscle soreness (DOMS) following eccentric exercise in humans. Twelve male subjects completed a pre-test DOMS questionnaire, performed a strength test and had 100 ml blood withdrawn for analysis of plasma IL-6 and MHC content. The neutrophils were separated, labelled with 99mTc, and re-infused into the subjects immediately before the exercise. Following 300 eccentric repetitions of the right quadriceps muscles on an isokinetic dynamometer, the subjects had 10 ml of blood withdrawn with repeated the eccentric torque exercise tests and DOMS questionnaire at 0, 2, 4, 6, 20, 24, 48, 72 h, and 6 and 9 days. Bilateral images of the quadriceps muscles were taken at 2, 4, and 6 h. Computer analysis of regions of interest was used to determine the average count per pixel. The 99mTc neutrophils and IL-6 increased up to 6 h post-exercise (P < 0.05). The neutrophils were greater in the exercised muscle than the non-exercised muscle (P < 0.01). The DOMS was increased from 0 to 48 h, eccentric torque decreased from 2 to 24 h, and MHC peaked at 72 h post-exercise (P < 0.001). Significant relationships were found between IL-6 and 2 h and DOMS at 24 h post-exercise (r = 0.68) and assessment of the magnitude of change between IL-6 and MHC (r = 0.66). These findings suggest a relationship between damage to the contractile proteins and inflammation, and that DOMS is associated with inflammation but not with muscle damage.

Adult↗
PubMed2000

The effects of a prolonged running exercise on strength characteristics.

The aim of this study was to examine concentric, isometric, and eccentric strength reductions in the quadriceps muscle following a prolonged running exercise. Before and after a 2 h run (28.4+/-1.4 km) peak torque (PT) of the knee extensors at angular velocities of -120, -90, -60, 0, 60, 120, 180, 240 degrees x s(-1) using an isokinetic dynamometer, electromyographic (EMG) activity of the vastus lateralis (VL) and vastus medialis (VM) muscles and height of a counter movement jump were recorded in twelve well-trained triathletes. Counter movement jump performances decreased by 10% and PT values were all significantly lower (p < 0.01) at each angular velocity following the run. The torque loss was significantly (p < 0.01) greater under eccentric contractions (from 18 to 21%) than under concentric ones (from 11 to 14%). EMG activity (RMS) was lower in both VL and VM muscles after the 2 h run but no difference existed in RMS losses between concentric and eccentric contractions. The present results demonstrate that 1) a prolonged running exercise more greatly affects eccentric force production in the quadriceps muscle, and 2) this specificity seems to be due to an impairment of the muscular contractile mechanism rather than a modification to the neural input.

Adult↗
PubMed2006

Indicators of maximal hiking performance in Laser sailors.

Laser class sailors have to hike out, i.e. hook their feet under the toe straps near the centreline of the boat and hold their upper bodies over the edge of the boat, to counteract the heeling forces generated by the sails. To identify the parameters that are associated with maximal hiking performance, this cross-sectional observational study measures various knee extensor and hip flexor muscle performance characteristics in 55 Laser sailors and correlates each with the area-under-the-curve hiking moment over 3 min of hiking on a hiking dynamometer (HM180). Our results showed that higher body mass and HM180 were significantly associated with better race scores (Spearman's rho = - 0.69 and - 0.62, respectively, both P < 0.01) in male sailors who participated in the National Inter-School Laser competition. Body mass (Pearson's correlation coefficient, r > or = 0.95, P < 0.01 in both males and females), maximum voluntary isometric strength of the quadriceps (r > or = 0.80, P < 0.01 in both males and females), and 3-RM knee extension strength (r > or = 0.80, P < 0.01 in both males and females) were associated with a higher HM180. The correlations between height, abdominal muscle endurance (crunches), explosive lower body strength (vertical jumps), cycling time-to-exhaustion, quadriceps strength endurance, or isometric quadriceps endurance with incremental loads (bucket test), and HM180 were weaker (r < 0.60). HM180 may be a useful performance indicator for Laser racing. Since strength measures correlated well with HM180, greater emphasis should be placed on developing maximum strength in the quadriceps to improve maximal hiking performance.

Adolescent↗
PubMed2000

Asymmetrical strength changes and injuries in athletes training on a small radius curve indoor track.

OBJECTIVES: 1) To evaluate strength changes in the hindfoot invertor and evertor muscle groups of athletes training and competing primarily in the counterclockwise direction on an indoor, unbanked track, and 2) to observe injuries occurring in these same runners over the course of an indoor season. DESIGN: Prospective observational study. SETTING: Fowler-Kennedy Sport Medicine Clinic, The University of Western Ontario, London, Ontario. PARTICIPANTS: A convenience sample of 25 intercollegiate, long sprinters (200-600 m) and middle distance runners (800-3,000 m) competing and training with the 1995-1996 University of Western Ontario Track and Field team. MAIN OUTCOME MEASURES: A standardized protocol using the Cybex 6000 isokinetic dynamometer was used to measure peak torques of the hindfoot invertor and evertor muscle groups of both limbs using concentric and eccentric contractions performed at angular velocities of 60, 120, and 300 degrees/sec. Changes in peak torques between the preseason and postseason values were calculated and compared using a repeated measures analysis of variance test. Injury reports were collected by student athletic trainers and in the Sport Medicine and Physiotherapy clinic. RESULTS: Primary analysis indicated that the left (inside limb) invertors increased in strength significantly more than the right (outside limb) invertors (p = 0.01), while the right evertors increased in strength significantly more than the left evertors (p = 0.04). A high incidence of lower extremity injury (68%) occurred in this sample of runners, corresponding to an injury rate of 0.75 injuries per 100 person-hours of sport exposure. Although sample size was limited, secondary analysis indicated that strength changes were not significantly different for injured (n = 17) and uninjured (n = 8) runners (p > 0.05). CONCLUSIONS: The observed small, but statistically significant, asymmetrical changes in strength of the hindfoot invertor and evertor muscle groups can best be described as a training effect. Altered biomechanics proposed to occur in the stance foot while running on the curve of the track are discussed in relation to the observed strength imbalance. A causal link between strength changes and lower extremity injuries cannot be inferred from this study, but suggestions for further research are made.

Adaptation, Physiological↗
PubMed2001

Strength, power, and coactivation in children with developmental coordination disorder.

Strength, power, and coactivation levels were measured during knee extension and flexion tasks in 20 children (13 males, 7 females) with developmental coordination disorder (DCD) and 20 age-matched control children (12 males, 8 females). Participants were classified according to results obtained on the McCarron Assessment of Neuromuscular Development, with each group including two age levels: 6 to 7 and 9 to 10 years. Tasks were performed on a Biodex dynamometer under isometric and isokinetic conditions with surface EMG recorded from the vastus lateralis and biceps femoris muscles. Significant effects of group and age were observed for the measures of peak torque (isometric and isokinetic) and power, with the decreased power in the group with DCD being more apparent at higher velocities. A lower flexor-extensor percentage was recorded for the group with DCD but only under isokinetic conditions. From a neuromuscular perspective, the group with DCD had increased levels of coactivation (RMS agonist:RMS antagonist) during the isometric flexion and isokinetic extension actions. Possible causes of the strength and power deficits observed in children with DCD are discussed.

Anthropometry↗
PubMedDate not supplied

Association of muscle strength with maximum walking speed in disabled older women.

Our aim was to study the association of lower limb strength with maximum walking speed in disabled older women and to try to detect the reserve capacity threshold for maximum walking speed and the minimum strength required for walking at a speed of 1.22 m x s(-1), which is required in crossing signaled intersections. The data are from the baseline of Women's Health and Aging Study, a population-based study on causes and course of disability. Altogether, 1,002 disabled women participated in the tests, which took place at their homes. Maximum isometric hip flexion and knee extension forces were measured on both sides using a handheld dynamometer. For analytic purposes, knee extension torque/body mass ratio (KET/BM) was calculated. Maximum walking speed was measured with a stopwatch during a 4-m walk. KET/BM had a significant effect on walking speed after controlling for number of chronic conditions, balance, use of walking aid, joint pain, age, and body height and mass. A total of 42.3% of the variation in maximum walking speed was explained by these variables. The cumulative percentage distribution of KET/BM of those able to attain a maximum walking speed of 1.22 m x s(-1) (n = 148) was flat to the level of 1.1 N x m x kg(-1), after which it turned upward, indicating that the probability of attaining 1.22 m x s(-1) started to increase after that level. By using segmented linear regression analysis, 2.3 N x m x kg(-1) was found to be the cutoff point beyond which an increase in KET/BM did not correspond to an increase in maximum walking speed. Muscle strength was positively but not linearly associated with maximum walking speed. Strength testing may help to identify people close to functional thresholds and, thus, at risk of impaired walking, who would benefit most from strengthening exercises.

Activities of Daily Living↗
PubMed2006

Systemic inflammatory responses to maximal versus submaximal lengthening contractions of the elbow flexors.

We compared changes in markers of muscle damage and systemic inflammation after submaximal and maximal lengthening muscle contractions of the elbow flexors. Using a cross-over design, 10 healthy young men not involved in resistance training completed a submaximal trial (10 sets of 60 lengthening contractions at 10% maximum isometric strength, 1 min rest between sets), followed by a maximal trial (10 sets of three lengthening contractions at 100% maximum isometric strength, 3 min rest between sets). Lengthening contractions were performed on an isokinetic dynamometer. Opposite arms were used for the submaximal and maximal trials, and the trials were separated by a minimum of two weeks. Blood was sampled before, immediately after, 1 h, 3 h, and 1-4 d after each trial. Total leukocyte and neutrophil numbers, and the serum concentration of soluble tumor necrosis factor-alpha receptor 1 were elevated after both trials (P < 0.01), but there were no differences between the trials. Serum IL-6 concentration was elevated 3 h after the submaximal contractions (P < 0.01). The concentrations of serum tumor necrosis factor-alpha, IL-1 receptor antagonist, IL-10, granulocyte-colony stimulating factor and plasma C-reactive protein remained unchanged following both trials. Maximum isometric strength and range of motion decreased significantly (P < 0.001) after both trials, and were lower from 1-4 days after the maximal contractions compared to the submaximal contractions. Plasma myoglobin concentration and creatine kinase activity, muscle soreness and upper arm circumference all increased after both trials (P < 0.01), but were not significantly different between the trials. Therefore, there were no differences in markers of systemic inflammation, despite evidence of greater muscle damage following maximal versus submaximal lengthening contractions of the elbow flexors.

Adult↗
PubMed2000

Critical power of knee extension exercises does not depend upon maximal strength.

A possible dependence of critical power (CP) and the Y-intercept of the work/exhaustion time relationship (Y(intercept)) on maximal muscular strength of the same muscle group has been studied in nine endurance-trained subjects, seven gymnasts, and seven weight-lifters. CP was calculated as being equal to the slope of the linear relationship between exhaustion time and the work performed at exhaustion on a knee extension ergometer. Y(intercept) was equal to the intercept between this relationship and the work axis. The muscular strength of the knee was evaluated by measuring the torques exerted on a Biodex knee isokinetic dynamometer at four angular velocities: 0 degrees x s(-1) (T0), 90 degrees x s(-1) (T90), 180 degrees x s(-1) (T180) and 240 degrees x s(-1) (T240). The results of the present study do not support the hypothesis that CP depends upon maximal strength. Indeed, CP was not correlated with T0, T90, T180 or T240 (¿r¿ < 0.01). Y(intercept) was significantly and positively correlated only with T90.

Adult↗
PubMed2004

Management of a patient with a forearm fracture and median nerve injury.

STUDY DESIGN: Case report. OBJECTIVES: Patients with peripheral nerve injury may demonstrate long-lasting impairments and functional limitations. In this case report, we describe the diagnosis of a patient with a peripheral nerve injury and a conventional plan of care, along with the novel intervention of neuromuscular electrical stimulation (NMES). We feel that the additional NMES intervention was instrumental in achieving more rapid functional improvements than the more traditional interventions that are reported in the literature. BACKGROUND: The patient was a 21-year-old male who sustained a forearm fracture that was complicated by injury to the anterior interosseous branch of the median nerve. He was unable to flex the interphalangeal (IP) joint of his thumb, had decreased strength of thenar eminence musculature, and was unable to perform fine motor activities with his hand. METHODS AND MEASURES: Electrophysiological tests revealed partial denervation of the flexor pollicis longus and pronator quadratus muscles. In the fifth physical therapy session, NMES to the flexor pollicis longus and thenar muscles was added to the patient's conventional plan of care. RESULTS: With a conventional ROM and strengthening plan of care, no improvement was seen in thumb IP joint flexion over a period of 2 weeks. After 3 sessions of NMES and conventional interventions, gains in active ROM were made in thumb IP joint flexion. After 9 sessions of NMES and conventional interventions, force of thumb IP flexion was registered on a pinch dynamometer. Twenty weeks after initial examination, strength and ROM measures had improved and the patient reported no functional deficits. CONCLUSIONS: The patient showed gains in strength of the thumb IP joint after a few NMES sessions, which suggests that NMES was a helpful adjunct to the plan of care, even though the precise mechanism underlying the functional gains are not known.

Adult↗
PubMed2000

The relationship between lower extremity injury, low back pain, and hip muscle strength in male and female collegiate athletes.

OBJECTIVE: To determine the relationship of previous lower extremity (LE) injury and/or low back pain (LBP) on hip abduction and extension strength. DESIGN: Cohort study of college athletes at time of preparticipation screening physical. SETTING: An NCAA Division I college. PARTICIPANTS: Two hundred ten college athletes (140 males and 70 females) from an NCAA Division I school. MAIN OUTCOME MEASURES: Mean and maximal hip abduction and extension strengths were recorded using a specially designed dynamometer anchoring station. Previous injury to the LE or LBP in the past year was recorded via personal interview at the time of screening and verified by review of previous injury records. RESULTS: A significant difference in side-to-side symmetry of maximum hip extension strength was observed in female subjects who reported LE injury or LBP as compared to those who did not. Side-to-side difference in hip strength, however, did not differ between male athletes, regardless of reported LE injury or LBP status. CONCLUSION: Female athletes appear to have a differing response of the proximal hip musculature to LE injury or LBP, as compared with their male counterparts. Research is under way to further validate these findings. CLINICAL RELEVANCE: This study provides some reasoning to support the screening of hip strength during the preparticipation physical, as it may be important in the prevention of LE injury and LBP in collegiate athletes.

Adult↗
PubMed1993

Concentric and eccentric muscle strength before, during and after fatigue in 13 year-old boys.

The purpose of this study was to investigate the force-producing characteristics of boys aged 13 years in relation to fatigue of elbow flexor muscles. Maximal voluntary force in elbow flexion was measured before and after a muscle endurance test (MET) by using an isokinetic dynamometer isometrically, concentrically and eccentrically at three velocities, i.e. 0.21, 0.52, and 1.05 rad.s-1. The MET consisted of maximal concentric and eccentric muscle actions performed alternately at 0.52 rad.s-1 for 50 consecutive trials. Muscle cross-sectional area (CSA) of elbow flexor muscles (biceps brachii and brachialis) was measured by a B-mode ultrasound apparatus. Although eccentric force showed significantly higher values than concentric force during MET, there was no significant difference in the rate of decline in force between the two actions. There was no significant difference in the rate of decline in force after MET for each velocity and muscle action. Isometric, concentric and eccentric force before MET was significantly related to muscle CSA whereas, after MET, concentric force significantly correlated with muscle CSA but there was no significant correlation between muscle CSA and isometric or eccentric force. From our study, it is therefore suggested that in development to maturity, isometric, concentric and eccentric force decrease at the same rate with advancing muscle fatigue; however, there might be differences among muscle actions in factors affecting force development.

Adolescent↗
PubMed1986

Caffeine ingestion and isokinetic strength.

The purpose of this study was to investigate the effects of caffeine on maximum voluntary contractions of the dominant knee extension and flexion muscles in 12 male intercollegiate track sprinters. Caffeine (5 mg.kg-1) and placebo (225 mg methylcellulose) gelatin capsules were administered orally in randomly assigned order. Muscle function was measured isokinetically by a Cybex II dynamometer interfaced with a data reduction computer. Six repetitions maximum of the extensors and flexors were performed at three sequential ordered speeds (30 degrees, 150 degrees and 300 degrees s-1) with a one-minute rest between varying velocities. Peake torque and power were than assessed after treatment conditions, as well as a fatigue index calculated from a series of 60 repetitions maximum ato 150 degrees s-1. Results of the 2 X 3 ANOVA and paired t-test indicated no difference in measures of peak torque and power at the varying contracting velocities and fatigue index after caffeine ingestion. These findings indicate the ingestion of caffeine in a small dose exerts no ergogenic effect on muscle function under anaerobic conditions.

Administration, Oral↗
PubMed2005

Evaluation of female pelvic-floor muscle function and strength.

Evaluation of pelvic-floor muscle (PFM) function and strength is necessary (1) to be able to teach and give feedback regarding a woman's ability to contract the PFM and (2) to document changes in PFM function and strength throughout intervention. The aims of this article are to give an overview of methods to assess PFM function and strength and to discuss the responsiveness, reliability, and validity of data obtained with the methods available for clinical practice and research today. Palpation, visual observation, electromyography, ultrasound, and magnetic resonance imaging (MRI) measure different aspects of PFM function. Vaginal palpation is standard when assessing the ability to contract the PFM. However, ultrasound and MRI seem to be more objective measurements of the lifting aspect of the PFM. Dynamometers can measure force directly and may yield more valid measurements of PFM strength than pressure transducers. Further research is needed to establish reliability and validity scores for imaging techniques. Imaging techniques may become important clinical tools in future physical therapist practice and research to measure both pathophysiology and impairment of PFM dysfunction.

Electromyography↗