Introduction: Supervised exercise treadmill is a recommended therapy for claudication in peripher... more Introduction: Supervised exercise treadmill is a recommended therapy for claudication in peripheral arterial disease (PAD). While repetitive claudication during exercise improves symptoms, the mechanisms of benefit are not well understood and the technique is poorly tolerated. Near infrared spectroscopy (NIRS) allows for real-time assessment of skeletal muscle blood flow during exercise and can be used as measure of tissue hypoxia. Moreover, in health and in PAD, NIRS-derived post-exercise recovery of muscle oxygen consumption fit to a mono-exponential curve yields a time constant (Tc) that is an index of mitochondrial capacity. Methods and Results: We devised a novel supervised treadmill exercise training program wherein subjects with claudication from PAD trained thrice weekly for hour-long sessions over a 12 week period. Exercise intensity was determined by 15% reduction in resting skeletal muscle oxygenation by NIRS rather than by symptoms of pain. We randomly assigned subjects to NIRS-guided training...
Journal of Cardiopulmonary Rehabilitation, Mar 1, 1996
Orientation sessions are sometimes used to habituate subjects before exercise stress testing. The... more Orientation sessions are sometimes used to habituate subjects before exercise stress testing. The extent of habituation in older subjects has not been clearly defined. Additionally, the use of repetitive maximal stress testing as an orientation method may not be necessarily applicable in the aged. To determine if the employment of a submaximal orientation session would effect cardiopulmonary cycle ergometer exercise results, 266 older adults (68.6 +/- 5.0 years) male (n = 100) and female (n = 166) subjects participated in this study. One hundred thirty-one subjects received an orientation before stress testing. One hundred thirty-five did not. Analysis of resting values revealed no significant differences. Separate gender analysis was performed at submaximal workloads. Men were examined at 0, 60, and 105 Watts; women at 0, 45, and 75 Watts. Oriented subjects displayed significantly lower heart rates for both males and females at all submaximal workloads. Oxygen uptake was significantly lower for oriented women at 45 Watts (P < or = .05) and men at 60 Watts (P < or = .05). Oriented males displayed significantly lower systolic blood pressure at 0 Watts (P < or = .05), 60 Watts (P < or = .01), and 105 Watts (P < or = .05). The oriented group reached ventilatory threshold (VeT) at a higher workload (P < or = .001), lower heart rate (P < or = .001), and higher VO2 uptake (P < or = .05). Nonoriented subjects obtained a significantly higher maximal heart rate than oriented subjects (147 +/- 15.7 beats per minute (bpm) vs. 140 +/- 17.1 bpm, P < or = .01). Separate gender analysis revealed a significant difference (P < or = .01) in maximal heart rate in males (oriented = 137.4 +/- 18.8 bpm vs. nonoriented = 147.7 +/- 15.7 bpm). Although nonoriented women achieved a higher maximal heart rate, the difference was not significant (146.9 +/- 15.8 bpm vs. 142.6 +/- 16.0 bpm). These results indicate that both male and female older subjects display significant modification in physiologic performance from habituation after a single submaximal exercise orientation session. This effect was greater at submaximal than maximal workloads, and appears to be greater than that previously reported in younger subjects.
OBJECTIVE To assess the reliability and reproducibility of using a four arterial occlusions proto... more OBJECTIVE To assess the reliability and reproducibility of using a four arterial occlusions protocol and near-infrared spectroscopy (NIRS) to measure resting and post-exercise muscle oxidative metabolism (mVO2). APPROACH mVO2 was measured on the forearm muscles on two different days (day1 and day2) within one week in 11 healthy young adults (24.2 ± 2.7 years; 5 males). mVO2 was measured using NIRS during four repeated arterial occlusions at rest, and 5 minutes after exercise consisting of 90 seconds of rapid concentric contractions (5minEPOC). MAIN RESULTS Resting mVO2 with four measurements was 17.88 ± 3.04%/min on day one and 19.42 ± 3.03%/min on day two (p = 0.171) with a coefficient of variation (CV) of 10.1%. When using only the first measurement, the CV increased to 18.5% (p = 0.039). 5minEPOC was 212.4 ± 142.5% and 177.1 ± 125.8% higher than resting and was not different between days one and two (53.83 ± 21.17%/min and 52.22 ± 22.10%/min, respectively, p = 0.199). The CV and intraclass correlation (ICC) for 5minEPOC between days one and two were, 6.5% and 0.98, respectively. Using only the first value for 5minEPOC resulted in slightly higher CV but similar ICC (7.6% and 0.98, respectively; both p > 0.05). SIGNIFICANCE Our results suggest that within a single testing session, one arterial occlusion can provide reproducible measurements for both resting and post-exercise mVO2 similar to that of a four arterial occlusions protocol. While a four arterial occlusion protocol provides similar reliability for post-exercise mVO2 with one arterial occlusion, it reduces the day-to-day variance for resting mVO2 and therefore should be employed for longitudinal studies.
The effects of ovariectomy on metabolism of high-energy phosphate compounds during and after exer... more The effects of ovariectomy on metabolism of high-energy phosphate compounds during and after exercise were studied in hindleg muscles of 14 rats. Sciatic nerve stimulation was used to establish different work loads, and the changes in inorganic phosphate-to-phosphocreatine ratios (Pi/PCr) were recorded by 31P nuclear magnetic resonance (NMR) in vivo. Four weeks after ovariectomy, there was evidence of significantly higher Pi/PCr during work at stimulation rates greater than 0.5 Hz. The slope for the stimulation rate-to-Pi/PCr relationship decreased from 1.98 +/- 0.15 to 1.36 +/- 0.2 Hz/Pi/PCr after ovariectomy. The normalized tension output of these muscles, tested separately using identical stimulation protocols, was not changed with ovariectomy. Thus the relationship between work (tension-time integral) and bioenergetic cost (Pi/PCr) suggested reduced maximal enzyme activity (Vmax) by 9-17% as a result of lack of ovarian sex hormones, but no change in Michaelis-Menten constant (Km) was found. Postexercise recovery was also significantly slower (3.27 +/- 0.54 PCr/Pi units per minute compared with 4.04 +/- 1.08 in controls). It is suggested that reduced levels of ovarian sex hormones decrease oxidative phosphorylation. Cytochrome oxidase activity was reduced in these muscles by 40%, but other mitochondrial enzyme systems may be affected as well. The possible significance of these data is the implication of a reduced capacity for menopausal women or amenorrheic female athletes to perform prolonged intensive exercise.
We used phosphorus magnetic resonance spectroscopy (31P-MRS) to study the effect of exercise-indu... more We used phosphorus magnetic resonance spectroscopy (31P-MRS) to study the effect of exercise-induced muscle injury in the calf muscle of 7 DMD/BMD carriers and 6 non-carrier females. All subjects performed 50-80 lengthening contractions with the right calf muscles. 48 h after lengthening exercise non-carriers showed increased sensitivity to pressure in their gastrocnemius accompanied by increased T2 relaxation times and by elevated Pi/PCr ratios at rest. DMD/BMD carriers did not show any effect of lengthening exercise on these measurements. In-magnet exercise revealed in all carriers a reduced initial rate of Pi recovery and an increased time to fully recovery the resting value of intracellular pH. Lengthening exercise further decreased the initial rate of Pi recovery. Non-carriers did not show any variation attributable to lengthening exercise either during in-magnet work or during recovery from exercise. We found that lengthening exercise contractions causes: (1) less muscle injury in carriers compared to non-carriers, (2) even slower rate of Pi recovery, but (3) no effect on Pi recovery in non-carriers. The use of lengthening exercise and measurements of Pi recovery may be a useful method to evaluate the disease process in DMD/BMD.
American Journal of Physiology-cell Physiology, Feb 1, 1988
Chronic stimulation converts skeletal muscle of mixed fiber type to a uniform muscle made up of t... more Chronic stimulation converts skeletal muscle of mixed fiber type to a uniform muscle made up of type I, fatigue-resistant fibers. Here, the bioenergetic correlates of fatigue resistance in conditioned canine latissimus dorsi are assessed with in vivo phosphorus-31 nuclear magnetic resonance (31P-NMR) spectroscopy. After chronic electrical stimulation, five dogs underwent 31P-NMR spectroscopic and isometric tension measurements on conditioned and contralateral control muscle during stimulation for 200, 300, 500, and 800 ms of an 1,100-ms duty cycle. With stimulation, phosphocreatine (PCr) fell proportional to the degree of stimulation in both conditioned and control muscle but fell significantly less in conditioned muscle at all but the least intense stimulation period (200 ms). Isometric tension, expressed as a tension time index per gram muscle, was significantly greater in the conditioned muscle at the two longest stimulation periods. The overall small change in PCr and the lack of a plateau in tension observed in the conditioned muscle are similar to that seen in cardiac muscle during increased energy demand. This study indicates that the conditioned muscle's markedly enhanced resistance to fatigue is in part the result of its increased capacity for oxidative phosphorylation.
Oxidative capacity within selected muscles can be measured non‐invasively using Near Infrared Spe... more Oxidative capacity within selected muscles can be measured non‐invasively using Near Infrared Spectroscopy (NIRS) by employing a series of transient arterial occlusion cuffs after a metabolic stimulus. Traditionally, this protocol involves voluntary contraction of a single limb followed by up to 22 transient ischemic occlusions per measurement. Our lab has adapted an established protocol 1 to develop a novel protocol that allows for an increased number of measurements using fewer (i.e. 6) ischemic occlusions combined with surface electrical stimulation (E‐stim) in both limbs simultaneously. However, reproducibility has not yet been established with this protocol.PURPOSETo determine the within‐day and between‐day reproducibility of this protocol in both the vastus lateralis and medial hamstring muscles.METHODSThe protocol involved 2 NIRS probes placed over the vastus lateralis (VL) muscles or the medial hamstring (MH) muscles in healthy adults to sense changes in muscle oxygenation. ...
Background Supervised exercise training is recommended for intermittent claudication in periphera... more Background Supervised exercise training is recommended for intermittent claudication in peripheral artery disease (PAD), but the relationship between work achieved during exercise and clinical outcomes is not well described. As in other training modalities, increased effort measured by cumulative work production is expected to be translate into to positive performance adaptations. In settings of constrained limb blood flow, this relationship is unknown. In addition, the impact of exercise on skeletal muscle oxygen use capacity changes is unknown. Near infrared spectroscopy (NIRS) offers a method of characterizing skeletal muscle mitochondrial adaptations before and after training programs. Methods We enrolled subjects (n=17, age 71±8.8 years, 20% female) with PAD and intermittent claudication (ankle brachial index [ABI]=0.76±0.21) in a 12-week supervised training program, randomized to traditional pain-based training strategy versus hypoxia-based training (using NIRS to direct train...
Background Symptoms of fatigue and pain are often reported for the trapezius muscle in the should... more Background Symptoms of fatigue and pain are often reported for the trapezius muscle in the shoulder. The present study evaluated endurance in the trapezius muscles of healthy participants using electric twitch mechanomyography (ETM). Methods Surface electrodes and a tri-axial accelerometer were placed over the left trapezius muscle. Muscles were stimulated for 3 min each at 2 Hz, 4 Hz and 6 Hz. Maintenance of acceleration during muscle twitches was used to calculate an endurance index (EI). Subjects (n = 9) were tested on two separate days to assess reproducibility of the trapezius EI measurements. The endurance measurements were made on the wrist flexor and vastus lateralis muscles for comparison. Near infrared spectroscopy was used to measure muscle oxygenation (HbO2) during the stimulation protocol (n = 8). Results Mean (SD) EI was 84.9% (8.7%), 63.3% (19.1%) and 41.7% (20.0%) for 2 Hz, 4 Hz and 6 Hz, respectively. The coefficients of variation were 7.4%, 11.3% and 24.0% for 2 Hz...
BACKGROUND Fatigue is a particularly debilitating symptom for people with multiple sclerosis (MS)... more BACKGROUND Fatigue is a particularly debilitating symptom for people with multiple sclerosis (MS). Although personality traits and MS have been studied, interoception and emotional susceptibility and their links to fatigue have not yet been explored. METHODS Study participants provided demographic information and completed standardized patient-reported outcomes of walking function, physical activity, subjective fatigue, interoceptive awareness, and emotional susceptibility. A subset of participants participated in semistructured interviews discussing fatigue, body sensations, emotions, and their effects on exercise. Quantitative data were analyzed using multiple regression. Qualitative data were analyzed using thematic analysis. RESULTS Mean ± SD Fatigue Severity Scale scores (5.0 ± 1.3) indicated that fatigue was a problematic symptom. Mean ± SD Multidimensional Assessment of Interoceptive Awareness, Version 2 (2.8 ± 0.6) and Emotional Susceptibility Scale (3.0 ± 1.0) scores indica...
Introduction: Supervised exercise treadmill is a recommended therapy for claudication in peripher... more Introduction: Supervised exercise treadmill is a recommended therapy for claudication in peripheral arterial disease (PAD). While repetitive claudication during exercise improves symptoms, the mechanisms of benefit are not well understood and the technique is poorly tolerated. Near infrared spectroscopy (NIRS) allows for real-time assessment of skeletal muscle blood flow during exercise and can be used as measure of tissue hypoxia. Moreover, in health and in PAD, NIRS-derived post-exercise recovery of muscle oxygen consumption fit to a mono-exponential curve yields a time constant (Tc) that is an index of mitochondrial capacity. Methods and Results: We devised a novel supervised treadmill exercise training program wherein subjects with claudication from PAD trained thrice weekly for hour-long sessions over a 12 week period. Exercise intensity was determined by 15% reduction in resting skeletal muscle oxygenation by NIRS rather than by symptoms of pain. We randomly assigned subjects to NIRS-guided training...
Journal of Cardiopulmonary Rehabilitation, Mar 1, 1996
Orientation sessions are sometimes used to habituate subjects before exercise stress testing. The... more Orientation sessions are sometimes used to habituate subjects before exercise stress testing. The extent of habituation in older subjects has not been clearly defined. Additionally, the use of repetitive maximal stress testing as an orientation method may not be necessarily applicable in the aged. To determine if the employment of a submaximal orientation session would effect cardiopulmonary cycle ergometer exercise results, 266 older adults (68.6 +/- 5.0 years) male (n = 100) and female (n = 166) subjects participated in this study. One hundred thirty-one subjects received an orientation before stress testing. One hundred thirty-five did not. Analysis of resting values revealed no significant differences. Separate gender analysis was performed at submaximal workloads. Men were examined at 0, 60, and 105 Watts; women at 0, 45, and 75 Watts. Oriented subjects displayed significantly lower heart rates for both males and females at all submaximal workloads. Oxygen uptake was significantly lower for oriented women at 45 Watts (P < or = .05) and men at 60 Watts (P < or = .05). Oriented males displayed significantly lower systolic blood pressure at 0 Watts (P < or = .05), 60 Watts (P < or = .01), and 105 Watts (P < or = .05). The oriented group reached ventilatory threshold (VeT) at a higher workload (P < or = .001), lower heart rate (P < or = .001), and higher VO2 uptake (P < or = .05). Nonoriented subjects obtained a significantly higher maximal heart rate than oriented subjects (147 +/- 15.7 beats per minute (bpm) vs. 140 +/- 17.1 bpm, P < or = .01). Separate gender analysis revealed a significant difference (P < or = .01) in maximal heart rate in males (oriented = 137.4 +/- 18.8 bpm vs. nonoriented = 147.7 +/- 15.7 bpm). Although nonoriented women achieved a higher maximal heart rate, the difference was not significant (146.9 +/- 15.8 bpm vs. 142.6 +/- 16.0 bpm). These results indicate that both male and female older subjects display significant modification in physiologic performance from habituation after a single submaximal exercise orientation session. This effect was greater at submaximal than maximal workloads, and appears to be greater than that previously reported in younger subjects.
OBJECTIVE To assess the reliability and reproducibility of using a four arterial occlusions proto... more OBJECTIVE To assess the reliability and reproducibility of using a four arterial occlusions protocol and near-infrared spectroscopy (NIRS) to measure resting and post-exercise muscle oxidative metabolism (mVO2). APPROACH mVO2 was measured on the forearm muscles on two different days (day1 and day2) within one week in 11 healthy young adults (24.2 ± 2.7 years; 5 males). mVO2 was measured using NIRS during four repeated arterial occlusions at rest, and 5 minutes after exercise consisting of 90 seconds of rapid concentric contractions (5minEPOC). MAIN RESULTS Resting mVO2 with four measurements was 17.88 ± 3.04%/min on day one and 19.42 ± 3.03%/min on day two (p = 0.171) with a coefficient of variation (CV) of 10.1%. When using only the first measurement, the CV increased to 18.5% (p = 0.039). 5minEPOC was 212.4 ± 142.5% and 177.1 ± 125.8% higher than resting and was not different between days one and two (53.83 ± 21.17%/min and 52.22 ± 22.10%/min, respectively, p = 0.199). The CV and intraclass correlation (ICC) for 5minEPOC between days one and two were, 6.5% and 0.98, respectively. Using only the first value for 5minEPOC resulted in slightly higher CV but similar ICC (7.6% and 0.98, respectively; both p > 0.05). SIGNIFICANCE Our results suggest that within a single testing session, one arterial occlusion can provide reproducible measurements for both resting and post-exercise mVO2 similar to that of a four arterial occlusions protocol. While a four arterial occlusion protocol provides similar reliability for post-exercise mVO2 with one arterial occlusion, it reduces the day-to-day variance for resting mVO2 and therefore should be employed for longitudinal studies.
The effects of ovariectomy on metabolism of high-energy phosphate compounds during and after exer... more The effects of ovariectomy on metabolism of high-energy phosphate compounds during and after exercise were studied in hindleg muscles of 14 rats. Sciatic nerve stimulation was used to establish different work loads, and the changes in inorganic phosphate-to-phosphocreatine ratios (Pi/PCr) were recorded by 31P nuclear magnetic resonance (NMR) in vivo. Four weeks after ovariectomy, there was evidence of significantly higher Pi/PCr during work at stimulation rates greater than 0.5 Hz. The slope for the stimulation rate-to-Pi/PCr relationship decreased from 1.98 +/- 0.15 to 1.36 +/- 0.2 Hz/Pi/PCr after ovariectomy. The normalized tension output of these muscles, tested separately using identical stimulation protocols, was not changed with ovariectomy. Thus the relationship between work (tension-time integral) and bioenergetic cost (Pi/PCr) suggested reduced maximal enzyme activity (Vmax) by 9-17% as a result of lack of ovarian sex hormones, but no change in Michaelis-Menten constant (Km) was found. Postexercise recovery was also significantly slower (3.27 +/- 0.54 PCr/Pi units per minute compared with 4.04 +/- 1.08 in controls). It is suggested that reduced levels of ovarian sex hormones decrease oxidative phosphorylation. Cytochrome oxidase activity was reduced in these muscles by 40%, but other mitochondrial enzyme systems may be affected as well. The possible significance of these data is the implication of a reduced capacity for menopausal women or amenorrheic female athletes to perform prolonged intensive exercise.
We used phosphorus magnetic resonance spectroscopy (31P-MRS) to study the effect of exercise-indu... more We used phosphorus magnetic resonance spectroscopy (31P-MRS) to study the effect of exercise-induced muscle injury in the calf muscle of 7 DMD/BMD carriers and 6 non-carrier females. All subjects performed 50-80 lengthening contractions with the right calf muscles. 48 h after lengthening exercise non-carriers showed increased sensitivity to pressure in their gastrocnemius accompanied by increased T2 relaxation times and by elevated Pi/PCr ratios at rest. DMD/BMD carriers did not show any effect of lengthening exercise on these measurements. In-magnet exercise revealed in all carriers a reduced initial rate of Pi recovery and an increased time to fully recovery the resting value of intracellular pH. Lengthening exercise further decreased the initial rate of Pi recovery. Non-carriers did not show any variation attributable to lengthening exercise either during in-magnet work or during recovery from exercise. We found that lengthening exercise contractions causes: (1) less muscle injury in carriers compared to non-carriers, (2) even slower rate of Pi recovery, but (3) no effect on Pi recovery in non-carriers. The use of lengthening exercise and measurements of Pi recovery may be a useful method to evaluate the disease process in DMD/BMD.
American Journal of Physiology-cell Physiology, Feb 1, 1988
Chronic stimulation converts skeletal muscle of mixed fiber type to a uniform muscle made up of t... more Chronic stimulation converts skeletal muscle of mixed fiber type to a uniform muscle made up of type I, fatigue-resistant fibers. Here, the bioenergetic correlates of fatigue resistance in conditioned canine latissimus dorsi are assessed with in vivo phosphorus-31 nuclear magnetic resonance (31P-NMR) spectroscopy. After chronic electrical stimulation, five dogs underwent 31P-NMR spectroscopic and isometric tension measurements on conditioned and contralateral control muscle during stimulation for 200, 300, 500, and 800 ms of an 1,100-ms duty cycle. With stimulation, phosphocreatine (PCr) fell proportional to the degree of stimulation in both conditioned and control muscle but fell significantly less in conditioned muscle at all but the least intense stimulation period (200 ms). Isometric tension, expressed as a tension time index per gram muscle, was significantly greater in the conditioned muscle at the two longest stimulation periods. The overall small change in PCr and the lack of a plateau in tension observed in the conditioned muscle are similar to that seen in cardiac muscle during increased energy demand. This study indicates that the conditioned muscle's markedly enhanced resistance to fatigue is in part the result of its increased capacity for oxidative phosphorylation.
Oxidative capacity within selected muscles can be measured non‐invasively using Near Infrared Spe... more Oxidative capacity within selected muscles can be measured non‐invasively using Near Infrared Spectroscopy (NIRS) by employing a series of transient arterial occlusion cuffs after a metabolic stimulus. Traditionally, this protocol involves voluntary contraction of a single limb followed by up to 22 transient ischemic occlusions per measurement. Our lab has adapted an established protocol 1 to develop a novel protocol that allows for an increased number of measurements using fewer (i.e. 6) ischemic occlusions combined with surface electrical stimulation (E‐stim) in both limbs simultaneously. However, reproducibility has not yet been established with this protocol.PURPOSETo determine the within‐day and between‐day reproducibility of this protocol in both the vastus lateralis and medial hamstring muscles.METHODSThe protocol involved 2 NIRS probes placed over the vastus lateralis (VL) muscles or the medial hamstring (MH) muscles in healthy adults to sense changes in muscle oxygenation. ...
Background Supervised exercise training is recommended for intermittent claudication in periphera... more Background Supervised exercise training is recommended for intermittent claudication in peripheral artery disease (PAD), but the relationship between work achieved during exercise and clinical outcomes is not well described. As in other training modalities, increased effort measured by cumulative work production is expected to be translate into to positive performance adaptations. In settings of constrained limb blood flow, this relationship is unknown. In addition, the impact of exercise on skeletal muscle oxygen use capacity changes is unknown. Near infrared spectroscopy (NIRS) offers a method of characterizing skeletal muscle mitochondrial adaptations before and after training programs. Methods We enrolled subjects (n=17, age 71±8.8 years, 20% female) with PAD and intermittent claudication (ankle brachial index [ABI]=0.76±0.21) in a 12-week supervised training program, randomized to traditional pain-based training strategy versus hypoxia-based training (using NIRS to direct train...
Background Symptoms of fatigue and pain are often reported for the trapezius muscle in the should... more Background Symptoms of fatigue and pain are often reported for the trapezius muscle in the shoulder. The present study evaluated endurance in the trapezius muscles of healthy participants using electric twitch mechanomyography (ETM). Methods Surface electrodes and a tri-axial accelerometer were placed over the left trapezius muscle. Muscles were stimulated for 3 min each at 2 Hz, 4 Hz and 6 Hz. Maintenance of acceleration during muscle twitches was used to calculate an endurance index (EI). Subjects (n = 9) were tested on two separate days to assess reproducibility of the trapezius EI measurements. The endurance measurements were made on the wrist flexor and vastus lateralis muscles for comparison. Near infrared spectroscopy was used to measure muscle oxygenation (HbO2) during the stimulation protocol (n = 8). Results Mean (SD) EI was 84.9% (8.7%), 63.3% (19.1%) and 41.7% (20.0%) for 2 Hz, 4 Hz and 6 Hz, respectively. The coefficients of variation were 7.4%, 11.3% and 24.0% for 2 Hz...
BACKGROUND Fatigue is a particularly debilitating symptom for people with multiple sclerosis (MS)... more BACKGROUND Fatigue is a particularly debilitating symptom for people with multiple sclerosis (MS). Although personality traits and MS have been studied, interoception and emotional susceptibility and their links to fatigue have not yet been explored. METHODS Study participants provided demographic information and completed standardized patient-reported outcomes of walking function, physical activity, subjective fatigue, interoceptive awareness, and emotional susceptibility. A subset of participants participated in semistructured interviews discussing fatigue, body sensations, emotions, and their effects on exercise. Quantitative data were analyzed using multiple regression. Qualitative data were analyzed using thematic analysis. RESULTS Mean ± SD Fatigue Severity Scale scores (5.0 ± 1.3) indicated that fatigue was a problematic symptom. Mean ± SD Multidimensional Assessment of Interoceptive Awareness, Version 2 (2.8 ± 0.6) and Emotional Susceptibility Scale (3.0 ± 1.0) scores indica...
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