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The superimposed tetanic twitch technique has been employed to demonstrate a failure in voluntary neural drive This technique involves superimposing brief tetani on an isometric contraction and examining the possible increase in force produced (ie, the increase above maximal voluntary force production) This provides an indication of voluntary drive and results from studies employing this technique have demonstrated a decline in motor unit discharge during sustained or intermittent maximal voluntary contractions (MVCs; Lloyd et al 1991; Thomas et al 1989) and hence the development of central fatigue Transcranial stimulation of the motor cortex during isometric MVCs may also result in the addition of progressively more force above that generated voluntarily, again demonstrating central fatigue during isometric activity (Gandevia 2001).

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Gandevia (2001) suggests that the decline in motor unit discharge during fatigue is accompanied by changes in muscle spindles, Golgi tendon organs, small diameter muscle afferents, motoneurons, and Renshaw cells This may result in reduced spinal re ex facilitation and increase inhibition to corticospinal cells (Fig 29a,b) Changes in intramuscular receptors produce competing excitatory and inhibitory in uences on the motoneuron pool that may in uence this declining discharge rate Group III and IV muscle afferents may also reduce voluntary drive through a supraspinal action Drive to the corticospinal cells is increased during fatigue, which results in the recruitment of additional muscles The failure of supraspinal drive to the motoneurons may act to protect the muscle and neuromuscular junction against continued fatigue (Gandevia 2001) Recent research involving motor cortical stimulation has examined the degree of central nervous system activation on muscles at differing levels of fatigue (Todd et al.

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2003) Using a novel technique involving stimulation of the brachial plexus, stimulation of the biceps brachii/brachialis intramuscular nerve bers, and transcranial magnetic stimulation of the motor cortex, the authors were able to demonstrate both peripheral and central fatigue When maximal voluntary force produced by the elbow exors dropped to 40% of prefatigued values, resting twitch evoked by motor nerve stimulation.

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If the clinician suspects that the fatigue and underperformance is physiological in origin, the appropriate management is employed and may include training/rest interventions, further specialized determination and manipulation of training/rest ratios, and, if indicated, dietary and psychological support Ongoing reassessment and monitoring of the athlete by the multidisciplinary team is essential Further special investigations should be conducted if: (i) the athlete does not respond to rest, dietary or psychological intervention; (ii) the cause of the chronic fatigue is not directly apparent; or (iii) there are abnormalities of the baseline investigations These expanded investigations could include a full blood and differential count, serum electrolyte determination (including sodium, potassium, magnesium, and chloride), liver function tests, thyroid function tests, viral serology studies, serum creatinine kinase concentration, and a glucose tolerance test.

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