Journal of Bodywork & Movement Therapies (2010) 14, 411e417 available at www.sciencedirect.com FASCIA PHYSIOLOGY Muscle fascia and force transmission Peter P. Purslow, PhD Department of Food Science, University of Guelph, Guelph, Ontario N1G 2W1, Canada Received 13 October 2009; received in revised form 3 January 2010; accepted 7 January 2010 KEYWORDS Muscle; Connective tissue; Extracellular matrix; Mechanical function; Myofascial force transmission; Endomysium; Perimysium; MMPs; ECM turnover Summary This paper reviews the major intramuscular extracellular matrix (IM-ECM) structures (endomysium, perimysium and epimysium) and their possible mechanical contributions to muscle functions. The endomysium appears to provide an efficient mechanism for transmission of contractile forces from adjacent muscle fibres within fascicles. This coordinates forces and deformations within the fascicle, protects damaged areas of fibres against over-extension, and provides a mechanism whereby myofibrils can be interrupted to add new sarcomeres during muscle growth without loss of contractile functionality of the whole column. Good experimental evidence shows that perimysium and epimysium are capable in some circumstances to act as pathways for myofascial force transmission. However, an alternative role for perimysium is reviewed, which involves the definition of slip planes between muscle fascicles which can slide past each other to allow large shear displacements due to shape changes in the whole muscle during contraction. As IM-ECM is continually remodelled so as to be mechanically adapted for its roles in developing and growing muscles, control of the processes governing IM-ECM turnover and repair may be an important avenue to explore in the reduction of fibrosis following muscle injury. ª 2010 Elsevier Ltd. All rights reserved. Introduction The soft connective tissues associated with muscle tissue have been referred to as the intramuscular extracellular matrix (IM-ECM), intramuscular connective tissue (IMCT) and muscle fasciae (MF). Although these general names can be used interchangeably, the term IM-ECM will be used here. Substantial reviews of the structure, development, composition and function of IM-ECM exist (Purslow and Duance, 1990; Purslow 2002, 2008). The mechanisms and pathways by which IM-ECM is remodelled and adapted due to changing functional demands during muscle growth and repair, and in response to exercise training or disuse, are addressed by Kjær and Magnusson (2008). Like most other soft connective tissue structures, the amount and composition of IM-ECM structures are not simply programmed during embryogenesis and subsequent post-natal maturation processes. The amounts and composition of the various IM-ECM structures in living tissue represent a dynamic balance between deposition, growth, remodelling and degradation, which is affected by the interplay between E-mail address: ppurslow@uoguelph.ca 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.01.005 PREVENTION & REHABILITATIONdFASCIA PHYSIOLOGY journal homepage: www.elsevier.com/jbmt 412 P.P. Purslow PREVENTION & REHABILITATION dFASCIA PHYSIOLOGY functional demands on the tissue and the mechanical environment. The cellular mechanisms of mechanotransduction in fibroblasts are reviewed by Chiquet et al. (2009). The purpose of the current review is to highlight information pointing to the crucial roles of IM-ECM in force transmission and accommodation of shape changes in functioning muscle. General structure and biochemical composition of IM-ECM As schematically shown in Fig. 1, each muscle is surrounded by epimysium, a connective tissue layer that is continuous with the tendons that attach the muscles to the bones. In some long strap-like muscles the epimysium is composed of two parallel sets of wavy collagen fibres in a crossed-ply arrangement, embedded in a proteoglycan matrix (see Fig. 2). When the muscle is at its resting length, the two sets of collagen fibres are arranged at angles of approximately 55 to the long axis of the muscle fibres. In other muscles, and especially in pennate muscles, the arrangement of collagen fibres in the epimysium is parallel to the long axis of the muscle and forms a dense surface layer that functions as a surface tendon. The perimysium is a continuous network of connective tissue which divides the muscle up into fascicles or muscle fibre bundles. Fascicles run along the length of the muscle from tendon to tendon, and the ends of muscle fibres form highly folded interdigitating joints (the myotendinous junction) with the tendon at this point (Trotter, 1993). The perimysial network merges into the epimysium at the surface of the muscle and is mechanically connected to it. Within each fascicle or muscle fibre bundle, the endomysium is a continuous network of connective tissue that separates individual muscle fibres. Each of the epimysium, perimysium, and endomysium layers has its own structure and composition, but generally these connective tissue layers are composed of collagen fibres in an amorphous matrix of hydrated proteoglycans (PGs) which plays a crucial role in mechanically linking Fig. 1 Schematic diagram of IM-ECM structures in a skeletal muscle. Epimysium delineates the surface of the muscle, perimysium separates muscle fascicles and endomysium separates individual muscle fibres. Also depicted are the contractile myofibrils within each muscle fibre. (Artwork: Dr. L.-T. Lim). Fig. 2 Light micrograph of epimysium from bovine sternomandibularis muscle, showing arrangement of collagen fibres in crossed-plies. The fibres are in two parallel layers lying at þ55 and 55 to the muscle fibre axis. From Purslow (1999), with permission. In epimysium from other muscles the collagen is more aligned with the muscle fibre direction and acts as an exo-tendon or aponeurosis. together the collagen fibre networks in these structures (Scott, 1990). Listrat et al. (1999, 2000) show that collagen types I, III, IV, V, VI, XII and XIV are all expressed in muscle development. Collagen typically represents 1e10% of the dry weight of adult skeletal muscle (Bendall, 1967). Fibres of elastin can be found in the IM-ECM of some muscles, principally in the perimysium. However, the amount of elastin is small in most muscles and is typically less than 1% of muscle dry weight (Bendall, 1967). Collagen fibres are stabilised by the formation of covalent crosslinks directed by a clear set of post-translational modifications which act on the collagen molecules extracellularly after assembly of the collagen molecules into the quarter-stagger overlapped arrangement characteristic of fibrils (Bruns and Gross, 1973). The formation of crosslinks is essential for the mechanical strength and stiffness of collagen fibres (Bailey et al., 1998). During gestation and post-natal maturation there are changes in the types and amounts of covalent crosslinks that stabilise the collagen molecules within all connective tissues in the body, including IM-ECM. There are also non-enzymatic reactions of collagen with glucose and other aldehydes. Formation of additional crosslinks through advanced glycation end products (AGEs) is typical of the changes in connective tissues in diabetes and during ageing and glycation, and is thought to be a significant contributor to changes in the mechanical properties of connective tissues with age (Paul and Bailey, 1996). Advanced glycation end products can be incorporated into the body from dietary sources (e.g. heat processing of some foods creates AGEs) and from tobacco smoke (Avery and Bailey, 2008). In this way, diet and lifestyle may affect the mechanical properties of IM-ECM via AGE-cross-linking of collagens. IM-ECM changes during muscle development During embryonic development of intramuscular connective tissue, the amounts of the various collagens and PGs changes (Velleman et al., 1999; Listrat et al., 1999; Lawson and Purslow, 2001). Spatial variations between the endomysium and perimysium within one muscle (Nishimura et al., 1997) and differences in expression of both collagen type I and PG components such as laminin between muscles (Lawson and Purslow, 2001) are both determined early in prenatal development. In bovine muscles, type I collagen expression is always higher than type III expression at all stages of gestation and post-natally (Listrat et al., 1999). Thus some differences in the composition of intramuscular connective tissue appear to be pre-programmed in embryogenesis. However, there are some variations in the amounts of collagens as muscle development progresses. In bovine psoas and triceps muscles the total collagen concentration and amounts of collagen type I is maximum at the point in gestation when the expression of myosin within muscle fibres changes from the embryonic to the adult form (Listrat et al., 1999). After this, the growing diameter of the muscle fibres dilutes out the connective tissue content of the muscle. In contrast, the pectoralis and quadriceps muscles of the chick show steady increases in collagen type I content and laminin content through gestation and post-natally (Lawson and Purslow, 2001). Whether these differences between bovine and chick muscle growth are due to avian versus mammalian phyla differences or due to functional differences in the muscles studied remains unclear. The amounts and composition of endomysium and perimysium vary between functionally different muscles In fully developed adult animals, there are large differences in the amounts and composition of IM-ECM between different muscles in the body. Histological comparison (see Fig. 4 in Purslow, 2005) illustrates that the continuous perimysial network surrounds or separates fascicles of radically different sizes and shapes in different muscles from the same animal. This difference also results in different thicknesses of perimysial connective tissue. A comparison of the connective tissue content of 14 bovine muscles shows that the endomysial collagen content is between 0.47% and 1.2% of dry weight, but the perimysial collagen content in the same muscles ranges from 0.43% up to 4.6% of dry weight (Purslow, 1999). The amount of perimysium in muscles varies far more than the amount of endomysium. These variations, especially in the amount and spatial organisation of the perimysium have long been taken to show that IM-ECM must play strong roles in the normal physiological functioning of each muscle. As reviewed in the following two sections, some possible explanations of these roles are emerging but are far from complete. Structure and functional roles of the endomysium As reviewed by Purslow and Duance (1990), each muscle cell is surrounded by its own plasmalemma and basement membrane. Filling the intervening region between the basement membranes of two adjacent muscle cells is the much more substantial reticular layer, which is comprised 413 of a network of collagen fibrils and fibres in a proteoglycan matrix. The thickness of the endomysium as a whole varies with muscle length, becoming thicker at short muscle lengths and thinner as the muscle is extended (see Trotter and Purslow, 1992). Transmission electron micrography of intact endomysium in situ confirms that all of the collagen fibres in the network layer lie in the plane of the layer (Trotter and Purslow, 1992). The only location where this does not hold true is in the junction zones between the perimysium and the endomysium of muscle cells that lie in the surface of the fascicle. Swatland (1975) concluded that the reticular layer was a single structure shared between adjacent muscle cells, and that this endomysial structure forms a continuous network that runs across the whole muscle fascicle. This interpretation is very strongly borne out by scanning electron microscopy of endomysial collagen networks prepared by NaOH-extraction of muscle to remove all cell components, PGs, plasmalemma, and basement membrane structures (Trotter and Purslow, 1992; Purslow and Trotter, 1994; Nishimura et al., 1994, 1995; Liu et al., 1995). This preparation technique was first demonstrated on connective tissues generally by Ohtani et al. (1988). Fig. 3 (from Purslow and Trotter, 1994) shows such a preparation. The structure of the endomysium appears broadly identical in all SEM preparations from skeletal muscle from different muscles and species, and also in cardiac muscle (Purslow, 2008). The planar network of collagen fibres in the thick reticular region of the endomysium is often described as a random or quasi-random network of irregularly wavy fibres. These collagen fibres run at almost every angle to the muscle fibre long axis, but the network is not truly random. Detailed image analysis of the distribution of fibre directions with respect to the long axis of adjacent muscle cells reveals that there is a preferred direction in the wide distribution of collagen fibre orientations, and that this preferred orientation changes with muscle length (Purslow and Trotter, 1994). At short muscle lengths, more of the collagen fibres in the endomysial network are aligned circumferentially, and at long muscle lengths there is a higher preference for fibres to be aligned longitudinally. The reorientation of collagen fibres in this network at short and long muscle lengths also involves some stretching out of the wavy fibres, but at all sarcomere lengths a very large proportion of the collagen fibres are still wavy. The mechanical consequence of this is that the planar network will be very compliant in tension at all physiologically relevant muscle lengths, and can easily deform to follow changing muscle lengths in vivo. Although this behaviour potentially provides overload protection at high deformations, such protection will only occur at muscle lengths well above those experienced in normal function. These implications are confirmed by detailed modelling of the in-plane tensile properties of the endomysium (Purslow and Trotter, 1994). Their models of the tensile properties of the endomysial network are in agreement with experimental forcelength measurements by Podolsky (1964) and Magid and Law (1985) who compared the tensile properties of relaxed single muscle fibres with and without endomysium. The difference that the removal of the endomysium makes to PREVENTION & REHABILITATIONdFASCIA PHYSIOLOGY Muscle fascia and force transmission PREVENTION & REHABILITATION dFASCIA PHYSIOLOGY 414 Fig. 3 Scanning electron micrographs of the collagen fibre scaffolding in IM-ECM structures in bovine sternomandibularis muscle as revealed by NaOH-digestion of myofibrils, cytoskeletal proteins, cell membranes, and proteoglycans. Upper panel; low-magnification view, showing thicker perimysial sheets surrounding fascicles. Lower panel; high-magnification oblique view, showing endomysial networks. From Purslow and Trotter (1994) with permission. the passive elasticity of single fibres is very small at physiologically relevant sarcomere lengths, showing that the endomysium is extremely compliant in tension along the muscle fibre direction over normal working muscle lengths in vivo. Many muscles in species from many phyla contain muscle fibres that do not run along the entire length of fascicles, but terminate before reaching the myotendinous junction (Gans and Gaunt, 1991; Trotter, 1993; Trotter et al., 1995). Muscle fibres in series-fibred muscles are relatively short compared to the length of the fascicle except in humans, which appear to have relatively longer fibres in their seriesfibred muscles. Although some intrafascicularly terminating muscle fibres do seem to have attachments to connective tissue P.P. Purslow bands internal to the muscle and occasionally have myomuscular junctions where two muscle fibres have interdigitating folded joints between them, the most common termination is a gentle tapering down to an end. These tapering fibres have no terminating structure that would link them directly to another muscle fibre or to the tendon (Trotter, 1993). The fibres are staggered by about one quarter of their length with respect to the adjacent muscle fibres, so that the tapering end of one fibre terminates with the endomysial network surrounding it forming a seamless connection to the endomysium of its neighbours (Purslow and Trotter, 1994). The endomysium is the only structure that links muscle fibres together within fascicles. In seriesfibred muscles, transmission of tension generated in intrafascicularly terminating fibres to the ends of the fascicles absolutely necessitates transmission of force through the endomysial network, as this is the only structure continuously linking the fibres (Trotter et al., 1995). Trotter and Purslow (1992) show that the endomysium is compliant in tension, so that force transmission is unlikely by this means, but they also suggest that force transmission is by shear through its thickness. The key idea is that the endomysium, while very compliant to tensile forces acting within the plane of the network, is much more efficient in providing a non-compliant linkage by shear through its thickness. A formal derivation from fibre composites theory shows that, for practical purposes, the stiffness of the endomysium in shear through its thickness varies only slightly with the orientation of the collagen fibrils in the plane of the endomysium (Purslow, 2002). Any linkage that transmits forces from intrafascicularly terminating muscle fibres to tendinous attachments must be non-compliant (i.e. high stiffness) in order to be efficient. Especially in isometric muscle contractions, any significant stretching in the length of the fascicle due to stretchy connections would result in a very poor transmission of contractile force. The serieselastic nature of this shear linkage can be represented as an apparent longitudinal stiffness Eapp (Purslow, 2002) given by . 2 Eapp ZG L T ð1Þ where G is the translaminar shear modulus of the endomysium, T is its thickness and L the muscle fibre length. Even if we take a fibre as short as 1 cm in length, L/T is in the order of 2000, so that Eapp is going to be in the order of 4 106 greater than the true translaminar shear modulus of the endomysium. In a ‘‘composite’’ consisting of two parallel muscle cells with the endomysium sandwiched between them, the apparent longitudinal stiffness of endomysium as it deforms in shear will still be orders of magnitude higher than the tensile stiffness of the muscle fibres themselves. Due to this high value of Eapp the longitudinal stiffness of the entire assembly is going to be dominated by stretching in the muscle fibres themselves rather than in the linking endomysium. This shear linkage through the thickness of the endomysium provides a force transduction pathway from one muscle cell to its neighbours which is highly efficient. However, the endomysium can deform easily in the plane of the network, due to its low tensile stiffness, and so does not restrict changes in muscle fibre length and diameter as muscles contract and relax. Lateral load sharing through the endomysium is an important concept that also explains how it is possible for muscles to grow and to repair damaged sarcomeres. Lateral load sharing and coordination of deformations means that a fibre can be interrupted for the addition of new sarcomeres necessary for muscle lengthening during growth, without loss of function of an entire contractile column. By the same mechanism, the contractile capacity of the weakness of a sarcomere in which damaged myofibrils are being broken down and remodelled during muscle repair does not lead to tearing of the fibre at this point, as the endomysial connections between adjacent fibres serve to keep the strains uniform throughout the tissue. In submaximal contractions not all the motor units in the muscle are recruited, so that many non-contracting fibres are usually adjacent to contracting fibres. Coordination by shear linkages through the endomysium explains how sarcomere lengths in non-contacting fibres keep in register with those in adjacent, contracting fibres. This maintains uniform sarcomere lengths in the muscle. The continuous meshwork of endomysium that connects adjacent muscle fibres together, therefore, forms a connecting matrix that coordinates force transmission between fibres in a fascicle and keeps fibres in uniform register (Purslow, 2008). Functional anatomy of the perimysium Two sizes of fascicles and, therefore, two levels of perimysial structure can be distinguished in cross-sections of muscle. Small (primary) fascicles or muscle fibre bundles are delineated by primary perimysium. Groups of primary fascicles are then organised into larger, secondary fascicles by secondary perimysium, which tends to be thicker than primary perimysium. In porcine semitendinosus muscle, the thicker secondary perimysium is in the order of 10 mm thick at birth and increases to approach 50 mm in 55 month old pigs (Fang et al., 1999). The thickness of primary perimysium in cattle muscles ranges from 54.6 m to 133 mm (Brooks and Savell, 2004). Both of these perimysial layers form a fenestrated network that extends across the entire cross-section of the whole muscle. The perimysium does not form a distinct sheath that surrounds one fascicle, but rather is a shared structure lying between two fascicles (Purslow and Trotter, 1994). Nodes form at the junction between perimysial sheets and the fascicles occupy polygonal ‘‘holes’’ in this network, in a manner similar to muscle fibres occupying polygonal ‘‘holes’’ in the endomysial network (but at a larger scale). At the surface of the muscle the perimysium merges and seamlessly joins with the epimysium (Nishimura et al., 1994). The perimysial layer separating two fascicles is primarily comprised of crossed-plies of wavy collagen fibres in a proteoglycan matrix. In a few muscles (e.g. bovine semitendinosus) there are substantial amounts of elastin fibres associated with the collagenous network (Rowe, 1981). The collagen fibre bundles are far larger in diameter than the fine fibres and fibrils in the endomysium and have a regular sinusoidal waviness, with all collagen fibre bundles lying parallel to each other in each ply, and having the same wave periodicity. In porcine semitendinosus muscle the degree of waviness has been observed to increase with animal age 415 (Fang et al., 1999). The collagen fibres lie in the plane of the perimysium, do not run through its thickness, and all the collagen fibres in each ‘‘ply’’ are parallel to each other and lie at 55 to the muscle fibre axis at the resting length of the muscle. This angle changes with muscle length, varying from around 80 at an extremely short sarcomere length of 1.1 mm to approximately 20 at a long sarcomere length of 3.9 mm (Purslow, 1989). Mathematical modelling of the tensile properties in the plane of this network using fibrous composites theory (Purslow, 1989), and direct measurements of the tensile strength and stiffness of perimysial sheets dissected from muscle (Lewis and Purslow, 1989; Purslow, 1999), show that the perimysium is easily deformed in tension until the collagen fibres have become aligned along the stretching direction and the waviness in the fibres pulled out straight. This shows that the perimysium can build up a high tensile stiffness and carry large loads in tension, but only at very large extensions well beyond the range of working lengths in living muscle. The tensile properties of the perimysium are, therefore, similar is nature to the endomysium. Both are initially easily deformed networks that can follow length and diameter changes imposed by the muscle fibres and fascicles contracting and being lengthened by the action of antagonistic muscles. It is tempting to extend the analogy between endomysium and perimysium by proposing that the perimysium could also act to transmit the forces generated in fascicles to their adjacent neighbours by translaminar shear. Although it can be shown that force transmission by such a mechanism can be invoked in circumstances of extreme muscle damage or by cutting the tendinous attachments to some fascicles (Huijing, 2009), there are two considerations that we can raise that diminish the likelihood of this mechanism being involved in living muscle, at least under normal working conditions. Firstly, considering again that the series-elastic nature of a shear linkage can be represented as an apparent longitudinal stiffness Eapp and that Eapp given by Eq. (1) above then even if the perimysium can be up to 50 times thicker than endomysium, the (L/T )2 term in this equation could be up to 2500 times smaller for the same length of perimysium than for the endomysium. If the translaminar shear modulus of the perimysium and endomysium would even be within an order of magnitude of each other, this means that thicker perimysium would have a far smaller Eapp, i.e., it would be far more compliant in shear than the endomysium. This would represent a rather sloppy and inefficient force transmission pathway. The second consideration revolves around the observation that the amounts and structure of endomysium are relatively constant and only slightly vary between different muscles, whereas the amounts of perimysium, its thickness, and the size and shape of primary and secondary muscle fascicles vary tremendously. The endomysial structures providing tight shear linkages between adjacent muscle fibres are reasonably conservative and do not vary so much from muscle to muscle. So, if the perimysial network functions similarly, why should its amounts and spatial arrangement vary so much more? Schmalbruch (1985) cites a model originally proposed by Feneis which proposes that the perimysium provides ‘neutral’ connections between adjacent fascicles. These PREVENTION & REHABILITATIONdFASCIA PHYSIOLOGY Muscle fascia and force transmission PREVENTION & REHABILITATION dFASCIA PHYSIOLOGY 416 connections permit fascicles to slide past each other, and also facilitate shape changes in the muscle during contraction. All fan-shaped, fusiform, and especially pennate muscles change shape when contracting, and in order to accommodate this there must be slippage, or sliding, of some elements within the muscle (i.e. shear deformations). For pennate muscles it is easy to formally calculate the shear strains within the muscles as they contract and the pennation angles change. In ultrasonic images of human muscles, ‘‘boundaries’’ between fascicles can be seen, and measurement of changes in the angle of these during contraction allows shear strains to be predicted. Shear strains within working human muscles are substantial and vary considerably between human muscles such as quadriceps, vastus lateralis and gastrocnemius (Purslow, 2002). If the endomysium maintains adjacent muscle fibres in tight shear register, then where can these large and variable shear strains be accommodated? Simple observations on rigor muscle that is manipulated to produce internal shear show that deformations preferentially occur at the boundaries between fascicles, and that very little shear displacements occur within a fascicle (Purslow, 1999). If the theory that the division of muscle into fascicles is to facilitate shear deformations that are necessary for contracting muscle to change shape is correct, then it seems to offer an explanation of why the amount and distribution of perimysium changes so very markedly from muscle to muscle. Thin perimysia surrounding small fascicles in long strap-like muscles may be associated with relatively small shear displacements, whereas thicker perimysial sheets and larger primary fascicles may relate to larger shear displacements. However, comprehensive data on the relationship between perimysial thickness, fascicle size, and the actual distributions of shear strains in working muscles need to be collected to test this theory. Control of turnover of IM-ECM as a possible treatment in muscle injury and repair of fibrosis Muscle growth, turnover, and repair necessitate remodelling of IM-ECM, principally under the control of matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs (TIMPs). MMPs are expressed by muscle cells as well as by fibroblasts in the IM-ECM (Balcerzak et al., 2001). Adaptation of muscle, including muscle hypertrophy following exercise training is known to involve increased expression of a range of MMPs (Kjaer, 2004). Expression of MMPs is stimulated by mechanical forces, hormones, and growth factors as well as nutritional components. Myoblasts express almost as much MMP and total collagenase activity as fibroblasts in cell culture and tend to increase this expression more strongly than fibroblasts when mechanically stimulated by biaxial stretching (Cha and Purslow, unpublished data). Numerically, muscle cells vastly outnumber fibroblasts within normal muscle tissue. Epinephrine (adrenaline) is a general agonist of all types of adrenergic receptors, and in muscle principally acts to increase glycolysis via a signalling pathway involving AMP-activated protein kinase (Shen and Du, 2005). There is also adrenergic control of protein metabolism in skeletal muscle. Epinephrine acts to increase calpastatin levels, so reducing protein turnover by calpains and resulting in net muscle accretion (Navegantes P.P. Purslow et al., 2009). Beta-adrenergic agonists (e.g. clenbuterol, ractopamine, cimaterol, salbutamol) mimic this effect and chronic administration of these growth promoters leads to muscle hypertrophy or amelioration of muscle wasting (Navegantes et al., 2002). Although some reports associate the effect of catecholamines on protein metabolism with c-AMP dependent kinase, Yamaguchi et al. (1997) showed that the p38 MAPK pathway can be activated by beta-adrenergic receptors in kidney cells. Expression of MMPs 1 and 13 is activated by the p38 MAPK pathway in keratinocytes (Johansson et al., 2000). Recent work in our laboratory (Cha and Purslow, unpublished data) shows that both skeletal muscle fibroblasts and myoblasts increase MMP expression in the presence of epinephrine, but with different time-courses and degrees of correlation with expression of AMP-activated protein kinase. Cardiac muscle is obviously different from striated muscle functionally and structurally, yet there are striking similarities about the organisation and function of ECM structures between the two muscle types (Purslow, 2008). A change in the balance between synthesis and degradation of ECM in the myocardium is a characteristic of many types of heart failure, including hypertensive heart failure and infarction/ ischemia (Berk et al., 2007; Graham et al., 2008). Banfi et al. (2005) reported increased plasma levels of MMPs 2&9 in patients with chronic heart failure and also a significant correlation between norepinephrine and MMP2 levels. Cardiac fibroblasts are known to react to both mechanical stimuli and catecholamines in terms of both proliferation and expression (Villareal and Kim, 1997), and cardiomyocytes from chick embryos are known to react to stimulation of the alpha-adrenergic receptor via noradrenaline by activation of p38 MAPK (Tsang and Rabkin, 2009). 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