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Effects of Testosterone and Evoked Resistance Exercise After Spinal Open Access Protocol Effects of Testosterone and Evoked BMJ Open: first published as 10.1136/bmjopen-2016-014125 on 4 April 2017. Downloaded from Resistance Exercise after Spinal Cord Injury (TEREX-SCI): study protocol for a randomised controlled trial Ashraf S Gorgey,1,2 Refka E Khalil,1 Ranjodh Gill,3,4 Laura C O’Brien,1 Timothy Lavis,1,2 Teodoro Castillo,1 David X Cifu,1,2 Jeannie Savas,5 Rehan Khan,6 Christopher Cardozo,7,8 Edward J Lesnefsky,9,10 David R Gater,11 Robert A Adler3,4 To cite: Gorgey AS, ABSTRACT et al Strengths and limitations of this study Khalil RE, Gill R, . Effects Introduction: Individuals with spinal cord injury (SCI) of Testosterone and Evoked are at a lifelong risk of obesity and chronic metabolic ▪ Resistance Exercise after The trial will investigate the use of surface neuro- disorders including insulin resistance and Spinal Cord Injury (TEREX- muscular electrical stimulation-induced resist- SCI): study protocol for a dyslipidemia. Within a few weeks of injury, there is a ance training (NMES-RT) to restore muscle size randomised controlled trial. significant decline in whole body fat-free mass, after spinal cord injury (SCI). BMJ Open 2017;7:e014125. particularly lower extremity skeletal muscle mass, and ▪ The trial will provide evidence on the effective- doi:10.1136/bmjopen-2016- subsequent increase in fat mass (FM). This is ness of testosterone replacement therapy (TRT) 014125 accompanied by a decrease in anabolic hormones to restore muscle size and lean mass and serve including testosterone. Testosterone replacement as an alternative approach for those who cannot ▸ Prepublication history for therapy (TRT) has been shown to increase skeletal benefit from NMES. this paper is available online. muscle mass and improve metabolic profile. ▪ The trial will determine how restoring muscle To view these files please Additionally, resistance training (RT) has been shown size and lean mass by RT+TRT or TRT can visit the journal online to increase lean mass and reduce metabolic benefit the metabolic profile after SCI. (http://dx.doi.org/10.1136/ disturbances in SCI and other clinical populations. ▪ The study is only limited to men with complete bmjopen-2016-014125). Methods and analysis: 26 individuals with chronic, SCI. http://bmjopen.bmj.com/ motor complete SCI between 18 and 50 years old were ▪ Received 6 September 2016 Surface NMES may not benefit those with full Revised 17 January 2017 randomly assigned to a RT+TRT group (n=13) or a sensation or lower motor neuron denervation. Accepted 16 February 2017 TRT group (n=13). 22 participants completed the initial 16-week training phase of the study and 4 participants withdrew. 12 participants of the 22 completed 16 weeks of detraining. The TRT was provided via INTRODUCTION transdermal testosterone patches (4–6 mg/day). The There are ∼11 000–12 000 new cases of RT+TRT group had 16 weeks of supervised unilateral spinal cord injury (SCI) in the USA annually progressive RT using surface neuromuscular electrical with an overall prevalence of 250 000–400 on October 1, 2021 by guest. Protected copyright. stimulation with ankle weights. This study will 000.12Persons with motor complete injury investigate the effects of evoked RT+TRT or TRT alone have loss of sensation and motor function on body composition (muscle cross-sectional area, below the level of injury, while incomplete visceral adipose tissue, %FM) and metabolic profile injury is characterised by preserved motor or (glucose and lipid metabolism) in individuals with sensory function. Chronic SCI, defined as motor complete SCI. Findings from this study may 1 year postinjury, is associated with dramatic help in designing exercise therapies to alleviate the 3–5 deterioration in body composition after SCI and skeletal muscle atrophy, increase of fat 6–8 decrease the incidence of metabolic disorders in this mass (FM) and decrease of fat-free mass 67 clinical population. (FFM). Collectively, these factors put indi- Ethics and dissemination: The study is currently viduals with SCI at risk for metabolic disor- approved by the McGuire VA Medical Center and ders such as type II diabetes and For numbered affiliations see Virginia Commonwealth University. All participants read cardiovascular disease. end of article. and signed approved consent forms. Results will be Previous studies reveal that 60% of indivi- submitted to peer-reviewed journals and presented at duals with SCI in the USA are either over- – Correspondence to national and international conferences. weight or obese.2911 Despite a low body Dr Ashraf S Gorgey; Trial registration number: Pre-result, mass index (BMI) in 50% of the SCI popula- [email protected] NCT01652040. tion, individuals are likely to have more than Gorgey AS, et al. BMJ Open 2017;7:e014125. doi:10.1136/bmjopen-2016-014125 1 Open Access 30% of their body mass as FM. Furthermore, person decreased energy production and therefore play a signifi- BMJ Open: first published as 10.1136/bmjopen-2016-014125 on 4 April 2017. Downloaded from with SCI are 13% fatter per unit BMI than able-bodied cant role in the altered metabolic profile following SCI.44 individuals. Individuals with SCI also have a redistribu- Body composition and metabolic changes after SCI tion of adipose tissue, with greater trunk FM and visceral may be further exacerbated by reduced anabolic hor- adipose tissue (VAT) compared to age and waist circum- mones including testosterone (T), growth hormone and – ference matched able-bodied controls.12 14 Adipose the growth hormone second messenger insulin-like tissue, particularly VAT, secretes proinflammatory cyto- growth factor-1 (IGF-1).45 46 Previous studies have shown kines including interleukin-6 (IL-6) and tumour-necrosis that 60% of men with SCI have low T and that testoster- factor-α (TNF-α). Therefore, the increase in VAT after one replacement therapy (TRT) increases IGF-1 in – SCI may contribute to metabolic syndrome by stimulat- men.47 50 In rodent models of SCI, TRT attenuates the ing the hepatic production of C reactive protein (CRP), loss of muscle.51 52 TRT decreases total body fat, – which is tied to vascular inflammation.15 18 Another type increases lean mass53 54 and increases the number of of ectopic adipose tissue, intramuscular fat (IMF), is proliferating skeletal muscle satellite cells in men.55 increased after SCI and has been correlated with These findings suggest that TRT may provide metabolic reduced insulin sensitivity.19 20 benefits to individuals with SCI. Metabolic changes also accompany SCI, with previous Resistance training (RT) improves insulin sensitivity studies finding that more than 50% of individuals with and increases fatty acid and carbohydrate metabolism, as SCI are glucose intolerant, while one of five is dia- well as attenuates sarcopenia in the elderly and after – – betic.2911 21 Other studies report that 55% of indivi- SCI.56 63 Moreover, RT has been shown to influence duals with SCI are at risk of developing metabolic body composition by increasing lean mass, decreasing – syndrome.21 23 Individuals with complete tetraplegia are FM and reducing VAT, suggesting that the benefits of RT more likely to experience decreased glucose and carbo- could overcome the risk of developing insulin resist- – hydrate tolerance and have a higher prevalence of heart ance.56 59 Functional electrical stimulation (FES) has disease than those with incomplete injuries.24 25 been shown to improve fatty acid kinetics, carbohydrate – Likewise, depressed HDL-C (<35 mg/dL) and a higher metabolism and vascular health after SCI.60 63 total cholesterol/HDL-C ratio, predictors of coronary Electrically evoked RT using neuromuscular electrical heart disease, were noted in those with chronic SCI com- stimulation (NMES-RT) and ankle weights is another pared with able-bodied controls.24 26 These are not uni- form that has been shown to be effective in inducing versal findings, however, as a systematic review of muscle hypertrophy in individuals with chronic SCI.59 64 carbohydrate and lipid disorders in persons with SCI did One study showed a 40% increase in skeletal muscle size not find strong evidence of increased risk beyond that of and improved glucose tolerance after 12 weeks of train- the general population.27 ing.59 Another study showed that following 12 weeks of While previous studies have shown a link between NMES-RT, whole thigh, knee extensor and flexor cross- http://bmjopen.bmj.com/ body composition and metabolic profile after SCI, the sectional areas (CSAs) increased by 28%, 35% and 16%, cellular mechanisms remain unknown. Mitochondria respectively. Moreover, the ratio of leg FFM to whole are the site of oxygen consumption and energy produc- body FFM increased by 20% following intervention. tion from glucose and lipid metabolism. Unfortunately, There was 32% decrease in glucose area under the mitochondrial function is impaired in a number of dis- curve adjusted to muscle CSA following 12 weeks of eases including neurodegenerative disease, atheroscler- NMES-RT. However, there were only modest effects on – osis, hypertension and cancer.28 31 Fewer and smaller whole body composition, as well as a non-significant mitochondria are found in skeletal muscle of insulin decrease in VAT.64 It is possible that the limited effects on October 1, 2021 by guest. Protected copyright. resistant, obese and type II diabetic individuals.32 of NMES-RT on parameters of body composition and Previous studies found decreased muscle oxidative cap- VAT can be possibly explained by depressed T-level in acity and succinate dehydrogenase activity, complex II of persons with SCI. Supplementing exogenous T may opti- – the electron transport chain, after SCI.33 35 mise the outcomes of NMES-RT on parameters of body One hypothesis is that skeletal muscle mitochondrial composition and metabolic profile such as increased function is decreased in metabolic disorders, leading to basal metabolic rate (BMR).
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