A secondary analysis of testosterone and electrically evoked resistance training versus testosterone only (TEREX-SCI) on untrained muscles after spinal cord injury: a pilot randomized clinical trial

Musculoskeletal and body composition response to high-dose testosterone with finasteride after chronic incomplete spinal cord injury-a randomized, double-blind, and placebo-controlled pilot study

Background

High-dose testosterone replacement therapy (TRT), paired with finasteride (type II 5α-reductase inhibitor), improves body composition, muscle strength, and bone mineral density (BMD) in older men, without inducing prostate enlargement-a side effect associated with TRT. Men with spinal cord injury (SCI) exhibit neuromuscular impairment, muscle atrophy, bone loss, and increased central adiposity, along with low testosterone. However, sparse evidence supports TRT efficacy after SCI.

Methods

This parallel-group, double-blind, placebo-controlled, and randomized clinical trial (RCT) is a pilot study that enrolled men (N = 12) with low to low-normal testosterone and gait impairments after chronic motor-incomplete SCI. Participants received high-dose intramuscular TRT (testosterone-enanthate, 125 mg/week) with finasteride (5 mg/day) vs. vehicle+placebo for 12 months. Change relative to baseline was determined for body composition, musculoskeletal outcomes, and prostate size, with effect sizes calculated between groups using Hedges' g. Adverse events and feasibility were assessed.

Results

TRT + finasteride consistently increased testosterone (g = 1.16-3.08) and estradiol (g = 0.43-3.48), while concomitantly reducing dihydrotestosterone (g = 0.31-2.27). Very large effect sizes at both 6 and 12 months suggest TRT + finasteride increased whole-body fat-free (lean) mass (+3-4% vs. baseline, g = 2.12-2.14) and knee extensor (KE) whole-muscle cross-sectional area (+8-11% vs. baseline, g = 2.06-2.53) more than vehicle+placebo. Moderate-to-large effect sizes suggest TRT + finasteride increased KE maximal voluntary isometric torque (+15-40% vs. baseline, g = 0.47-1.01) and femoral neck and distal femur BMD from 6 months onward (g = 0.51-1.13), compared with vehicle+placebo, and reduced fat mass 9-14% within the whole-body, trunk, and android (visceral) regions at 12 months (g = 0.77-1.27). TRT + finasteride also produced small effect sizes favoring lesser prostate growth than vehicle+placebo (g = 0.31-0.43). The participant retention, drug compliance, and incidence and severity of adverse events were similar among the groups.

Conclusion

These data provide proof-of-concept and rationale for larger RCTs aimed at discerning the impact of TRT + finasteride on body composition, musculoskeletal health, and physical function in men with SCI, along with effect sizes and variance of responses to assist in planning subsequent trials.

Clinical trial registration

ClinicalTrials.gov, identifier NCT02248701.

A Systematic Review of Testosterone Therapy in Men With Spinal Cord Injury or Traumatic Brain Injury

Spinal cord injuries (SCI) and traumatic brain injuries (TBI) increase the risk of testosterone deficiency and result in adverse changes in body composition and poor functional outcomes. The current systematic review aims to provide insights into the use of testosterone therapy for treating men with SCI and TBI. The PubMed and EMBASE databases were systematically reviewed using appropriate terms, and resulting manuscripts were screened using defined Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The patient population included male patients with SCI or TBI. Further inclusion criteria were: a) human participants 18 years of age or older; b) manuscript published in English; c) study included an intervention with exogenous testosterone; and d) articles published in peer-reviewed journals with full text available. Two reviewers independently extracted data regarding injury type, intervention, and outcomes. Following screening for inclusion/exclusion criteria, a total of 12 primary research studies conducted over the last 30 years were included. Men with SCI were investigated in 11 articles. The combination of testosterone patches and resistance training with functional electrical stimulation (FES) for 16 weeks in men with SCI and an average baseline testosterone level above the cutoff for testosterone deficiency increased muscle mass, strength, bone quality, and basal metabolic rate while testosterone patches without exercise for 16 weeks produced no significant changes in these parameters. Testosterone patches for 12 months in men with SCI and testosterone deficiency also increased lean tissue mass (LTM) and resting energy expenditure (REE). In one study, men with TBI and testosterone deficiency receiving testosterone gel for eight weeks showed a non-statistically significant greater absolute change in functional independence measure (FIM) and grip strength compared to a placebo group. Testosterone therapy with exercise may help improve muscle mass, bone health, strength, energy expenditure, and cardiac health in men with SCI without major side effects. It is difficult to draw conclusions regarding the effects of testosterone therapy in men with TBI based on the limited available evidence. Further investigation is warranted to explore the relationship between testosterone therapy and recovery after SCI and TBI.

Effects of Electrical Stimulation Training on Body Composition Parameters After Spinal Cord Injury: A Systematic Review

OBJECTIVE

To determine the effects of neuromuscular electrical stimulation (NMES) or functional electrical stimulation (FES), or both, training on different body composition parameters in individuals with spinal cord injury.

DATA SOURCES

Three independent reviewers searched PubMed, Web of Science, Scopus, Cochrane Central, and Virtual Health Library until March 2020.

STUDY SELECTION

Studies were included if they applied NMES/FES on the lower limb muscles after spinal cord injury, reported stimulation parameters (frequency, pulse duration, and amplitude of current), and body composition parameters, which included muscle cross-sectional area (CSA), fat-free mass, lean mass (LM), fat mass, visceral adipose tissue, and intramuscular fat.

DATA SYNTHESIS

A total of 46 studies were included in the final analysis with a total sample size of 414 subjects. NMES loading exercise and FES cycling exercise were commonly used for training. Increases in muscle CSA ranged from 5.7-75%, with an average of 26% (n=33). Fifteen studies reported changes (both increase and decrease) in LM or fat-free mas ranged from -4% to 35%, with an average of less than 5%. Changes in fat mass (n=10) were modest. The effect on ectopic adipose tissue is inconclusive, with 2 studies showing an average reduction in intramuscular fat by 9.9%. Stimulation parameters ranged from 200-1000 μs for pulse duration, 2-60 Hz for the frequency, and 10-200 mA in amplitude. Finally, increase in weekly training volumes after NMES loading exercise resulted in a remarkable increase in percentage changes in LM or muscle CSA.

CONCLUSIONS

NMES/FES is an effective rehabilitation strategy for muscle hypertrophy and increasing LM. Weekly training volumes are associated with muscle hypertrophy after NMES loading exercise. Furthermore, positive muscle adaptations occur despite the applied stimulation parameters. Finally, the included studies reported wide range of stimulation parameters without reporting rationale for such selection.

Protocols aiming to increase muscle mass in persons with motor complete spinal cord injury: a systematic review

PURPOSE

The purpose of this review was to compare all intervention modalities aimed at increasing skeletal muscle mass (SMM) in the paralysed limbs of persons with chronic (>1-year post-injury), motor complete spinal cord injury (SCI).

MATERIALS AND METHODS

A systematic review of EMBASE, MEDLINE, Scopus, and SPORTDiscus databases was conducted from inception until December 2021. Published intervention studies aimed to increase SMM (measured by magnetic resonance imaging, computed tomography, ultrasound, muscle biopsy, or lean soft tissue mass by dual X-ray absorptiometry) in the paralysed limbs of adults (>18 years) with SCI were included.

RESULTS

Fifty articles were included that, overall, demonstrated a high risk of bias. Studies were categorised into six groups: neuromuscular electrical stimulation (NMES) with and without external resistance, functional electrical stimulation cycling, walking- and standing-based interventions, pharmacological treatments, and studies that compared or combined intervention modalities. Resistance training (RT) using NMES on the quadriceps produced the largest and most consistent increases in SMM of all intervention modalities.

CONCLUSIONS

Current evidence suggests that clinical practise aiming to increase SMM in the paralysed limbs of persons with motor complete SCI should perform NMES-RT. However, more high-quality randomised control trials are needed to determine how training variables, such as exercise volume and intensity, can be optimised for increasing SMM. Implications for rehabilitationPersons with spinal cord injury (SCI) experience severe reductions in skeletal muscle mass (SMM) post-injury, which may exacerbate their risk of obesity and metabolic disease.Out of all exercise and non-exercise-based interventions, this systematic review shows that neuromuscular electrical stimulation-based resistance training demonstrates the most robust and consistent evidence for increasing skeletal muscle mass in the paralysed limbs of adults with motor complete spinal cord injury.The findings from this review can be used to inform evidence-based practise for exercise practitioners, as well as direct future research focused on increasing muscle mass in this population.

Role of exercise on visceral adiposity after spinal cord injury: a cardiometabolic risk factor

PURPOSE

Visceral adipose tissue (VAT) is associated with cardiometabolic disease risk in able-bodied (AB) populations. However, the underlying mechanisms of VAT-induced disease risk are unknown in persons with spinal cord injury (SCI). Potential mechanisms of VAT-induced cardiometabolic dysfunction in persons with SCI include systemic inflammation, liver adiposity, mitochondrial dysfunction, and anabolic deficiency. Moreover, how exercise interventions impact these mechanisms associated with VAT-induced cardiometabolic dysfunction are still being explored.

METHODS

A search for relevant scientific literature about the effects of exercise on VAT and cardiometabolic health was conducted on the PubMed database. Literature from reference lists was also included when appropriate.

RESULTS

Both aerobic and resistance exercise training beneficially impact health and VAT mass via improving mitochondrial function, glucose effectiveness, and inflammatory signaling in SCI and AB populations. Specifically, aerobic exercise appears to also modulate cellular senescence in AB populations and animal models, while resistance exercise seems to augment anabolic signaling in persons with SCI.

CONCLUSIONS

The current evidence supports regular engagement in exercise to reduce VAT mass and the adverse effects on cardiometabolic health in persons with SCI. Future research is needed to further elucidate the precise mechanisms by which VAT negatively impacts health following SCI. This will likely facilitate the development of rehabilitation protocols that target VAT reduction in persons with SCI.

Endocrine Therapy for the Functional Recovery of Spinal Cord Injury

Spinal cord injury (SCI) is a major cause of physical disability and leads to patient dissatisfaction with their quality of life. Patients with SCI usually exhibit severe clinical symptoms, including sensory and motor dysfunction below the injured levels, paraplegia, quadriplegia and urinary retention, which can exacerbate the substantial medical and social burdens. The major pathological change observed in SCI is inflammatory reaction, which induces demyelination, axonal degeneration, and the apoptosis and necrosis of neurons. Traditional medical treatments are mainly focused on the recovery of motor function and prevention of complications. To date, numerous studies have been conducted to explore the cellular and molecular mechanism of SCI and have proposed lots of effective treatments, but the clinical applications are still limited due to the complex pathogenesis and poor prognosis after SCI. Endocrine hormones are kinds of molecules that are synthesized by specialized endocrine organs and can participate in the regulation of multiple physiological activities, and their protective effects on several disorders have been widely discussed. In addition, many studies have identified that endocrine hormones can promote nerve regeneration and functional recovery in individuals with central nervous system diseases. Therefore, studies investigating the clinical applications of endocrine hormones as treatments for SCI are necessary. In this review, we described the neuroprotective roles of several endocrine hormones in SCI; endocrine hormone administration reduces cell death and promotes functional repair after SCI. We also proposed novel therapies for SCI.

Considerations for Studying Sex as a Biological Variable in Spinal Cord Injury

In response to NIH initiatives to investigate sex as a biological variable in preclinical animal studies, researchers have increased their focus on male and female differences in neurotrauma. Inclusion of both sexes when modeling neurotrauma is leading to the identification of novel areas for therapeutic and scientific exploitation. Here, we review the organizational and activational effects of sex hormones on recovery from injury and how these changes impact the long-term health of spinal cord injury (SCI) patients. When determining how sex affects SCI it remains imperative to expand outcomes beyond locomotor recovery and consider other complications plaguing the quality of life of patients with SCI. Interestingly, the SCI field predominately utilizes female rodents for basic science research which contrasts most other male-biased research fields. We discuss the unique caveats this creates to the translatability of preclinical research in the SCI field. We also review current clinical and preclinical data examining sex as biological variable in SCI. Further, we report how technical considerations such as housing, size, care management, and age, confound the interpretation of sex-specific effects in animal studies of SCI. We have uncovered novel findings regarding how age differentially affects mortality and injury-induced anemia in males and females after SCI, and further identified estrus cycle dysfunction in mice after injury. Emerging concepts underlying sexually dimorphic responses to therapy are also discussed. Through a combination of literature review and primary research observations we present a practical guide for considering and incorporating sex as biological variable in preclinical neurotrauma studies.