Testosterone and Resistance Training Improve Muscle Quality in Spinal Cord Injury

Electrical stimulation paradigms on muscle quality and bone mineral density after spinal cord injury

The goal of the work was to determine the effects of altering muscle quality (peak torque and muscle CSA) via NMES-RT on bone mineral density (BMD) following application of FES-lower extremity cycling. Components of muscle quality were altered and attenuated the decline in BMD after SCI.

INTRODUCTION

Spinal cord injury (SCI) negatively impacts muscle quality and bone health. Neuromuscular electrical stimulation-resistance training (NMES-RT) has been shown to enhance muscle quality. It is unclear whether adding NMES-RT to functional electrical stimulation (FES)-lower extremity cycling may further augment muscle quality and subsequently enhance bone mineral density (BMD).

METHODS

Thirty-two participants were randomized into either 12 weeks of NMES-RT followed by 12 weeks of FES- lower extremity cycling (NMES-RT + FES; n = 16) or 12 weeks of passive movement training (PMT) followed by 12 weeks of FES-lower extremity cycling (PMT + FES; n = 16). Measurements were conducted at baseline (BL), post-interventions 1 and 2 (P1 and P2) separated evenly by 12 weeks. Left thigh muscle isometric and isokinetic torques were measured using an isokinetic dynamometer. Magnetic resonance imaging measured whole thigh and knee extensor (KE) muscle CSAs. Dual energy X-ray absorptiometry measured total and regional BMD.

RESULTS

NMES-RT elicited a trend towards greater isometric torque at 80 Hz (P = 0.057) and isokinetic torque (60 deg/s; P = 0.009 and 180 deg/s; P = 0.003) compared to PMT. Muscle CSA was greater in left whole thigh (F (2,20) = 9.1; P = 0.007) and KE (F (2,20) = 15.5; P = 0.001) by 11.0 and 8.0 cm2 respectively at P1 in the NMES-RT + FES compared to PMT + FES. In the NMES-RT + FES, ankle weights were positively associated with muscle CSA, isometric and isokinetic torques as well as muscle quality following P1. Compared to PMT + FES, NMES-RT + FES maintained BMD at the distal femur.

CONCLUSION

NMES-RT + FES enhanced muscle quality as measured by torque production and muscle CSA as result of increasing ankle weights. The addition of FES- lower extremity cycling to NMES-RT maintained but did not further augment muscle quality. Furthermore, NMES-RT + FES may help maintain BMD after SCI.

CLINICAL TRIAL REGISTRATION

Registered with clinicaltrials.gov: NCT02660073.

Epidural Stimulation and Resistance Training (REST-SCI) for Overground Locomotion After Spinal Cord Injury: Randomized Clinical Trial Protocol

Introduction: Implanted spinal cord epidural stimulation (SCES) is an emerging neuromodulation approach that increases the excitability of the central pattern generator [CPG] and enhances tonic and rhythmic motor patterns after spinal cord injury (SCI). We determine the effects of exoskeleton-assisted walking [EAW] + epidural stimulation [ES] + resistance training [RT] on volitional motor control as a primary outcome, as well as autonomic cardiovascular profile, body composition, and bladder function compared to EAW + delayed ES + noRT in persons with motor-complete SCI AIS A and B. Methods and Analysis: Twenty male and female participants [age 18-60 years] with traumatic motor-complete SCI [2 years or more post injury], and level of injury below C5 were randomized into either EAW + ES + RT or EAW + delayed-ES + no-RT groups for more than 12 months. Baseline, post-interventions 1 and 2 were conducted six months apart. Measurements included body composition assessment using anthropometry, dual x-ray absorptiometry, and magnetic resonance imaging prior to implantation to evaluate the extent of spinal cord damage, neurophysiologic assessments to record H-reflexes, overground ambulation and peak torque for both groups, and the Walking Index for Spinal Cord Injury Scale [WISCI 2]. Metabolic profile measurements included the resting metabolic rate, fasting biomarkers of HbA1c, lipid panels, total testosterone CRP, IL-6, TNF-α, plasma IGF-I, IGFBP-3, and then a glucose tolerance test. Finally, urodynamic testing was conducted to assess functional bladder improvement due to ES. Results: The restoration of locomotion with ES and EAW may result in a reduction in psychosocial, cardiovascular, and metabolic bladder parameters and socioeconomic burden. The addition of the resistance training paradigm may further augment the outcomes of ES on motor function in persons with SCI. Conclusions: Percutaneous SCES appears to be a feasible and safe rehabilitation approach for the restoration of motor function in persons with SCI. The procedure may be successfully implemented with other task-specific training similar to EAW and resistance training.

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.

Neurogenic Aging After Spinal Cord Injury: Highlighting the Unique Characteristics of Aging After Spinal Cord Injury

Emanating from several decades of study into the effects of the aging process after spinal cord injury (SCI), "accelerated aging" has become a common expression as the SCI accelerates the onset of age-related pathologies. However, the aging process follows a distinct trajectory, characterized by unique patterns of decline that differ from those observed in the general population without SCI. Aging brings significant changes to muscles, bones, and hormones, impacting overall physical function. Muscle mass and strength begin to decrease with a reduction in muscle fibers and impaired repair mechanisms. Bones become susceptible to fractures as bone density decreases. Hormonal changes combined with decreased physical activity accelerate the reduction of muscle mass and increase in body fat. Muscle atrophy and skeletal muscle fiber type transformation occur rapidly and in a unique pattern after SCI. Bone loss develops more rapidly and results in an increased risk of fractures in body regions unique to individuals with SCI. Other factors, such as excessive adiposity, decreased testosterone and human growth hormone, and increased systemic inflammation, contribute to a higher risk of neuropathically driven obesity, dyslipidemia, glucose intolerance, insulin resistance, and increasing cardiovascular disease risk. Cardiorespiratory changes after SCI result in lower exercise heart rates, decreased oxygenation, and mitochondrial dysfunction. While it is important to acknowledge the accelerated aging processes after SCI, it is essential to recognize the distinct differences in the aging process between individuals without physical disabilities and those with SCI. These differences, influenced by neuropathology, indicate that it may be more accurate to describe the aging process in individuals with chronic SCI as neurogenic accelerated aging (NAA). Research should continue to address conditions associated with NAA and how to ameliorate the accelerated rate of premature age-related conditions. This review focuses on the NAA processes and the differences between them and the aging process in those without SCI. Recommendations are provided to help slow the development of premature aging conditions.

Effects of two different paradigms of electrical stimulation exercise on cardio-metabolic risk factors after spinal cord injury. A randomized clinical trial

Objective

To examine the combined effects of neuromuscular electrical stimulation-resistance training (NMES-RT) and functional electrical stimulation-lower extremity cycling (FES-LEC) compared to passive movement training (PMT) and FES-LEC in adults with SCI on (1) oxygen uptake (VO2), insulin sensitivity and glucose disposal in adults with SCI; (2) Metabolic and inflammatory biomarkers; (3) skeletal muscle, intramuscular fat (IMF) and visceral adipose tissue (VAT) cross-sectional areas (CSAs).

Materials and methods

Thirty-three participants with chronic SCI (AIS A-C) were randomized to 24 weeks of NMES-RT + FES or PMT + FES. The NMES-RT + FES group underwent 12 weeks of evoked surface NMES-RT using ankle weights followed by an additional 12 weeks of progressive FES-LEC. The control group, PMT + FES performed 12 weeks of passive leg extension movements followed by an additional 12 weeks of FES-LEC. Measurements were performed at baseline (BL; week 0), post-intervention 1 (P1; week 13) and post-intervention 2 (P2; week 25) and included FES-VO2 measurements, insulin sensitivity and glucose effectiveness using the intravenous glucose tolerance test; anthropometrics and whole and regional body composition assessment using dual energy x-ray absorptiometry (DXA) and magnetic resonance imaging to measure muscle, IMF and VAT CSAs.

Results

Twenty-seven participants completed both phases of the study. NMES-RT + FES group showed a trend of a greater VO2 peak in P1 [p = 0.08; but not in P2 (p = 0.25)] compared to PMT + FES. There was a time effect of both groups in leg VO2 peak. Neither intervention elicited significant changes in insulin, glucose, or inflammatory biomarkers. There were modest changes in leg lean mass following PMT + FES group. Robust hypertrophy of whole thigh muscle CSA, absolute thigh muscle CSA and knee extensor CSA were noted in the NMES-RT + FES group compared to PMT + FES at P1. PMT + FES resulted in muscle hypertrophy at P2. NMES-RT + FES resulted in a decrease in total VAT CSA at P1.

Conclusion

NMES-RT yielded a greater peak leg VO2 and decrease in total VAT compared to PMT. The addition of 12 weeks of FES-LEC in both groups modestly impacted leg VO2 peak. The addition of FES-LEC to NMES-RT did not yield additional increases in muscle CSA, suggesting a ceiling effect on signaling pathways following NMES-RT.

Clinical trial registration

identifier NCT02660073.

Impact of rehabilitation on volumetric muscle loss in subjects with traumatic spinal cord injury: A systematic review

BACKGROUND

Spinal cord injury (SCI) leads to spinal nerve fiber tract damage resulting in functional impairments. Volumetric muscle loss (VML), a skeletal muscle volume abnormal reduction, is represented by atrophy below the injury level. The strategies for VML management included personalized approaches, and no definite indications are available.

OBJECTIVE

To identify the rehabilitation effects of VML in subjects with SCI (humans and animals).

METHODS

PubMed, Scopus, and Web of Science databases were systematically searched to identify longitudinal observational studies with individuals affected by traumatic SCI as participants; rehabilitation treatment as intervention; no control, sham treatment, and electrical stimulation programs as control; total lean body and lower limb lean mass, cross-sectional area, functional gait recovery, muscle thickness, and ultrasound intensity, as outcome.

RESULTS

Twenty-four longitudinal observational studies were included, evaluating different rehabilitation approaches' effects on the VML reduction in subjects affected by SCI. The data showed that electrical stimulation and treadmill training are effective in reducing the VML in this population.

CONCLUSION

This systematic review underlines the need to treat subjects with traumatic SCI (humans and animals) with different rehabilitation approaches to prevent VML in the subacute and chronic phases. Further clinical observations are needed to overcome the bias and to define the intervention's timing and modalities.

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.

Employment of Neuromuscular Electrical Stimulation to Examine Muscle and Bone Qualities after Spinal Cord Injury

(1) Background: Resource intensive imaging tools have been employed to examine muscle and bone qualities after spinal cord injury (SCI). We tested the hypothesis that surface neuromuscular electrical stimulation (NMES) amplitude can be used to examine knee extensor muscle quality, distal femur and proximal tibia bone mineral density (BMD) in persons with SCI. (2) Methods: Seventeen persons (2 women) with chronic SCI participated in three weeks of NMES-resistance training twice weekly of 4 sets of 10 repetitions. Participants were classified according to the current amplitude (>100 mA) and the number of repetitions (>70 reps) of leg extension into greater (n = 8; 1 woman; group A) and lower (n = 9; 1 woman; group B) musculoskeletal qualities. Magnetic resonance imaging, dual energy x-ray absorptiometry, isometric peak torque, Modified Ashworth and Penn spasm frequency scales were conducted. (3) Results: In between group comparisons, current amplitude was lower (38−46%) in group A. Whole (27−32%; p = 0.02), absolute (26−33%, p = 0.02) thigh muscle and absolute knee extensor muscle cross-sectional areas (22−33%, p = 0.04) were greater in group A. Right distal femur (24%; p = 0.08) and proximal tibia (29%; p = 0.03) BMDs were lower in group B, and peak isometric torque (p < 0.01), extensor spasticity scorers (p = 0.04) and muscle spasm scores (p = 0.002) were significantly higher in group A. Regression models revealed that amplitude of current, repetitions and body weight can accurately predict musculoskeletal qualities in persons with SCI. (4) Conclusions: Surface NMES amplitude and repetitions of leg extension differentiated between SCI survivors with greater versus lower musculoskeletal qualities. The study may shed the light on the interplay between muscle and bone in persons with SCI.

Early Changes in Androgen Levels in Individuals with Spinal Cord Injury: A Longitudinal SwiSCI Study

We aimed to explore longitudinal changes in androgen levels in individuals with spinal cord injury (SCI) within initial inpatient rehabilitation stay and identify clinical/injury characteristics associated with hormone levels. Linear regression analysis was applied to explore the association between personal/injury characteristics and androgen hormones (total testosterone, free testosterone, sex hormone-binding globulin (SHBG), dehydroepiandrosterone (DHEA), and dehydroepiandrosterone sulfate (DHEA-S)) at admission to rehabilitation. Longitudinal changes in androgen levels were studied using linear mixed models. Analyses were stratified by sex and by injury type. We included 70 men and 16 women with SCI. We observed a non-linear association between age, time since injury, and androgens at baseline. At admission to initial rehabilitation, mature serum SHBG (full-length, protein form which lacks the N-terminal signaling peptide) was higher, while DHEA and DHEA-S were lower among opioid users vs. non-users. Serum levels of total testosterone and DHEA-S increased over rehabilitation period [β 3.96 (95%CI 1.37, 6.56), p = 0.003] and [β 1.77 (95%CI 0.73, 2.81), p = 0.01], respectively. We observed no significant changes in other androgens. Restricting our analysis to men with traumatic injury did not materially change our findings. During first inpatient rehabilitation over a median follow up of 5.6 months, we observed an increase in total testosterone and DHEA-S in men with SCI. Future studies need to explore whether these hormonal changes influence neurological and functional recovery as well as metabolic parameters during initial rehabilitation stay.

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.

Testosterone Treatment As a Function-Promoting Therapy in Sarcopenia Associated with Aging and Chronic Disease

Sarcopenia is characterized by loss of muscle strength and physical ability because of aging and/or chronic disease. Supplemental testosterone and other androgenic-anabolic steroids have been investigated as countermeasures to ameliorate the negative consequences of sarcopenia; these trials show dose-related improvements in lean body mass, maximal voluntary strength, stair climbing power, aerobic capacity, hemoglobin, and self-reported function, but less consistent improvements in walking speed. Randomized clinical trials with large cohorts and patient-important outcome measures are needed to determine long-term efficacy and safety of testosterone treatment in improving physical function and reducing physical disability, falls, and fractures in older adults with sarcopenia.

Invasive and Non-Invasive Approaches of Electrical Stimulation to Improve Physical Functioning after Spinal Cord Injury

This review of literature provides the latest evidence involving invasive and non-invasive uses of electrical stimulation therapies that assist in restoring functional abilities and the enhancement of quality of life in those with spinal cord injuries. The review includes neuromuscular electrical stimulation and functional electrical stimulation activities that promote improved body composition changes and increased muscular strength, which have been shown to improve abilities in activities of daily living. Recommendations for optimizing electrical stimulation parameters are also reported. Electrical stimulation is also used to enhance the skills of reaching, grasping, standing, and walking, among other activities of daily living. Additionally, we report on the use of invasive and non-invasive neuromodulation techniques targeting improved mobility, including standing, postural control, and assisted walking. We attempt to summarize the effects of epidural stimulation on cardiovascular performance and provide a mechanistic explanation to the current research findings. Future trends such as the combination of epidural stimulation and exoskeletal-assisted walking are also discussed.

The Therapeutic Intervention of Sex Steroid Hormones for Sarcopenia

Sarcopenia, characterized by the excessive loss of skeletal muscle mass, strength, and function, is associated with the overall poor muscle performance status of the elderly, and occurs more frequently in those with chronic diseases. The causes of sarcopenia are multifactorial due to the inherent relationship between muscles and molecular mechanisms, such as mitochondrial function, inflammatory pathways, and circulating hormones. Age-related changes in sex steroid hormone concentrations, including testosterone, estrogen, progesterone, and their precursors and derivatives, are an important aspect of the pathogenesis of sarcopenia. In this review, we provide an understanding of the treatment of sarcopenia through the regulation of sex steroid hormones. The potential benefits and future research emphasis of each sex steroid hormone therapeutic intervention (testosterone, SARMs, estrogen, SERMs, DHEA, and progesterone) for sarcopenia are discussed. Enhanced understanding of the role of sex steroid hormones in the treatment for sarcopenia could lead to the development of hormone therapeutic approaches in combination with specific exercise and nutrition regimens.

Effects of dose de-escalation following testosterone treatment and evoked resistance exercise on body composition, metabolic profile, and neuromuscular parameters in persons with spinal cord injury

The dose de-escalation (DD) effects of testosterone and evoked resistance training (RT) on body composition, cardiometabolic, and neuromuscular variables were investigated. Thirteen men with chronic complete spinal cord injury (SCI) were followed for additional 16 weeks after receiving either testosterone treatment only (TT) or TT+RT. During the 16-week DD period, the TT+RT group underwent a program of once weekly electrical stimulation with gradually decreasing ankle weights and testosterone patches of 2 mg day-1 (TT+RT group). The TT only group did not receive any intervention throughout the detraining period (no-TT group). Body composition was tested using anthropometrics, dual energy X-ray absorptiometry, and magnetic resonance imaging. After an overnight fast, basal metabolic rate (BMR), lipid panel, serum testosterone, inflammatory biomarkers, glucose effectiveness, and insulin sensitivity were measured. Finally, peak isometric and isokinetic torques were measured only in the TT+RT group. All measurements were conducted at the beginning and at the end of DD. Absolute thigh muscle cross-sectional areas (CSAs) demonstrated interaction effects (p < 0.05) between the TT+RT (-8.15%, -6.5%) and no-TT (2.3%, 4.4%) groups. Similarly, absolute knee extensor muscle CSA demonstrated interaction effects (p < 0.05) between the TT+RT (-11%, -7.0%) and no-TT (2.6%, 3.8%) groups. There was a trend (p = 0.07) of increasing visceral adipose tissue (VAT) CSAs in the TT+RT (18%) and in the no-TT (16% cm2 ) groups. There was an interaction (p = 0.005) between TT+RT (decreased by 3.7%) and no-TT groups (increased by 9.0%) in BMR. No interactions were evident between groups over time for biomarkers related to carbohydrate, lipid metabolism, or inflammation. Finally, there were no changes (p > 0.05) in peak isometric or isokinetic torques and rise time following 16 weeks of the DD period in the TT+RT group. TT+RT during 16 weeks of DD was minimally effective at preventing detraining relative to no-TT on muscle size, BMR, and VAT. However, neuromuscular gains were successfully maintained.

Bone and non-contractile soft tissue changes following open kinetic chain resistance training and testosterone treatment in spinal cord injury: an exploratory study

Twenty men with spinal cord injury (SCI) were randomized into two 16-week intervention groups receiving testosterone treatment (TT) or TT combined with resistance training (TT + RT). TT + RT appears to hold the potential to reverse or slow down bone loss following SCI if provided over a longer period.

INTRODUCTION

Persons with SCI experience bone loss below the level of injury. The combined effects of resistance training and TT on bone quality following SCI remain unknown.

METHODS

Men with SCI were randomized into 16-week treatments receiving TT or TT + RT. Magnetic resonance imaging (MRI) of the right lower extremity before participation and post-intervention was used to visualize the proximal, middle, and distal femoral shaft, the quadriceps tendon, and the intermuscular fascia of the quadriceps. For the TT + RT group, MRI microarchitecture techniques were utilized to elucidate trabecular changes around the knee. Individual mixed models were used to estimate effect sizes.

RESULTS

Twenty participants completed the pilot trial. A small effect for yellow marrow in the distal femur was indicated as increases following TT and decreases following TT + RT were observed. Another small effect was observed as the TT + RT group displayed greater increases in intermuscular fascia length than the TT arm. Distal femur trabecular changes for the TT + RT group were generally small in effect (decreased trabecular thickness variability, spacing, and spacing variability; increased network area). Medium effects were generally observed in the proximal tibia (increased plate width, trabecular thickness, and network area; decreased trabecular spacing and spacing variability).

CONCLUSIONS

This pilot suggests longer TT + RT interventions may be a viable rehabilitation technique to combat bone loss following SCI.

CLINICAL TRIAL REGISTRATION

Registered with clinicaltrials.gov : NCT01652040 (07/27/2012).

Neuromuscular electrical stimulation resistance training enhances oxygen uptake and ventilatory efficiency independent of mitochondrial complexes after spinal cord injury: a randomized clinical trial

The purpose of the study was to determine whether neuromuscular electrical stimulation resistance training (NMES-RT)-evoked muscle hypertrophy is accompanied by increased V̇o₂ peak, ventilatory efficiency, and mitochondrial respiration in individuals with chronic spinal cord injury (SCI). Thirty-three men and women with chronic, predominantly traumatic SCI were randomized to either NMES-RT (n = 20) or passive movement training (PMT; n = 13). Functional electrical stimulation-lower extremity cycling (FES-LEC) was used to test the leg V̇o₂ peak, V̇E/V̇co₂ ratio, and substrate utilization pre- and postintervention. Magnetic resonance imaging was used to measure muscle cross-sectional area (CSA). Finally, muscle biopsy was performed to measure mitochondrial complexes and respiration. The NMES-RT group showed a significant increase in postintervention V̇o₂ peak compared with baseline (ΔV̇o₂ = 14%, P < 0.01) with no changes in the PMT group (ΔV̇o₂ = 1.6%, P = 0.47). Similarly, thigh (ΔCSA_thigh = 19%) and knee extensor (ΔCSA_knee = 30.4%, P < 0.01) CSAs increased following NMES-RT but not after PMT. The changes in thigh and knee extensor muscle CSAs were positively related with the change in V̇o₂ peak. Neither NMES-RT nor PMT changed mitochondrial complex tissue levels; however, changes in peak V̇o₂ were related to complex I. In conclusion, in persons with SCI, NMES-RT-induced skeletal muscle hypertrophy was accompanied by increased peak V̇o₂ consumption which may partially be explained by enhanced activity of mitochondrial complex I.NEW & NOTEWORTHY Leg oxygen uptake (V̇o₂) and ventilatory efficiency (V̇E/V̇co₂ ratio) were measured during functional electrical stimulation cycling testing following 12-16 wk of either electrically evoked resistance training or passive movement training, and the respiration of mitochondrial complexes. Resistance training increased thigh muscle area and leg V̇o₂ peak but decreased V̇E/V̇co₂ ratio without changes in mitochondrial complex levels. Leg V̇o₂ peak was associated with muscle hypertrophy and mitochondrial respiration of complex I following training.

Skeletal muscle stiffness as measured by magnetic resonance elastography after chronic spinal cord injury: a cross-sectional pilot study

Skeletal muscle stiffness is altered after spinal cord injury (SCI). Assessing muscle stiffness is essential for rehabilitation and pharmaceutical interventions design after SCI. The study used magnetic resonance elastography to assess the changes in stiffness after chronic SCI compared to matched able-bodied controls and determine its association with muscle size, spasticity, and peak torque in persons with SCI. Previous studies examined the association between muscle stiffness and spasticity, however, we are unaware of other studies that examined the effects of muscle composition on stiffness after SCI. Ten participants (one female) with chronic SCI and eight (one female) matched able-bodied controls participated in this cross-sectional study. Magnetic resonance elastography was utilized to monitor stiffness derived from shear waves propagation. Modified Ashworth scale was used to evaluate spasticity scores in a blinded fashion. Peak isometric and isokinetic torques were measured using a biodex dynamometer. Stiffness values were non-significantly lower (12.5%; P = 0.3) in the SCI group compared to able-bodied controls. Moreover, stiffness was positively related to vastus lateralis whole muscle cross-sectional area (CSA) (r² = 0.64, P < 0.005) and vastus lateralis absolute muscle CSA after accounting for intramuscular fat (r² = 0.78, P < 0.0007). Stiffness was also positively correlated to both isometric (r²= 0.55-0.57, P < 0.05) and isokinetic peak (r²= 0.46-0.48, P < 0.05) torques. Our results suggest that larger clinical trial is warranted to confirm the preliminary findings that muscle stiffness is altered after SCI compared to healthy controls. Stiffness appeared to be influenced by infiltration of intramuscular fat and modestly by the spasticity of the paralyzed muscles. The preliminary data indicated that the relationship between muscle stiffness and peak torque is not altered with changing the frequency of pulses or angular velocities. All study procedures were approved by the Institutional Review Board at the Hunter Holmes McGuire VA Medical Center, USA (IRB #: 02314) on May 3, 2017.

Sixteen weeks of testosterone with or without evoked resistance training on protein expression, fiber hypertrophy and mitochondrial health after spinal cord injury

We investigated the effects of testosterone replacement therapy (TRT) with and without evoked resistance training (RT) on protein expression of key metabolic and hypertrophy regulators, muscle fiber cross-sectional area (CSA), and markers of mitochondrial health after spinal cord injury (SCI). Twenty-two men with chronic motor complete SCI were randomly assigned to either TRT + RT (n = 11) or TRT (n = 11) for 16 wk. TRT + RT men underwent twice weekly progressive RT using electrical stimulation with ankle weights. TRT was administered via testosterone patches (2-6 mg/day). Muscle biopsies were obtained before and after 16 wk from the right vastus lateralis. Expression of proteins associated with oxidative muscles and mechanical loading (PGC-1α and FAK), muscle hypertrophy (total and phosphorylated Akt, total and phosphorylated mTOR), and cellular metabolism (total and phosphorylated AMPK and GLUT4) were evaluated. Immunohistochemistry analysis was performed to measure fiber CSA and succinate dehydrogenase (SDH) activity as well as mitochondrial citrate synthase (CS) activity and complex III (CIII) activities. TRT + RT demonstrated a robust 27.5% increase in average fiber CSA compared with a -9% decrease following TRT only (P = 0.01). GLUT4 protein expression was elevated in the TRT + RT group compared with TRT only (P = 0.005). Total Akt (P = 0.06) and phosphorylated Akt Ser³⁸⁹ (P = 0.049) were also elevated in the TRT + RT group. Mitochondrial activity of SDH (P = 0.03) and CS (P = 0.006) increased in the TRT + RT group, with no changes in the TRT-only group. Sixteen weeks of TRT with RT resulted in fiber hypertrophy and beneficial changes in markers of skeletal muscle health and function.NEW & NOTEWORTHY Fiber cross-sectional area (CSA), protein expression, mitochondrial citrate synthase (CS), and succinate dehydrogenase (SDH) were measured following 16 wk of low-dose testosterone replacement therapy (TRT) with and without electrically evoked resistance training (RT) in men with spinal cord injury (SCI). Fiber CSA and protein expression of total GLUT4, total Akt, and phosphorylated Akt increased following TRT + RT but not in the TRT-only group. Mitochondrial CS and SDH increased after TRT + RT but not in TRT-only group.

Locomotor training with adjuvant testosterone preserves cancellous bone and promotes muscle plasticity in male rats after severe spinal cord injury

Loading and testosterone may influence musculoskeletal recovery after spinal cord injury (SCI). Our objectives were to determine (a) the acute effects of bodyweight-supported treadmill training (TM) on hindlimb cancellous bone microstructure and muscle mass in adult rats after severe contusion SCI and (b) whether longer-term TM with adjuvant testosterone enanthate (TE) delivers musculoskeletal benefit. In Study 1, TM (40 min/day, 5 days/week, beginning 1 week postsurgery) did not prevent SCI-induced hindlimb cancellous bone loss after 3 weeks. In Study 2, TM did not attenuate SCI-induced plantar flexor muscles atrophy nor improve locomotor recovery after 4 weeks. In our main study, SCI produced extensive distal femur and proximal tibia cancellous bone deficits, a deleterious slow-to-fast fiber-type transition in soleus, lower muscle fiber cross-sectional area (fCSA), impaired muscle force production, and levator ani/bulbocavernosus (LABC) muscle atrophy after 8 weeks. TE alone (7.0 mg/week) suppressed bone resorption, attenuated cancellous bone loss, constrained the soleus fiber-type transition, and prevented LABC atrophy. In comparison, TE+TM concomitantly suppressed bone resorption and stimulated bone formation after SCI, produced near-complete cancellous bone preservation, prevented the soleus fiber-type transition, attenuated soleus fCSA atrophy, maintained soleus force production, and increased LABC mass. 75% of SCI+TE+TM animals recovered voluntary over-ground hindlimb stepping, while no SCI and only 20% of SCI+TE animals regained stepping ability. Positive associations between testosterone and locomotor function suggest that TE influenced locomotor recovery. In conclusion, short-term TM alone did not improve bone, muscle, or locomotor recovery in adult rats after severe SCI, while longer-term TE+TM provided more comprehensive musculoskeletal benefit than TE alone.

Skeletal muscle hypertrophy and attenuation of cardio-metabolic risk factors (SHARC) using functional electrical stimulation-lower extremity cycling in persons with spinal cord injury: study protocol for a randomized clinical trial

Background

Persons with spinal cord injury (SCI) are at heightened risks of developing unfavorable cardiometabolic consequences due to physical inactivity. Functional electrical stimulation (FES) and surface neuromuscular electrical stimulation (NMES)-resistance training (RT) have emerged as effective rehabilitation methods that can exercise muscles below the level of injury and attenuate cardio-metabolic risk factors. Our aims are to determine the impact of 12 weeks of NMES + 12 weeks of FES-lower extremity cycling (LEC) compared to 12 weeks of passive movement + 12 weeks of FES-LEC on: (1) oxygen uptake (VO₂), insulin sensitivity, and glucose disposal in adults with SCI; (2) skeletal muscle size, intramuscular fat (IMF), and visceral adipose tissue (VAT); and (3) protein expression of energy metabolism, protein molecules involved in insulin signaling, muscle hypertrophy, and oxygen uptake and electron transport chain (ETC) activities.

Methods/Design

Forty-eight persons aged 18–65 years with chronic (> 1 year) SCI/D (AIS A-C) at the C5-L2 levels, equally sub-grouped by cervical or sub-cervical injury levels and time since injury, will be randomized into either the NMES + FES group or Passive + FES (control group). The NMES + FES group will undergo 12 weeks of evoked RT using twice-weekly NMES and ankle weights followed by twice-weekly progressive FES-LEC for an additional 12 weeks. The control group will undergo 12 weeks of passive movement followed by 12 weeks of progressive FES-LEC. Measurements will be performed at baseline (B; week 0), post-intervention 1 (P1; week 13), and post-intervention 2 (P2; week 25), and will include: VO₂ measurements, insulin sensitivity, and glucose effectiveness using intravenous glucose tolerance test; magnetic resonance imaging to measure muscle, IMF, and VAT areas; muscle biopsy to measure protein expression and intracellular signaling; and mitochondrial ETC function.

Discussion

Training through NMES + RT may evoke muscle hypertrophy and positively impact oxygen uptake, insulin sensitivity, and glucose effectiveness. This may result in beneficial outcomes on metabolic activity, body composition profile, mitochondrial ETC, and intracellular signaling related to insulin action and muscle hypertrophy. In the future, NMES-RT may be added to FES-LEC to improve the workloads achieved in the rehabilitation of persons with SCI and further decrease muscle wasting and cardio-metabolic risks.

Trial registration

ClinicalTrials.gov, NCT02660073. Registered on 21 Jan 2016.