Evaluating the Impact of Focused Muscle Contraction Therapy in Retired American Professional Football Players
Phase: NA
Conditions: Chronic Pain Due to Injury, Acute Pain, Depression, Brain Injuries
Sponsor: University of Illinois at Chicago

GH APF Protocol, Version 8, Date: 03/24/21 
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Evaluating the Impact of Focused Muscle Contraction Therapy in Retired 
American Professional Football Players 
Principal Investigator: 
Enrico Benedetti, MD 
Professor and Head 
Department of Surgery 
University of Illinois Hospital and Health Sciences System 
 
 
 
Study Test Location(s): 
UIC Disability Health and Social Policy Building (UIC-DHSP) 
 1640 W. Roosevelt Road, Chicago, IL 60608 
 
Gh Fitlab 
1730 N Western Ave. 
 Chicago, IL 60647 
 
 
 
 
Version: 8 
Date: 03/24/21 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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1.0 
Project Summary/Abstract 
This study will investigate the effects of an exercise intervention on retired American 
professional football (APF) players. A total of 20 retired APF players (≥ 18 years of age), 
who suffer from chronic pain, will be enrolled. The study duration for each participants 
will be 18 months.  Enrolled participants will perform a 18 months exercise intervention 
which involves 90 exercise rehabilitation training visits. In addition, participants will also 
be tested on various measures of health and function both at baseline (prior to 
intervention), at 6 months, 12 months, and 18 months (post intervention). All testing and 
result interpretation will be performed by trained research personnel indicated on the 
Appendix P. Participants are not UIC participants; however study testing visits will occur 
at the University of Illinois at Chicago Disability Health and Social Policy Building (UIC-
DHSP), located at 1640 W. Roosevelt Road in Suites 158, 190, and 195, Chicago, IL  
0608. All exercise intervention training visits will occur at Gh Fitlab, located at 1730 N 
Western Ave., Chicago, IL 60647. 
 
2.0     Background/Scientific Rationale  
The World Health Organization estimates that one in five individuals world-wide live 
with chronic pain1. For individuals who suffer traumatic injury, over 60% report 
persistence of moderately severe, injury-related pain, in more than one body region, 
for several years after injury2-4. For APF players, the injury rate is nearly 100% and 
is associated with long-term physical and cognitive disabilities5. Participants who 
suffer with chronic pain experience difficulties sleeping, fatigue, depression, and 
demonstrate the lowest quality of life, the lowest of any medical condition 6,7. 
 
Opioids have been the traditional treatment of both acute and chronic pain in the 
APF5. In a study of retired APF players, opioid use was three times the rate of the 
general population8. Randomized clinical trials have demonstrated little evidence of 
long-term efficacy with opioids; in treatment of chronic low back pain, for example, 
pain relief is short term and leads to relief in less than 30% of those affected9. 
Opioid use is associated with several unwanted side effects which appear as early 
as two weeks after treatment and can include addiction, drug tolerance, overdose 
related mortality, myocardial infarction, and depression, and for these reasons, is not 
an acceptable treatment10,11. In an extensive review of treatment strategies 
including anti-depressants, anti-consultants, topical agents, injection therapy, physical 
therapy, and psychological approaches, none are known to provide more than 30% 
reduction in pain or improvement in function12. Similarly, a Cochrane review on 

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exercise therapies for the treatment of chronic pain have also demonstrated 30% 
or less efficacy in the treatment of chronic pain13. 
 
It is generally believed that chronic pain changes the structure of the brain14. 
Participants with chronic pain demonstrate brain atrophy with decreased cortical 
gray matter in the bilateral dorsolateral prefrontal cortex, thalamus, brainstem, 
primary somatosensory cortex (S1), and posterior parietal cortex15-17. The 
duration of pain and its intensity can predict regional atrophy in the dorsolateral 
prefrontal cortex of the brain15. Eliminating chronic pain is associated with restoration 
of brain anatomy and function. For example, following surgical or regional anesthetic 
block and loss of chronic pain symptoms, participants demonstrated reversal of 
abnormal brain anatomy and function18. However, only a small subset of participants 
can be treated in this fashion for durable relief of chronic pain; for the majority 
participants with injury-related, multiple site chronic pain, these are not treatment 
options. 
 
Areas of the brain in which anatomic volume and function are decreased due to chronic 
pain are also involved in the successful learning of new motor tasks. Activation 
of the dorsolateral prefrontal cortex is initially high in learning a new motor task 
but appears to progressively decrease when a motor task becomes more and more 
“automatic”; it is believed that this change in function may be due to the delegation 
of responsibility to other brain structures19, 20. This finding may also be a 
contributing factor in the lack of exercise activity, usually automatic in its structure, in 
treating chronic pain and restoring anatomic form and function. For example, for 
the past 15 years, a series of well-documented studies have demonstrated 
increased automaticity when the focus is external to the muscle, ie, task 
focused21. Such automatic responses would imply the recruitment of lower brain 
structures once the task has been learned9, 20; these areas of the brain would not be 
the ones involved in chronic pain. In contrast, deliberate focus on the contraction of 
the muscle requires intense concentration; such focused attention is most effective 
if accompanied by verbal instruction22. Such concentration would imply the need 
for higher order brain function, with likely engagement of brain areas such as the 
dorsolateral prefrontal cortex, which is highly engaged in learning new motor tasks. It 
is possible that active stimulation in a focused motor task may stimulate atrophic areas 
of the brain, thereby restoring brain anatomy and function and, as a consequence, 
also extinguish the perception of chronic pain. 
 
 
 

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Focused muscle contraction can lead to increased quality of contraction and 
increased recruitment and activation of adjacent muscle fibers23-25. Following 
muscle activation, skeletal muscle can release growth factors in the blood stream 
such as brain derived growth factor and nerve growth factor 26,27. These factors 
have been implicated in improved brain function. In addition, muscle activation can 
lead to the systemic release of other soluble factors, such as muscle specific 
microRNAs miR-1, -122a, and -124a, which serve as master regulators of multiple 
processes; these are produced by skeletal muscle and also found in the brain 28. It 
is possible that in addition to direct effects on brain anatomy and function, 
focused muscle contraction may release mediators, which indirectly augment brain 
anatomy and function. 
 
In our own studies of kidney transplant participants with multiple sites of chronic pain, a 
6 month, twice- weekly regimen led to sustainable decreases in chronic pain with 
return to work rates of 75%, over 5 times the national rate of 14%. In a similar new 
study of five retired APF players, this muscle contraction program led to greater 
than 90% resolution of all pain. Such rates of sustainable pain relief have not 
been described before using any treatment modality and warrant further study. 
 
At present, the field of pain control rests largely on devising new strategies of 
established treatments. Notably, no new effective therapeutics for the treatment of 
injury- related, chronic pain have been identified in the past decade. Further, the 
rate of opioid addition, depression, and escalating opioid-related suicide rates, continue 
to rise with no new alternative therapies. The use of focused muscle contraction 
therapy may serve as an important, non-pharmaceutical way of eliminating chronic 
pain in a durable sustained manner. 
 
 
 
3.0 
Objectives/Aims 
The present study aims to analyze the effectiveness of a specific physical activity 
training program (aka GH Method) in retired APF players.  
 
Hypotheses: 
1. Exercise will positively affect body composition. With this hypothesis we will test 
whether muscle strength (dynamometer) and muscle mass (DEXA scan) changes 
after 6 months, 12 months, 18 months of an exercise intervention. Baseline 
measurement will be performed before the intervention, at 6 months, 12 months, 
and at the end of the study (18 months) with muscle mass measured by DEXA 
and strength measured again by dynamometer. 
2. We expect participants will see improvements in their physical abilities after 18 
months in the exercise training sessions. This will be assessed by comparing 

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baseline, 6 months, 12 months, and 18 months, 8 foot walk, timed sit to stand, 
and balance testing scores. 
3. Participants enrolled in the exercise intervention will have an overall improved 
sense of well-being, increased independence, quality of life, and decreased 
depression.  Participants will be asked about their overall general health, mental 
health and pain intensity using the PROMIS, SF 36, BDI, Fatigue Severity Index, 
and pain assessments. 
4. APF players with chronic pain described as greater than 5 out of a 10 point scale 
and lasting greater than 12 months, will display alterations in brain wave function 
consistent with abnormal function of the bilateral dorsolateral prefrontal cortex 
(DLPFC) , thalamus (relays motor and sensory signals to the cortex) , brainstem, 
primary somatosensory cortex (S1, postcentral gyrus of the anterior parietal lobe) 
and posterior parietal cortex (posterior to the primary somatosensory cortex) 
4.0 
Eligibility 
This study will enroll retired APF players, who are 18 years of age or older, and 
suffer from chronic pain. Participants will be recruited by referral to the PI by Dr. 
Arthur (Archie) Roberts at the National Football Foundation. He will provide 
potential participants with an information sheet that will provide a brief summary 
of the research study and who to contact, if interested. They will then be 
screened (using the screening eligibility form) and consented by authorized 
research staff, if eligible to participate. Please reference Section 13.1 Informed 
Consent for more information on the consent process.  
 
4.1 Inclusion Criteria 
• Retired APF player (there is no minimum duration or career length 
required no minimum duration or career length required) 
• 18 years of age and older 
 
 
4.2 Exclusion Criteria 
• Unable to travel to the training center 
• Unable to give consent 
• Unable to understand the study  
• Unable to comply with the training program 
 
4.3 Excluded or Vulnerable Populations 
• This study will exclude non-English speaking participants as they would not 
be able to complete intensive survey requirement of the study as all surveys 
will be administered in the English language.  
 
5.0 
Participant Enrollment 

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• Participants will be recruited by referral to the PI by Dr. Roberts at the 
National Football Foundation. He will provide potential participants with an 
information sheet that will provide a brief summary of the research study 
and who to contact, if interested. 
• Eligible participants will give voluntary informed consent to participate in the 
study. 
 
 6.0 
Study Design and Procedures 
 
The study will include 20 retired APF players participating in a 18 month exercise 
rehabilitation. The study will consist of 94 visits (4 study testing visits and 90 exercise 
visits). Participants will come in for data collection visits at baseline (prior to starting 
the exercise program), at 6 months, 12 months, 18 months (after ending the exercise 
program). Each of those visits will take about 2-3 hours. All testing done in the 4 test 
visits will help assess the participant’s cardiovascular and functional responses 
and/or changes to the exercise intervention as indicated in the Objectives/Aims 
Section. The next section contains a list of the tests that will be performed at each 
visit.  After the initial baseline visit, participants will come twice weekly, for roughly 1 
hour each session, for 6 months (52 visits). From 6-12months, participants will come 
once a week, for roughly 1 hour each session (26 additional visits).  From 12-18 
months, participants will come twice a month, for roughly 1 hour sessions (12 visits). 
All study testing visits will occur at the UIC-DHSP, located at 1640 W. Roosevelt 
Road in Suites 158, 190, and 195, Chicago, IL 60608. All exercise intervention 
training visits will occur at Gh Fitlab, located at 1730 N Western Ave., Chicago, IL 
60647. 
 
Study Testing Visits: 
Mental Health and Quality of Life Assessments 
The following questionnaires will be performed at baseline, 6 months, 12 months, and 
18 months (please see protocol appendices for all questionnaires and data 
collection documents): 
• Measures of Pain and Disability: The transition from acute to chronic pain is 
associated with the fear that movement will promote significant pain or re-
injury. To avoid pain, movement is avoided which leads to disuse, disability, 
and depression. Hence, measures of baseline pain will include two measures 
29. The Numeric Rating Scale for Pain, is a visual analog scale in which the 
participant selects the number which best reflects the intensity of pain; this 
requires 1 minute to complete. The Pain Catastrophizing Scale is a 13 item 
scale which takes approximately 5 minutes to complete and assesses the 
degree of fear, and three subscale scores assessing rumination, magnification 
and helplessness 30. 

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• The PROMIS v.1.1 - Global Health short form will be administered to all 
participants. The PROMIS v.1.1 - Global Health short form will assesses 
health in general (i.e. overall health). The PROMIS Global Health short form is 
a 10-item instrument representing multiple domains (physical function, fatigue, 
pain, emotional distress, social health) as well as perceptions of general health 
that cut across domains. Global items allow respondents to weigh together 
different aspects of health to arrive at a “bottom-line” indicator of their health. 
Similar global health items have been found predictive of future health care 
utilization and mortality. 
• PROMIS 29 Profile v2.0 will be administered to all participants. The PROMIS 
29 Prolife v2.0 is a short form containing four items from seven PROMIS 
domains (Depression, Anxiety, Physical Function, Pain Interference, Fatigue, 
Sleep Disturbance, and Ability to Participate in Social Roles and Activities) 
along with a single item on Pain Intensity. 
• SF 36 will be administered to all participants.. The SF-36 has eight scaled 
scores; the scores are weighted sums of the questions in each section. Scores 
range from 0 - 100 Lower scores = more disability, higher scores = less 
disability Sections: • Vitality • Physical functioning • Bodily pain • General 
health perceptions • Physical role functioning • Emotional role functioning • 
Social role functioning • Mental health  
• The Beck’s Depression Inventory (BDI) will be administered.. BDI is a 
validated to measure depression in a general medical population and in 
chronic disease participants. 
• Fatigue: The Fatigue Severity Index is one of the few assessments which 
allows assessment over time 30. It requires 5 minutes to complete 
Body composition, strength and functional capacity 
All of the following assessments will be performed at baseline, at 6 months, 12 
months, and 18 months. 
• BMI will be calculated.  The participants will be DEXA scanned to provide the 
data about lean/fat tissue in specific body regions. Waist circumference as well 
as blood pressure will be measured for general health markers.  
• Waist Circumference: Waist circumference will be measured for general health 
markers.  Measurements will be taken at the narrowest part of the torso 
(above the umbilicus and below xiphoid process) in the standing position using 
a tape measure. 
• Blood Pressure: Blood pressure will be measured in the seated position in a 
dimly lit room after resting for five minutes. Resting blood pressure will be 
measured in the brachial artery using a digital sphygmomanometer according 
to the guidelines of the American Heart Association. Blood pressure will be 

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measured twice, one minute apart, and the average of the two values will use 
as resting blood pressure. 
• DEXA Scan: We will determine percent body fat via a whole body scan by dual 
energy x-ray absorptiometry (GE, IDXA, Madison, Wi), which will be operated 
and calibrated using the manufacturer’s stated guidelines.  The duration of the 
scan will be less than 10 min and the participant will be exposed to a radiation 
dose of 0.3 mrem based upon the manufacturer’s specifications and 
calculations from Standford Dosiometry, LLC RADAR Medical Procedure 
Radiation Dose Calculator.  This amount of research protocol radiation 
exposure is minimal given the estimated effective equivalent dose is below the 
100 mrem per year, a limit set by the Nuclear Regulatory Commission for 
“general public” exposure. 
• Grip strength in kilogram (kg), average of three trials. This will be measured in 
each participants’ dominant hand using a hand dynamometer. Contractions 
will be performed in the seated position with the dominant arm at a 90 degree 
angle. 
• Gait speed in meters/second. Participants will be asked to walk eight feet as 
quickly as they could. Participants unable to walk at all (i.e., wheelchair bound) 
were assigned a gait speed of 0.01 meters/second. 
• Timed repeated chair stands. Starting from a seated position, participants will 
be asked to stand up and sit down without using their arms for assistance for a 
total of five times without assistance. Participants unable to perform this test at 
all were assigned a chair stands score of 32 seconds, the 99%ile value among 
participants who were able to perform this test. Participants will also be asked 
to continue performing sit to stands until they feel they are unable to do 
anymore. This number will be collected as their maximum sit to stand score.  
• Short Physical Performance Battery. It comprises a summary of three separate 
measures (maximum of 4 points for each component): gait speed, balance, 
and timed repeated chair stands. This test requires the assessment of walking 
speed (time to walk 3 meters), a balance test (standing in 3 different positions 
for 10 seconds each-tandem, semi tandem, and side by side), and the time it 
takes to sit and stand 5 times in a chair (see above). Scoring is based on a 
scale of 0-12, lower numbers representing worse performance. Participants 
who cannot complete the test will receive a predetermined score or “0” that 
represents “not able”.  The Short Physical Performance Battery takes 
approximately 2–3 minutes to complete.1RM leg press strength testing: 
Participants will perform a warm-up set of 10 repetitions of a leg press at 
estimated 50% of 1RM, followed by a set of 5 repetitions at estimated 70% of 

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1RM, and a set of 3 repetitions at estimated 80% of 1RM. Participants then 
incrementally increased the weight after each successful 1RM attempt, defined 
as controlling the movement through the entire concentric and eccentric 
motions. 1RM was determined to be the most weight lifted one time after three 
consecutive failures of an increased weight (Protocol approved in study 
#2017-1016) 
• Participants will be assessed for their maximum weight lifted during a training 
session.. This data is a cumulated number of all weight lifted during all exercises 
and repetitions performed in a single training session (60 minutes). At baseline, a 
maximum weight lifted will be determined as the total of all weight lifted for all 
muscle groups in a single session.  This total will encompass all reps done of 
each exercise/weight, for an overall total. (example if 5 reps of 100lbs were done 
in arms and 5 reps of 100 pounds were done in legs in one session, the total 
weight lifted for that day would be 1000 lbs). 
 
Measures of brain anatomy and function  
All of the following assessments will be performed at baseline, at 6 months, 12 
months, and 18 months. 
•   A Quantitative Electroencephalogram (QEEG) is noninvasive, 19 sensors 
instrument, which produces comprehensive analysis of individual frequencies 
that make up the raw electroencephalograph (EEG) by measuring brain wave 
activities. A special cap made of stretchy material will be placed on the 
participant’s head that have these 19 sensors. The data gathered from QEEG 
is utilized for the creation of topographic brain maps of color-coded 
simulations of the electrical activity of the cerebral cortex, which can then be 
compared to a normative database and used for statistical analyses31. 
QEEG will be recorded during rest (in two conditions, eyes closed and eyes 
open) in order to get an understanding of differences in oscillatory activation 
across the full spectrum of QEEG bandwidths. Neli Cohen, PhD, Director, 
Holistic Neuro Psychological Interventions, (HNPI) (https://  
www.holisticneuropsych.com/about-us), will provide neurocognitive 
assessments. Dr. Cohen has treated football players with traumatic brain 
injuries and is extremely dedicated to the improvement in the quality of life of 
participants suffering with chronic pain. She will investigate brain functioning 
with QEEG two analyses: Spectral Analysis and LORETA. Maab Osman, 
Neuropsychological Technician, HNPI, will assisting Dr. Neli Cohen. The 
QEEG equipment will be brought to UIC-DHSP and tests will be performed 
on campus.  
•   The Integrated Visual and Auditory Scale (IVA-2) measures visual and 
auditory responses as a test of sustained attention32. Specifically, it measures 

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vigilance, focus, speed, prudence, consistency, stamina, comprehension, 
persistence and sensory /motor responses. This test is administered by 
computer and will be performed on campus. More information on this test can 
be found at https://www.braintrain.com/iva2/ . 
 
Employment Status 
• Employment status will be assessed through participant response at baseline, 
at 6 months, 12 months, and 18 months. 
 
Other measurements: Height and weight will be measured and body mass index will 
be calculated as weight (kg) divided by height (m) squared. Age, race, years in the APF 
league, number of concussions, number of fractures,  surgical history, and list of pain 
medications will be verbally asked for as part of qualitative data collection. 
Exercise Training Visits: 
Exercise Training Visits (GH Method session): 
• Participants will attend 2 trainings sessions a week from 0-6 months (52 visits). 
From 6-12 months, participants will attend 1 training session a week (26 
visits). From 12-18 months, participants 2 trainings sessions a month (12 
visits). Participants will complete a total of 90 exercise training visits in 18 
months. Each training session will be roughly an hour. All of these visits will 
occur at 1730 N Western Ave. Chicago IL 60647. 
• At least twice per week, GH personnel will attempt to follow-up with 
participants via text message, email or a phone call to evaluate their physical 
recuperation and overall health and energy or to track their performance with a 
behavior change goal. 
Consent Addendum (optional) 
• 
In a separate consent addendum, enrolled participants will be asked if they 
would like to provide their written permission to allow the GH team, and 
research staff to take photographs, or produce videotapes, or other types of 
media productions that capture their name, voice and/or image, and used for, 
but is not limited to: 
o Medical and/or educational training 
o Study Recruitment (i.e. participant progress videos may be created, at a 
later date, to be shown in addition to the recruiting info sheet) 
o Presentations and/or Publications 
o Fundraising (i.e. participant progress videos may be included on a 
future UIC donation page regarding this research (not yet created)) 
o Websites and social media 

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 The consent addendum will be thoroughly explained to the participants, which will detail 
all the uses of media production. Participants will be ensured that the items included in 
the consent addendum are optional and will not affect their current study participation. 
They will be notified that they can withdraw consent at any time and any media 
production will be destroyed.  Participants will be approached to sign the consent 
addendum at a study or exercise visit. Any uses for publicity or advertising for the 
fitness program that are not related to the research study will not be described or 
solicited from participants in the consent addendum. Research participants will not be 
asked to stage photographs, speech or video for promotional purposes as part of the 
research study.  In addition to the consent addendum, all participants will also sign the 
“UIC/UI Health Reporting, Publication or Broadcast Release for patients” for release of 
protected health information to media, which is available online: 
https://today.uic.edu/resources/photo-video-policies. Any media production will be sent 
to UIC’s Office of Public and Government Affairs and IRB review prior to release. 
 
 
Participants will be asked to complete a regimen based on the following: 
 
Summary of GH Study Visits: 
• Participants may be asked to repeat previous weeks and/or skip a particular 
week depending on their energy, progress, and overall health.  
• Depending on a participant’s individual physical need, mobility, the program may 
be slightly modified (number of repetitions, number of exercises, etc...) to be safe 
and appropriate for that individual.  
• Each week comprises two different exercise days, each incorporating 
approximately 5-10 minute light warm-up plus stretching and then the exercises. 
• On Weeks 6, 13,18, 25, 41, and 52 participants will focus on cardio and 
endurance exercises. These exercises may include running in place, or using a 
recumbent (stationary) bike. All other weeks consist of basic strength 
training/resistance workouts. 
• The attached exercise list includes all possible strength training exercises, and 
clients complete the appropriate exercises for that week during their two, one-
hour appointments each week.  Depending on a participants particular physical 
health (e.g. shoulder problems) certain exercises may be eliminated or modified 
in terms of the safe range of motion and intensity.  
• These sessions can be directly supervised by the GH instructors or performed by 
trained personnel implementing written instructions given by the instructors.   
 
• We would like participants to follow Table 1 on page 11-12 of the protocol as 
closely as possible. There is a set structure for the categories and duration of 
exercises as part of this research. However, intensity/weight for each participant 
will vary depending on personal ability. Keeping the participants safe is our main 
priority. 
Table 1 
Week 
Overview 
Intensity/Weight Breaks 

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Week 1 
1st Set:  30 Seconds with Only 
Safety Instruction 
2nd Set:  90 Seconds with 
More Focus on Form 
Light 
2 or more 
minutes 
Week 2 
1st Set:  Holding at top and 
bottom of range (20 seconds 
each hold) 
2nd Set:  20 rep’s and possible 
to add plus 5 depending on 
energy 
Light 
2 or more 
minutes 
Week 3 
1st Set:  Warm-Up of 15 
repetitions 
2nd Set:  Resistance focused 
60 seconds, possible plus 5 
Light/Moderate 
2 or more 
minutes 
Week 4 
3 Sets for every exercise.  
Each set is 12 repetitions with 
some holding for five 
seconds.   
Moderate 
30 seconds 
between sets.  2 
minutes 
between 
exercises. 
Week 5 
1 Warm Up Set of 15 
repetitions. 
1 Heavier Set of 11 
Repetitions. 
Moderate/Heavy 3 minute breaks 
Week 6 
Cardio Exercises (e.g. run in 
place, or on a recumbent 
bike).  5 different exercises 
are done as one round and 
two rounds total. 
Light/Moderate 
2 minutes 
between 
exercises and 4 
minutes 
between rounds. 
Week 7 
1st Set:  Warm up of 12 
repetitions. 
2nd Set: 6 repetitions 
Moderate/Heavy 3 minutes 
Week 8 
1 Set:  90 seconds 
Light 
3 minutes 
Week 9  1 Warm Up Set of 15 
Repetitions. 
3 Sets of 6-8 repetitions 
(depending on exercise) 
Moderate/Heavy 3 minutes 
Week 
10 
3 Sets of Declining Heaviness 
with 6 reps, 8 reps, and 10 
reps 
Moderate 
3 minutes 
Week 
11 
2 Sets Per Exercise without 
break between:  18 reps and 
16 reps 
Moderate/Light 
2 minutes 
Week 
12 
1 Set of 25 - 30 repetitions 
Moderate/Light 
2 minutes 

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Week 
13 
Cardio Exercises (e.g. run in 
place, or on a recumbent 
bike).  7 different exercises 
are done as one round and 
three rounds total. 
Moderate 
2 - 3minutes 
Week 
14 
1 Set of 12 - 16 Repetitions 
Moderate 
2 minutes 
Week 
15 
3 Sets of declining heaviness 
with 8, 10 and 12 repetitions 
Moderate 
3 minutes 
Week 
16 
3 Exercises in Each Set and 7 
sets 
Moderate 
3 minutes 
Week 
17 
1 Set 90 Seconds 
Moderate/Light 
3 minutes 
Week 
18 
Cardio Exercises (e.g. run in 
place, or on a recumbent 
bike).  3 different exercises 
per set.  3 Sets equal one 
Round.  Three Rounds total 
Light 
2 minutes 
Week 
19 
1 Warm-Up Set of 12 
repetitions 
1 Set of 7 Repetitions 
Moderate/Heavy 3 Minutes 
Week 
20 
1 Set of 25 - 30 Repetitions 
Moderate 
3 Minutes 
Week 
21 
1st Set:  Warm up of 12 
repetitions. 
2nd Set: 6 repetitions 
Moderate/Heavy 3 minutes 
Week 
22 
1 Set:  35 - 40 repetitions  
Moderate/Light 
3 minutes 
Week 
23 
1 Warm Up Set:  15 
repetitions 
1 Heavier Set 8 - 10 
repetitions 
Moderate/Heavy 3 minutes 
Week 
24 
1 Set of 90 Seconds focused 
on resistance 
Moderate 
3 minutes 
Week 
25 
Cardio Exercises (e.g. run in 
place, or on a recumbent 
bike).  10 exercises in a set.  2 
Sets. 
Moderate 
3 minutes 
Week 
26 
3 Exercises in 1 Set.  9 Sets. 
Moderate 
3 minutes 

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Week 
27 
1 Warm Up Set:  8 – 12 reps. 
1 Heavy Set:  8 – 12 reps.  
Slower Speed. 
Moderate/Heavy 2 minutes 
Week 
28 
1 Warm Up Set 8 reps 
1 Heavy Set 8 reps.  Medium 
speed. 
Heavy 
3 minutes 
Week 
29 
3 Sets on each exercise of 6, 
8, 12 repetitions. Lower 
weights each set.  Medium 
speed. 
Moderate 
3 minutes 
Week 
30 
1 set 90 seconds.  Medium 
speed. 
Lighter 
2 minutes 
Week 
31 
1 Warm Up Set:  8 – 12 reps. 
1 Heavy Set:  8 – 12 reps.  
Slower Speed. 
Moderate/Heavy 2 minutes 
Week 
32 
3 Sets on each exercise of 6, 
8, 12 repetitions. Lower 
weights each set.  Medium 
speed. 
Moderate 
3 minutes 
Week 
33 
1 set 90 seconds.  Medium 
speed. 
Lighter 
2 minutes 
Week 
34 
1 Warm Up Set:  8 – 12 reps. 
1 Heavy Set:  8 – 12 reps.  
Slower Speed. 
Moderate/Heavy 2 minutes 
Week 
35 
3 Sets on each exercise of 6, 
8, 12 repetitions. Lower 
weights each set.  Medium 
speed. 
Moderate 
3 minutes 
Week 
36 
1 set 90 seconds.  Medium 
speed. 
Lighter 
2 minutes 
Week 
37 
1 Warm Up Set:  8 – 12 reps. 
1 Heavy Set:  8 – 12 reps.  
Slower Speed. 
Moderate/Heavy 2 minutes 
Week 
38 
2 Sets Per Exercise without 
break between:  18 reps and 
16 reps 
Moderate/Light 
2 minutes 
Week 
39 
3 Sets on each exercise of 6, 
8, 12 repetitions. Lower 
weights each set.  Medium 
speed. 
Moderate 
3 minutes 

GH APF Protocol, Version 8, Date: 03/24/21 
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Week 
40 
1 set 90 seconds focused on 
resistance.  Medium speed. 
Lighter 
2 minutes 
Week 
41 
Cardio Exercises.  10 
exercises in a set.  2 Sets. 
Moderate 
3 minutes 
Week 
42 
1 Warm Up Set:  8 – 12 reps. 
1 Heavy Set:  8 – 12 reps.  
Slower Speed. 
Moderate/Heavy 2 minutes 
Week 
43 
3 Sets on each exercise of 6, 
8, 12 repetitions. Lower 
weights each set.  Medium 
speed. 
Moderate 
3 minutes 
Week 
44 
1 set 90 seconds focused on 
resistance.  Medium speed. 
Lighter 
2 minutes 
Week 
45 
1 Warm Up Set:  8 – 12 reps. 
1 Heavy Set:  8 – 12 reps.  
Slower Speed. 
Moderate/Heavy 2 minutes 
Week 
46 
3 Sets on each exercise of 6, 
8, 12 repetitions. Lower 
weights each set.  Medium 
speed. 
Moderate 
3 minutes 
Week 
47 
1 set 90 seconds focused on 
resistance.  Medium speed. 
Lighter 
2 minutes 
Week 
48 
1 Warm Up Set:  8 – 12 reps. 
1 Heavy Set:  8 – 12 reps.  
Slower Speed. 
Moderate/Heavy 2 minutes 
Week 
49 
3 Sets on each exercise of 6, 
8, 12 repetitions. Lower 
weights each set.  Medium 
speed. 
Moderate 
3 minutes 
Week 
50 
1 set 90 seconds focused on 
resistance.  Medium speed. 
Lighter 
2 minutes 
Week 
51 
1 Warm Up Set 8 reps 
1 Heavy Set 8 reps 
Heavy 
3 minutes 
Week 
52 
Cardio Exercises.  10 
exercises in a set.  2 Sets. 
Moderate 
3 minutes 
Week 
54 
1 Warm Up Set of 15 
repetitions. 
1 Heavier Set of 11 
Repetitions. 
Moderate/Heavy 3 minute breaks 

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Week 
56 
1 Warm Up Set of 15 
Repetitions. 
3 Sets of 6-8 repetitions 
(depending on exercise) 
Moderate/Heavy 3 minutes 
Week 
58 
1 Set of 25 - 30 Repetitions 
Moderate 
3 Minutes 
Week 
60 
1st Set:  Warm up of 12 
repetitions. 
2nd Set: 6 repetitions 
Moderate/Heavy 3 minutes 
Week 
62 
1 Set:  35 - 40 repetitions  
Moderate/Light 
3 minutes 
Week 
64 
1 Warm Up Set:  15 
repetitions 
1 Heavier Set 8 - 10 
repetitions 
Moderate/Heavy 3 minutes 
Week 
66 
1 Warm Up Set:  8 – 12 reps. 
1 Heavy Set:  8 – 12 reps.  
Slower Speed. 
Moderate/Heavy 2 minutes 
Week 
68 
1 Warm Up Set 8 reps 
1 Heavy Set 8 reps.  Medium 
speed. 
Heavy 
3 minutes 
Week 
70 
1 Warm Up Set:  8 – 12 reps. 
1 Heavy Set:  8 – 12 reps.  
Slower Speed. 
Moderate/Heavy 2 minutes 
Week 
72 
3 Sets on each exercise of 6, 
8, 12 repetitions. Lower 
weights each set.  Medium 
speed. 
Moderate 
3 minutes 
Week 
74 
1 Warm Up Set:  8 – 12 reps. 
1 Heavy Set:  8 – 12 reps.  
Slower Speed. 
Moderate/Heavy 2 minutes 
Week 
76 
1 Warm Up Set:  8 – 12 reps. 
1 Heavy Set:  8 – 12 reps.  
Slower Speed. 
Moderate/Heavy 2 minutes 
Week 
78 
1 Warm Up Set:  8 – 12 reps. 
1 Heavy Set:  8 – 12 reps.  
Slower Speed. 
Moderate/Heavy 2 minutes 
 
GH Method:  List of Strength/Resistance Exercises 
 
 
 
 
 
 
 
  

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Exercise 
Chest:  Smith Bench Press/Incline 
Glutes:  Abductor 
Biceps:  Cable Easy Curl/Free Bar 
Quads:  Leg Extension 
Calves:  Calf Machine 
Biceps:  Preacher 
Quads:  Leg Press 
Quads:  Leg Extension 
Abs:   Decline 
Back:  Pull Down Behind 
Hamstring:  Curl Machine 
Shoulders:  Dumbbell Press / Smith Press 
Back:  Low Roll  
Hamstring:  Good Morning with Dumbbell/ 1 
Leg Hamstring Curl 
Shoulders:  Side Rise with Dumbbells 
Triceps:  Push Down / Kick Back 
Abs:  Sit Ups 
Triceps:  Close Grip 
 
 
Flow Chart: 
 
 
 
 
 
 
 
 
 
7.0 
Expected Risks/Benefits 
 
The main risk of this research is loss of confidentiality of medical information.  Consent 
will be obtained for all participants. Master participant code list will be kept in a separate 
file accessible only by the primary investigator. A member of the UI healthcare team will 
be available to answer any questions or discuss any concerns that participants may 
have.  The participant may also experience mild anxiety or discomfort in providing 
information via questionnaires, or computer program, about your their health,  well-
being and brain function.  
 
Risks associated with the consent addendum:   
Baseline: All 
Data Collection 
Measures Listed 
Above 
Throughout: Exercise rehabilitation sessions (details listed above); 0-6 months: 2 days/week; 6-12 
months 1hour/session, 12-18 months 2 days/month 
6 months: All 
Data Collection 
Measures Listed 
Above 
12 months: All 
Data Collection 
Measures Listed 
Above 
18 months: All 
Data Collection 
Measures Listed 
Above 

GH APF Protocol, Version 8, Date: 03/24/21 
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The main risk is loss of confidentiality. Participants may also have a potential to feel 
anxiety when we take photographs, videotapes, or other types of media productions that 
capture their name, voice and/or image or when completing questionnaires. 
 
Risk associated with grip strength (Dynamometer) and 1RM tests include:  
Shortness of breath, fatigue, strains, sprains, and muscle soreness.  
 
Risks associated with physical activity including 3 meter walk, sit to stand, and short 
performance battery tests includes: 
Fatigue, being out of breath, muscle soreness, heart rhythm irregularities, dizziness, 
loss of consciousness and even death.  However, serious adverse events (side effects) 
are very rare and by careful screening and monitoring during the test, the risks of such 
events are minimized.  Further risks include slips and trips possibly resulting in ankle 
sprains and falls.  These risks will be minimized by having a research assistant within 
arm’s reach for stability.  All personnel assisting in testing are trained in CPR and 
emergency lab procedure. 
 
Risks associated with radiation exposure from the DEXA scan: 
The participant will be exposed to a radiation dose of less than or equal to 0.3 mrem 
based upon manufacturer’s specifications and pre-determined calculations.  This 
amount of radiation exposure is minimal given the estimated effective equivalent dose is 
below 100 mrem per year, a limit set by the Nuclear Regulatory Commission for 
“general public” exposure. 
 
Risk associated with a QEEG:  
An QEEG has no known medical risks. 
 
 
8.0 
Data Collection and Management Procedures 
Data collected from the participant will be collected on paper forms and transferred and 
kept in an excel database. Data collected will be used for research purposes for future 
publications, presentations and posters (if applicable) in order to analyze the outcomes. 
Record of data will be locked and stored in an electronic data file stored on hospital H 
drive and N drive using sequential, numeric code (001, 002, 003, etc.) on a password-
protected computer in a locked office . Master key linking code with participant name 
will be held in a separate file accessible only to the PI.  Limited access will be given to 
pre-determined personnel listed in Appendix P. Master participant list will be locked in 
suite 840 South Wood Street, Suite 617 Clinical Sciences North Building Chicago, IL 
60612-7316. Additional data collection excel documents are being kept at 1640 W. 
Roosevelt Rd, Chicago IL, 60608, UIC-DHSP.. Electronic original media production will 

GH APF Protocol, Version 8, Date: 03/24/21 
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be stored on a secured hospital server, N drive. Only investigator and co-investigators 
will have access to study data. 
 
9.0 
Data Analysis 
The coded collected data will be entered into a SAS database. Initial descriptive 
analysis will include calculating means, standard deviations, ranges and frequencies. 
ANOVA tests for continuous variables and Chi Square or Fischer exact tests of 
association for categorical variables will be used to compare results of the study for the 
efficacy parameters listed above. A P value<0.05 will be considered significant. 
 
11.0 Data and Safety Monitoring 
This protocol is not a drug or device research study, and for that reason, monitoring by 
a Data Safety Monitoring Board is not required at this time.  
  
All adverse events related to the physical therapy of the research will be reported 
promptly to the IRB. If a breach of participant privacy/confidentiality, occurs that the 
study PI views as greater than a minor occurrence, the IRB will be notified of such at the 
time of discovery and a mitigation plan will be developed in consultation with the IRB. 
Problems and adverse events will be identified by the investigator or co-investigator 
based on participant self-reporting at each visit and will be reported to the IRB when 
applicable per IRB policy. If participants declare that they have suicidal 
thoughts/intentions via the Beck’s Depression Inventory questionnaire, they will be 
asked if they have a plan for following through with suicidal intentions.  If they say yes, 
they will be sent to the ED. If they say they do not, the patient will be asked to follow up 
with their PCP to discuss potential depression. 
 
 Participants have the right to withdraw from (i.e., discontinue participation in) research 
at any time. If a participant decides to withdraw from all components of a research 
study, the investigator will discontinue all research activities involving that participant’s 
participation in that study. 
 
 
11.1  Monitoring and Reporting AE & SAEs 
The investigator will monitor participants for the occurrence of adverse events during 
the course of the study. The investigator will instruct participants to report any physical 
changes or new symptoms that they notice during the course of the study.  
 
Physicians and health care personnel involved in the participant’s medical care will be 
instructed to report all serious adverse events (defined above) as soon as possible to: 
 
Enrico Benedetti, MD  

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Department of Surgery 
University of Illinois 
840 South Wood Street, Suite 402 (MC958) 
Chicago, IL 60612 
Tel: 312 355-1493 
Email: enrico@uic.edu 
 
When an SAE is considered reportable to regulatory agencies, Dr. Benedetti will 
prepare the initial report and forward copies the Institutional Review Board (IRB) within 
the appropriate timeframe delegated by the IRB. Serious events will be followed until 
resolved or considered stable. The following attributes must be assigned: description, 
date of onset and resolution (if known when reported), severity, assessment of 
relatedness to test therapy, and action taken.  
 
12.0 Statistical Considerations 
The efficacy of the methods will be determined by comparing the same group’s 
baseline, 6 month and 12 month data. These factors will be analyzed: 
  
1. a significant difference in term of pre and post treatment perception of well-being  
   
2.a  significant difference in the lean/fat body mass ratio  
  
3. a significant difference in BMI  
 
4. Changes in strength, physical performance, and QEEG patterns.   
                                                            
  
The data will be entered into an Excel spreadsheet and stored on the UIMCC hospital 
server. The participant data, including age, sex, race, underlying kidney disease, length 
of hospital stay, rejection episode, comorbidities, and medications will be coded and 
participant names will not be included in the datasheet.  
 
The coded collected data will be entered into a SAS database. Initial descriptive 
analysis will include calculating means, standard deviations, ranges and frequencies. 
ANOVA tests for continuous variables and Chi Square or Fischer exact tests of 
association for categorical variables will be used to compare results of the study for the 
efficacy parameters listed above. A P value<0.05 will be considered significant. 
 
13.0 Regulatory Requirements 
13.1 Informed Consent  
This will occur in the UIC-DHSP building, located at 1640 W. Roosevelt Road. 
Participants will come to UIC per referral and information sheet. Participants will 

GH APF Protocol, Version 8, Date: 03/24/21 
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be screened using the screening eligibility form, before enrolling in the study. The 
study will be discussed with the potential participant by designated authorized 
research personnel. The consent will be reviewed, and any questions will be 
answered. The participant will be able to decide if they would like to participate in 
the study. It will be reinforced that participation is completely voluntary. If they are 
interested and state that they can comply with the study requirements, they will 
sign the consent form and then proceed with physical assessments and study 
visits.  
13.2 Subject Confidentiality  
The medical and research record will be confidential to the extent permitted by 
law. Study participants will be identified by a code for the research records which 
will be stored on a password protected computer in the principal investigators 
office.  Personal information from research records will not be released without 
written permission by the participant except: 
- 
If necessary to protect the participant’s rights and welfare (for example, if the 
participant is injured and needs emergency care or when the UIC Institutional 
Review Board monitors the research or consent process) 
- 
If required by law 

GH APF Protocol, Version 8, Date: 03/24/21 
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14.0 REFERENCES 
 
1. 
Gureje, O., Von Korff, M., Simon, G.E. & Gater, R. Persistent pain and well-
being: a World Health Organization Study in Primary Care. JAMA : the journal 
of the American Medical Association 280, 147-151 (1998). 
2. 
Rivara, F.P., et al. Prevalence of pain in patients 1 year after major trauma. 
Arch Surg 143, 282-287; discussion 288 (2008). 
3. 
Mkandawire, N.C., Boot, D.A., Braithwaite, I.J. & Patterson, M. Musculoskeletal 
recovery 5 years after severe injury: long term problems are common. Injury 33, 
111-115 (2002). 
4. 
Castillo, R.C., MacKenzie, E.J., Wegener, S.T., Bosse, M.J. & Group, L.S. 
Prevalence of chronic pain seven years following limb threatening lower 
extremity trauma. Pain 124, 321-329 (2006). 
5. 
Monty602. The NFL’s Problem with Pain: Part One. Vol. 2019 (ed. SBNation) 
(Vox Media, 2016). 
6. 
Lame, I.E., Peters, M.L., Vlaeyen, J.W., Kleef, M. & Patijn, J. Quality of life in 
chronic pain is more associated with beliefs about pain, than with pain intensity. 
Eur J Pain 9, 15-24 (2005). 
7. 
Breivik, H., Collett, B., Ventafridda, V., Cohen, R. & Gallacher, D. Survey of 
chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J 
Pain 10, 287-333 (2006). 
8. 
Cottler, L.B., et al. Injury, pain, and prescription opioid use among former 
National Football League (NFL) players. Drug Alcohol Depend 116, 188-194 
(2011). 
9. 
Deyo, R.A., Von Korff, M. & Duhrkoop, D. Opioids for low back pain. BMJ 350, 
g6380 (2015). 
10. 
Els, C., et al. Adverse events associated with medium- and long-term use of 
opioids for chronic non-cancer pain: an overview of Cochrane Reviews. 
Cochrane Database Syst Rev 10, CD012509 (2017). 
11. 
Chou, R., et al. The effectiveness and risks of long-term opioid therapy for 
chronic pain: a systematic review for a National Institutes of Health Pathways 
to Prevention Workshop. Ann Intern Med 162, 276-286 (2015). 
12. 
Turk, D.C., Wilson, H.D. & Cahana, A. Treatment of chronic non-cancer pain. 
Lancet 377, 2226-2235 (2011). 
13. 
Geneen, L.J., et al. Physical activity and exercise for chronic pain in adults: 
an overview of Cochrane Reviews. Cochrane Database Syst Rev 4, CD011279 
(2017). 
14. 
May, A. Chronic pain may change the structure of the brain. Pain 137, 7-15 
(2008). 
15. 
Apkarian, A.V., et al. Chronic back pain is associated with decreased prefrontal 
and thalamic gray matter density. J Neurosci 24, 10410-10415 (2004). 
16. 
Schmidt-Wilcke, T., et al. Affective components and intensity of pain correlate 
with structural differences in gray matter in chronic back pain patients. Pain 125, 
89-97 (2006). 
17. 
Buckalew, N., Haut, M.W., Morrow, L. & Weiner, D. Chronic pain is associated 
with brain volume loss in older adults: preliminary evidence. Pain Med 9, 240-
248 (2008). 
18. 
Seminowicz, D.A., et al. Effective treatment of chronic low back pain in humans 
reverses abnormal brain anatomy and function. J Neurosci 31, 7540-7550 
(2011). 
19. 
Eliassen, J.C., Souza, T. & Sanes, J.N. Human brain activation accompanying 
explicitly directed movement sequence learning. Experimental brain research. 

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Experimentelle Hirnforschung. Experimentation cerebrale 141, 269-280 (2001). 
20. 
Halsband, U. & Lange, R.K. Motor learning in man: a review of functional and 
clinical studies. J Physiol Paris 99, 414-424 (2006). 
21. 
Wulf, G. Attentional focus and motor learning: a review of 15 years. International 
Review of Sport and Exercise Psychology Volume 6, 77-104 (2013). 
22. 
Snyder, B.J. & Fry, W.R. Effect of verbal instruction on muscle activity during 
the bench press exercise. Journal of strength and conditioning research / 
National Strength & Conditioning Association 26, 2394-2400 (2012). 
23. 
Calatayud, J., et al. Importance of mind-muscle connection during progressive 
resistance training. 
Eur J Appl Physiol 116, 527-533 (2016). 
24. 
Marchant, D.C., Greig, M. & Scott, C. Attentional focusing instructions influence 
force production and muscular activity during isokinetic elbow flexions. Journal 
of strength and conditioning research / National Strength & Conditioning 
Association 23, 2358-2366 (2009). 
25. 
McNevin, N.H. & Wulf, G. Attentional focus on supra-postural tasks affects 
postural control. Hum Mov Sci 21, 187-202 (2002). 
26. 
Matthews, V.B., et al. Brain-derived neurotrophic factor is produced by skeletal 
muscle cells in response to contraction and enhances fat oxidation via activation 
of AMP-activated protein kinase. Diabetologia 52, 1409-1418 (2009). 
27. 
Sakuma, K. & Yamaguchi, A. The recent understanding of the neurotrophin's 
role in skeletal muscle adaptation. J Biomed Biotechnol 2011, 201696 (2011). 
28. 
Kirby, T.J. & McCarthy, J.J. MicroRNAs in skeletal muscle biology and exercise 
adaptation. Free Radic Biol Med 64, 95-105 (2013). 
29. 
Hawker, G.A., Mian, S., Kendzerska, T. & French, M. Measures of adult pain: 
Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain 
(NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain 
Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 
Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant 
Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken) 63 Suppl 11, S240-
252 (2011). 
30. 
Sullivan, M.J. The Pain Catastrophizing Scale User Manual. (2009). 
31. 
Demos JN. Getting started with neurofeedback. W.W. Norton & Company. 
(2005). 
32. 
IVA-2. (ed. BrainTrain, I.) (2019). 
 

GH APF Protocol, Version 8, Date: 03/24/21 
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APPENDICES 
PAPER COLLECTION FORM: 
 
 
GH APF Collection Form: 
ID: 
Baseline visit date: 
6 month date: 
12 month date:  
18 month date: 
Descriptive 
Weight : 
 
 
 
Height: 
 
 
 
Waist Circumference: 
 
 
 
BMI: 
 
 
 
Age/DOB: 
 
 
 
Race: 
 
 
 
Employment Status: 
 
Full or Part Time or Retired: 
 
 
Seeking Employment? 
School? 
 
Full or Part Time: 
 
 
 
BP: 
 
 
Location: 
Questions to verbally ask participant during study visit?: 
Years in APF 
 
 
Number of Concussions  
 
 
Surgery HX 
 
 

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Fracture Hx 
 
 
Taking pain medications?  
List medications:  
 
 
 
 
 
 
 
 

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HAND GRIP STRENGTH 
Dominant hand grip strength (kg)  
 
 
Hand Used: 
1 
2 
3 
Average 
 
 

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SIT-TO-STAND 
Time: _____sec (if five stands are completed)  
Number of Stands Completed:       1 2 3 4 5  
Chair Stand Ordinal Score: _____  
0 = unable  
1 = > 1 
.7 sec  
2 = 16.6-13.7 sec  
3 = 13.6-11.2 sec  
4 = < 11.1 sec 
  
Max Sit to Stand:__________ 

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8 FOOT WALK 
 
Time: _____ sec  
Gait Ordinal Score: _____  
0 = could not do  
1 = >5.7 sec (<0.43 m/sec)  
2 = 4.1-6.5 sec (0.44-0.60 m/sec)  
3 = 3.2-4.0 sec (0.61-0.77 m/sec)  
4 = <3.1 sec (>0.78 m/sec 
 
 
 

GH APF Protocol, Version 8, Date: 03/24/21 
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BALANCE: 
Side by side: 
Circle one number  
2. Held for 10 sec  
1. Held for less than 10 sec; number of seconds held _____  
0. Not attempted 
Semi Tandem 
 
Circle one number  
2. Held for 10 sec  
1. Held for less than 10 sec; number of seconds held _____  
0. Not attempted 
 
Tandem 
Circle one number  
2. Held for 10 sec  
1. Held for less than 10 sec; number of seconds held _____  
0. Not attempted 
 
Balance Ordinal Score: _____  
0 = side by side 0-9 sec or unable  
1 = side by side 10, <10 sec semitandem  
2 = semitandem 10 sec, tandem 0-2 sec  
3 = semitandem 10 sec, tandem 3-9 sec  
4 = tandem 10 sec 
 
 
 

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DEXA 
Percent body fat:  
 
Percent fat-free mass: 
 

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QUESTIONNAIRES (PRINT OUT ATTACHED) SEE BELOW 
 

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PROMIS: 
 
 

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GH APF Protocol, Version 8, Date: 03/24/21 
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GH APF Protocol, Version 8, Date: 03/24/21 
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SF 36 
Medical Outcomes Study Questionnaire Short Form 36 Health Survey 
 
This survey asks for your views about your health. This information will help keep 
track of how you feel and how well you are able to do your usual activities. Thank 
you for completing this survey! For each of the following questions, please circle 
the number that best describes your answer. 
 
1. In general, would you say your health 
is: 
Excellent 
1 
Very good 
2 
Good 
3 
Fair 
4 
Poor 
5 
2. Compared to one year ago, 
Much better now than one year ago 
1 
Somewhat better now than one year ago 
2 
About the same 
3 
Somewhat worse now than one year ago 
4 
Much worse now than one year ago 
5 
 
3. The following items are about activities you might do during a typical day. Does 
your health now limit you in these activities? If so, how much? 
 (Circle One Number on Each Line) 
 
Yes 
(1) 
No 
(2) 
a. Cut down the amount of time you spent on work or other 
activities 
1 
2 
b. Accomplished less than you would like 
1 
2 
c. Were limited in the kind of work or other activities 
1 
2 
d. Had difficulty performing the work or other activities (for 
example, it took extra effort) 
1 
2 
 
4. During the past 4 weeks, have you had any of the following problems with your 
work or other regular daily activities as a result of any emotional problems (such 
as feeling depressed or anxious)? 
(Circle One Number on Each Line) 

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Yes 
No 
a. Cut down the amount of time you spent on work or other 
activities 
1 
2 
b. Accomplished less than you would like 
1 
2 
c. Didn't do work or other activities as carefully as usual 
1 
2 
 
 
6. During the past 4 weeks, to what extent has your physical 
health or emotional problems interfered with your normal 
social activities with family, friends, neighbors, or groups? 
Not at all 
1 
Slightly 
2 
Moderately 
3 
Quite a bit 
4 
Extremely 
5 

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7. How much bodily pain have you had during the past 4 
weeks? 
None 
1 
Very mild 
2 
Mild 
3 
Moderate 
4 
Severe 
5 
Very severe 
6 
8. During the past 4 weeks, how much did pain interfere with 
your normal work (including both work outside the home and 
housework)? 
Not at all 
1 
A little bit 
2 
Moderately 
3 
Quite a bit 
4 
Extremely 
5 
 
These questions are about how you feel and how things have been with you during 
the past 4 weeks. For each question, please give the one answer that comes closest 
to the way you have been feeling. (Circle One Number on Each Line) 
 
9. How much of the time during the past 4 weeks . . . 
All of 
the 
Time 
Most 
of 
the 
Time 
A 
Good 
Bit of 
the 
Time 
Some 
of 
the 
Time 
A 
Little 
of the 
Time 
None 
of 
the 
Time 
a. Did you feel full of pep? 
1 
2 
3 
4 
5 
6 
b. Have you been a very 
nervous person? 
1 
2 
3 
4 
5 
6 
c. Have you felt so down in 
the dumps that nothing 
could cheer you up? 
1 
2 
3 
4 
5 
6 
d. Have you felt calm and 
peaceful? 
1 
2 
3 
4 
5 
6 
e. Did you have a lot of 
energy? 
1 
2 
3 
4 
5 
6 

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All 
of 
the 
Time 
Most 
of 
the 
Time 
A 
Good 
Bit of 
the 
Time 
Some 
of 
the 
Time 
A 
Little 
of the 
Time 
None 
of 
the 
Time 
f. Have you felt 
downhearted and blue? 
1 
2 
3 
4 
5 
6 
g. Did you feel worn out? 
1 
2 
3 
4 
5 
6 
h. Have you been a happy 
person? 
1 
2 
3 
4 
5 
6 
i. Did you feel tired? 
1 
2 
3 
4 
5 
6 
 
 
10. During the past 4 weeks, how much of the time has your 
physical health or emotional problems interfered with your 
social activities (like visiting with friends, relatives, etc.)? 
(Circle One Number) 
All of the time 
1 
Most of the time 
2 
Some of the time 
3 
A little of the time 
4 
None of the time 
5 
 
 
11. How TRUE or FALSE is each of the following statements for you. (Circle 
One Number on Each Line) 
 
 
Definitely 
True 
Mostly 
True 
Don't 
Know 
Mostly 
False 
Definitely 
False 
a. I seem to get sick a little 
easier than other people 
1 
2 
3 
4 
5 
b. I am as healthy as 
anybody I know 
1 
2 
3 
4 
5 
c. I expect my health to get 
worse 
1 
2 
3 
4 
5 
d. My health is excellent 
1 
2 
3 
4 
5 
 
 
 

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SHORT PHYSICAL PERFORMANCE BATTERY 
 
About: This battery assesses lower extremity function in adults. 
 
Items: 5 
 
Reliability: 
Internal consistency of the SPPB is 0.76 
 
Validity: 
Has predictive validity, showing a gradient of risk for mortality, nursing 
home admission, and disability. 
 
Scoring: 
See scoring information in each section. 
Scores range from 0 (worst performance) to 12 (best performance). 
 
References: 
Guralnik, J. M., Simonsick, E. M., Ferrucci, L., Glynn, R. J., Berkman, L. F., 
Blazer, D. G., Scherr, P. A., Wallace, R. B. (1994) A short physical 
performance battery assessing lower extremity function: Association 
with self-reported disability and prediction of mortality and nursing 
home admission. Journal of Gerontology, 49, M85-M94. 
 

GH APF Protocol, Version 8, Date: 03/24/21 
Page 41 of 54 
 
 
REPEATED CHAIR STANDS 
Instructions: Do you think it is safe for you to try and stand up from a chair 
five times without using your arms? Please stand up straight as quickly as 
you can five times, without stopping in between. After standing up each time, 
sit down and then stand up again. Keep your arms folded across your chest. 
Please watch while I demonstrate. I’ll be timing you with a stopwatch. Are 
you ready? Begin 
 
Grading: Begin stop watch when participant begins to stand up. Count aloud 
each time participant arises. Stop the stopwatch when participant has 
straightened up completely for the fifth time. Also stop if the participant uses 
arms, or after 1 minute, if participant has not completed rises, and if 
concerned about the participant’s safety.. Record the number of seconds 
and the presence of imbalance.. Then complete ordinal scoring. 
 
Time:  
sec (if five stands are completed) Number of Stands 
Completed: 1 2 3 4 5 
 
Chair Stand Ordinal Score:   
 
 
0 = unable 
1 = > 16.7 sec 
2 = 16.6-13.7 sec 
3 = 13.6-11.2 sec 
4 = < 11.1 sec 

GH APF Protocol, Version 8, Date: 03/24/21 
Page 42 of 54 
 
 
BALANCE TESTING 
Begin with a semitandem stand (heel of one foot placed by the big toe of the 
other foot). Individuals unable to hold this position should try the side-by-side 
position. Those able to stand in the semitandem position should be tested in 
the full tandem position. Once you have completed time measures, complete 
ordinal scoring. 
 
Semitandem Stand 
Instructions: Now I want you to try to stand with the side of the heel of one 
foot touching the big toe of the other foot for about 10 seconds. You may put 
either foot in front, whichever is more comfortable for you. 
Please watch while I demonstrate. 

 
GH APF Protocol, Version 8, Date: 03/24/21 
Page 43 of 54 
 
 
Grading: Stand next to the participant to help him or her into semitandem 
position. Allow participant to hold onto your arms to get balance. Begin 
timing when participant has the feet in position and lets go. 
 
Circle one number 
2. Held for 10 sec 
1. Held for less than 10 sec; number of seconds held   
 
0. Not attempted 
 
Side-by-Side stand 
Instructions: I want you to try to stand with your feet together, side by side, 
for about 10 sec. Please watch while I demonstrate. You may use your arms, 
bend your knees, or move your body to maintain your balance, but try not to 
move your feet. Try to hold this position until I tell you to stop. 
 
Grading: Stand next to the participant to help him or her into the side- by-
side position. Allow participant to hold onto your arms to get balance. Begin 
timing when participant has feet together and lets go. 
 
Grading 
2. Held of 10 sec 
1. Held for less than 10 sec; number of seconds held  
 
0. Not attempted 
 
Tandem Stand 
Instructions: Now I want you to try to stand with the heel of one foot in front 
of and touching the toes of the other foot for 10 sec. You may put either foot 
in front, whichever is more comfortable for you. Please watch while I 
demonstrate. 
 
Grading: Stand next to the participant to help him or her into the side- by-
side position. Allow participant to hold onto your arms to get balance. Begin 
timing when participant has feet together and lets go. 
 
Grading 
Held of 10 sec 
1. Held for less than 10 sec; number of seconds held  
 

 
GH APF Protocol, Version 8, Date: 03/24/21 
Page 44 of 54 
 
 
0. Not attempted 

 
GH APF Protocol, Version 8, Date: 03/24/21 
Page 45 of 54 
 
 
 
Balance Ordinal Score:   
 
0 = side by side 0-9 sec or unable 
1 = side by side 10, <10 sec semitandem 
2 = semitandem 10 sec, tandem 0-2 sec 
3 = semitandem 10 sec, tandem 3-9 sec 
4 = tandem 10 sec 
 

 
GH APF Protocol, Version 8, Date: 03/24/21 
Page 46 of 54 
 
 
8’ WALK (2.44 METERS) 
Instructions: This is our walking course. If you use a cane or other walking 
aid when walking outside your home, please use it for this test. I want you 
to walk at your usual pace to the other end of this course (a distance of 8’). 
Walk all the way past the other end of the tape before you stop. I will walk 
with you. Are you ready? 
 
Grading: Press the start button to start the stopwatch as the participant 
begins walking. Measure the time take to walk 8’. Then complete ordinal 
scoring. 
 
Time:  
sec Gait Ordinal Score: 
0 = could not do 
1 = >5.7 sec (<0.43 m/sec) 
2 = 4.1-6.5 sec (0.44-0.60 m/sec) 
3 = 3.2-4.0 sec (0.61-0.77 m/sec) 
4 = <3.1 sec (>0.78 m/sec) 
 
Summary Ordinal Score: 
Range: 0 (worst performance) to 12 (best performance). 
 
 
 
 
 
 

 
GH APF Protocol, Version 8, Date: 03/24/21 
Page 47 of 54 
 
 
BECK'S DEPRESSION INVENTORY 
This depression inventory can be self-scored. The scoring scale is at the end of the 
questionnaire. 1. 
0 
I do not feel sad. 
1 
I feel sad 
2 
I am sad all the time and I can't snap out of it. 
3 
I am so sad and unhappy that I can't stand it. 
2. 
0 
I am not particularly discouraged about the future. 
1 
I feel discouraged about the future. 
2 
I feel I have nothing to look forward to. 
3 
I feel the future is hopeless and that things cannot improve. 
3. 
0 
I do not feel like a failure. 
1 
I feel I have failed more than the average person. 
2 
As I look back on my life, all I can see is a lot of failures. 
3 
I feel I am a complete failure as a person. 
4. 
0 
I get as much satisfaction out of things as I used to. 
1 
I don't enjoy things the way I used to. 
2 
I don't get real satisfaction out of anything anymore. 
3 
I am dissatisfied or bored with everything. 
5. 
0 
I don't feel particularly guilty 
1 
I feel guilty a good part of the time. 
2 
I feel quite guilty most of the time. 
3 
I feel guilty all of the time. 
6. 
0 
I don't feel I am being punished. 
1 
I feel I may be punished. 
2 
I expect to be punished. 
3 
I feel I am being punished. 
7. 
0 
I don't feel disappointed in myself. 
1 
I am disappointed in myself. 
2 
I am disgusted with myself. 
3 
I hate myself. 

 
GH APF Protocol, Version 8, Date: 03/24/21 
Page 48 of 54 
 
 
8. 
0 
I don't feel I am any worse than anybody else. 
1 
I am critical of myself for my weaknesses or mistakes. 
2 
I blame myself all the time for my faults. 
3 
I blame myself for everything bad that happens. 
9. 
0 
I don't have any thoughts of killing myself. 
1 
I have thoughts of killing myself, but I would not carry them out. 
2 
I would like to kill myself. 
3 
I would kill myself if I had the chance. 
10. 
0 
I don't cry any more than usual. 
1 
I cry more now than I used to. 
2 
I cry all the time now. 
3 
I used to be able to cry, but now I can't cry even though I want to. 
11. 
0 
I am no more irritated by things than I ever was. 
1 
I am slightly more irritated now than usual. 
2 
I am quite annoyed or irritated a good deal of the time. 
3 
I feel irritated all the time. 
12. 
0 
I have not lost interest in other people. 
1 
I am less interested in other people than I used to be. 
2 
I have lost most of my interest in other people. 
3 
I have lost all of my interest in other people. 
13. 
0 
I make decisions about as well as I ever could. 
1 
I put off making decisions more than I used to. 
2 
I have greater difficulty in making decisions more than I used to. 
3 
I can't make decisions at all anymore. 
14. 
0 
I don't feel that I look any worse than I used to. 
1 
I am worried that I am looking old or unattractive. 
2 
I feel there are permanent changes in my appearance that make me 
look unattractive 
3 
I believe that I look ugly. 
15. 
0 
I can work about as well as before. 
1 
It takes an extra effort to get started at doing something. 

 
GH APF Protocol, Version 8, Date: 03/24/21 
Page 49 of 54 
 
 
2 
I have to push myself very hard to do anything. 
3 
I can't do any work at all. 
16. 
0 
I can sleep as well as usual. 
1 
I don't sleep as well as I used to. 
2 
I wake up 1-2 hours earlier than usual and find it hard to get back to sleep. 
3 
I wake up several hours earlier than I used to and cannot get back to sleep. 
 
17. 
0 
I don't get more tired than usual. 
1 
I get tired more easily than I used to. 
2 
I get tired from doing almost anything. 
3 
I am too tired to do anything. 
18. 
0 
My appetite is no worse than usual. 
1 
My appetite is not as good as it used to be. 
2 
My appetite is much worse now. 
3 
I have no appetite at all anymore. 
19. 
0 
I haven't lost much weight, if any, lately. 
1 
I have lost more than five pounds. 
2 
I have lost more than ten pounds. 
3 
I have lost more than fifteen pounds. 
20. 
0 
I am no more worried about my health than usual. 
1 
I am worried about physical problems like aches, pains, upset 
stomach, or constipation. 
2 
I am very worried about physical problems and it's hard to think of much else. 
3 
I am so worried about my physical problems that I cannot think of anything 
else. 
21. 
0 
I have not noticed any recent change in my interest in sex. 
1 
I am less interested in sex than I used to be. 
2 
I have almost no interest in sex. 
3 
I have lost interest in sex completely. 
 
 
INTERPRETING THE BECK DEPRESSION INVENTORY 
 

 
GH APF Protocol, Version 8, Date: 03/24/21 
Page 50 of 54 
 
 
Now that you have completed the questionnaire, add up the score for each of the 
twenty-one questions by counting the number to the right of each question you 
marked. The highest possible total for the whole test would be sixty-three. This would 
mean you circled number three on all twenty-one questions. Since the lowest 
possible score for each question is zero, the lowest possible score for the test would 
be zero. This would mean you circles zero on each question. 
You can evaluate your depression according to the 
Table below. Total Score  
Levels of Depression 
1-10  
These ups and downs are considered 
normal 11-16 
Mild mood disturbance 
17-20  
Borderline clinical 
depression 21-30  
Moderate depression 
31-40  
Severe 
depression over 40  
 Extreme 
depression 
 

 
GH APF Protocol, Version 8, Date: 03/24/21 
Page 51 of 54 
 
 
PAIN CATASTROPHIZING SCALE (COPYRIGHT 1995, 2001, 
2004, 2006, 2009 MICHAEL JL SULLIVAN, PHD) 
Everyone experiences painful situations at some point in their lives. Such 
experiences may include headaches, tooth pain, joint or muscle pain. 
People are often exposed to situations that may cause pain such as 
illness, injury, dental procedures or surgery. 
We are interested in the types of thoughts and feeling that you have when 
you are in pain. Listed below are thirteen statements describing different 
thoughts and feelings that may be associated with pain. Using the scale, 
please indicate the degree to which you have these thoughts and feelings 
when you are experiencing pain. 
 
Not 
at 
To a 
slight 
To a 
modera
To a 
great 
All 
the 
I worry all the time about whether the pain will end 
0 
1 
2 
3 
4 
I feel I can’t go on 
0 
1 
2 
3 
4 
It’s terrible and I think it’s never going to 
get any better 
0 
1 
2 
3 
4 
It’s awful and I feel that it overwhelms me 
0 
1 
2 
3 
4 
I feel I can’t stand it anymore 
0 
1 
2 
3 
4 
I become afraid that the pain will get worse 
0 
1 
2 
3 
4 
I keep thinking of other painful events 
0 
1 
2 
3 
4 
I anxiously want the pain to go away 
0 
1 
2 
3 
4 
I can’t seem to keep it out of my mind 
0 
1 
2 
3 
4 

 
GH APF Protocol, Version 8, Date: 03/24/21 
Page 52 of 54 
 
 
I keep thinking about how much it hurts 
0 
1 
2 
3 
4 
I keep thinking about how badly I want the 
pain to stop 
0 
1 
2 
3 
4 
There’s nothing I can do to reduce the 
intensity of the pain 
0 
1 
2 
3 
4 
I wonder whether something serious may happen 
0 
1 
2 
3 
4 
 

 
GH APF Protocol, Version 8, Date: 03/24/21 
Page 53 of 54 
 
 
FATIGUE SEVERITY SCALE (FSS) 
Date                                                              
Name                                                                      
 
Please circle the number between 1 and 7 which you feel best fits the following 
statements. This refers to your usual way of life within the last week. 1 indicates 
“strongly disagree” and 7 indicates “strongly agree.” 
 
Read and circle a number. 
Strongly Disagree 
Agree
→ 
Strongly 
1. My motivation is lower when I am 
fatigued
1          2          3 
4 
5          6 
7 
2. Exercise brings on my fatigue. 
1          2          3 
4 
5          6 
7 
3. I am easily fatigued. 
1          2          3 
4 
5          6 
7 
4. Fatigue interferes with my physical 
functioning. 
1          2          3 
4 
5          6 
7 
5. Fatigue causes frequent problems for 
me. 
1          2            3 
4 
5          6 
7 
6. My fatigue prevents sustained physical 
functioning. 
1          2            3 
4 
5          6 
7 
7. Fatigue interferes with carrying out 
certain duties and responsibilities. 
1          2            3 
4 
5          6 
7 
8. Fatigue is among my most disabling 
symptoms.
1          2            3 
4 
5          6 
7 
9. Fatigue interferes with my work, family, or 
social life.
1          2            3 
4 
5          6 
7 
 

 
GH APF Protocol, Version 8, Date: 03/24/21 
Page 54 of 54 
 
 
VISUAL ANALOGUE FATIGUE SCALE (VAFS) 
 
Please mark an “X” on the number line which describes your global fatigue with 0 
being worst and 10 being normal.