Testosterone and Long Pulse Width Stimulation for Denervated Muscles After Spinal Cord Injury
Phase: PHASE2
Conditions: Spinal Cord Injury
Sponsor: VA Office of Research and Development

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Testosterone and Long Pulse Width Stimulation for Denervated Muscles 
after Spinal Cord Injury 
 
 
Protocol-Version 4-12312018 
 
PI: Ashraf S. Gorgey, MPT, PhD 
 
 

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Table of Contents 
 
Contents 
Page 
Title 
1 
Table of Contents 
2 
1. Background and rationale 
3-7 
2.  Significance of this research to the VA population 
7 
3.  Preliminary Studies 
8-10 
4.  Research Design and Methods 
11-17 
5. Human Subject Section 
17-22 
6. Limitations and Alternatives 
22-24 
7. Risk to subjects  
24-28 
8. Subject’s burdens 
29-30 
9. Clinical Trails Requirements 
30 
10. Data Safety Monitoring Board  
31-32 
Additional Items 
 
Appendix 1 (Common Data Elements)  
 
Appendix 2 (Leisure Time Physical Activity Questionnaire) 
 

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1. Background and rationale 
Spinal cord injury (SCI) is a devastating medical condition that increases one’s risk for type II 
diabetes mellitus (DM), dyslipidemia and cardiovascular disease.1-5  The prevalence of 
individuals with SCI has been estimated to be 250,000-400,000 with a 14% growth since 
1988.6,7 The Department of Veteran Affairs cares for more than 46,000 Veterans with SCI-
related disability.  Due to advances in healthcare, individuals with SCI are now expected to have 
similar lifespans to able-bodied controls. The national aggregate direct costs of SCI in the 
United States have increased with a concomitant decline in mortality over the first year after 
SCI.8 Medical care costs per case may exceed 1 million dollars for acute stabilization and 
rehabilitation, with annual charges thereafter ranging from $41,000 to 182,000.6-8 The estimated 
lifetime costs can exceed 12 million dollars.8 Secondary health-related consequences challenge 
the productivity, quality of life and well-being of those with SCI, but may be reversible with 
appropriate exercise or pharmaceutical interventions that minimize SCI-related secondary 
disorders and favorably influence healthcare costs after SCI. 
 
The first few months post-injury, there is a rapid onset of skeletal muscle atrophy9-15, and 
decrease in fat free mass (FFM).9,16,17 This is accompanied by an increase in fat mass (FM)9-13, 
waist circumference13 and visceral adiposity (VAT). 15,16  The extensive muscle atrophy has 
been attributed to a number of factors including reduction in physical activity, unloading, disuse 
and reduction in anabolic hormone secretion as well as an increase release of pro-inflammatory 
cytokines. Cellular changes within skeletal muscle include decreased protein synthesis and 
increased protein degradation.9,16-18  Individuals with SCI suffer dramatic muscle atrophy that 
begins within a few weeks of injury and it continues at least until the end of the first year.16-18 
Skeletal muscle cross-sectional area (CSA) could be as low as 50% compared to healthy able-
bodied (AB) controls.16 Muscle atrophy is accompanied by extensive adipose tissue infiltration 
including intramuscular fat (IMF).17 IMF has been determined to account for a 70% reduction in 
glucose tolerance in individuals with complete SCI.20 Ectopic adipose tissue has been 
demonstrated to secrete large amounts of proinflammatory cytokines, including interleukin-6 (IL-
6) and tumor-necrosis factor- (TNF-). This stimulates hepatic production of C-reactive protein 
(CRP) which is predictive of vascular inflammation.21-23  
 
Denervation atrophy after SCI. Excellent reviews highlight in detail the deleterious changes in 
skeletal muscle following lower motor neuron (LMN) denervation.24,25 LMN denervation results in 
Wallerian degeneration, degeneration of neuromuscular junctions, loss of voluntary muscle 
contraction and dramatic changes in skeletal muscle fibers and quality.25,26  This loss impairs 
the electro-chemical signals between peripheral nerves and skeletal muscles through the 
neurotransmitter synapses. It also diminishes the trophic support of the peripheral nerves to the 
muscle. This impacts muscle morphology and results in denervation atrophy. 24-26 Denervation 
stops muscle electrical and contractile activity and leads to a decrease in the rate of muscle 
protein synthesis and an increase in the rate of protein degradation.24 Denervation atrophy is 
accompanied by a significant disorganization of the internal ultrastructure of fibers, and loss of 
striations and contractile materials.24-26  This is also accompanied by dramatic changes in the 
vascular bed, infiltration of fatty materials and accumulation of interstitial connective tissue.24-26  
The changes may be further exacerbated by associated reductions in the anabolic hormones, 
testosterone (T), and growth hormone (GH)  and the GH secondary messenger insulin like 
growth  factor-1 (IGF-1).18, 27-29 Growth hormone release is blunted and chronically depressed in 
SCI, as evidenced by reduced levels of IGF-129, a convenient indicator of chronic GH 
secretion.18, 27  Reduction in IGF-1 has been associated with skeletal muscle atrophy and 
increase in the FM in rats and humans.28,29  A fundamental difference between upper motor 
neuron and LMN SCI is spasticity, which has been shown to preserve muscle size up to 22% in 

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persons with higher compared to lower level of injury (T10 and below).18, 31  Moreover, spastic 
muscle  is associated with 44% greater release of IGF-1 compared to less spastic muscle.18  
 
Effects of Muscle Atrophy on Metabolic Activity. The loss of metabolically active muscle 
mass results in reduction of the resting energy expenditure (EE) which accounts for ~84% of 
total daily energy expenditure. 32, 33 Reduced muscle mass and resting energy expenditure 
(1634 ± 290 vs. 1735 ± 295 kcal/d) was observed in SCI vs. monozygotic AB twins.33 Another 
study found an association between whole body insulin-mediated glucose uptake and skeletal 
muscle mass in tetraplegics, suggesting loss of muscle mass as the primary reason for insulin 
insensitivity.34 The extensive loss of muscle mass may explain why up to one half of persons 
with chronic SCI have been shown to develop glucose intolerance and insulin resistance 35,36, 
with up to 50% and 80% of individuals with paraplegia and tetraplegia, respectively, having type 
II DM.36  Additionally, there is a decrease in high-density lipoprotein cholesterol (HDL-C) that 
correlated with an increase in serum triglycerides (TG).36  Nash et al. reported that 76% of 
individuals with paraplegia had HDL-C less than 40 mg/dl and 34% met the Adult Treatment 
Panel III-defined cut-point for metabolic syndrome.37  Another study reported that 55% of 
individuals with SCI were at risk of developing metabolic syndrome.38 
Effects of Muscle Atrophy on Mitochondrial Health. Mitochondria are the main site of 
oxygen consumption and energy production of all tissues including skeletal muscle. 
Mitochondrial size and activity are impaired in metabolic disorders such as obesity, type II DM, 
metabolic syndrome and cardiovascular disease.39 Individuals with SCI occupy the lowest end 
of the physical activity spectrum and a VO2 peak as low as 0.9 l/min. This lower VO2 peak was 
attributed to smaller muscle fibers, transformation to type II fibers, and/or a decrease in aerobic-
oxidative enzyme activity.40 Reduction in VO2 peak is due to reduction in the size, number or the 
activity of mitochondria in chronic SCI.41  Mitochondrial dysfunction leads to decreased fatty acid 
oxidation and may contribute to insulin resistance. This is associated with reduction in several of 
the key enzymes including cytochrome c oxidase, succinate dehydrogenase (SDH), pyruvate 
dehydrogenase and carnitine palmitoyltransferase I.42  Mitochondrial biogenesis is driven in part 
through peroxisome proliferator-activated receptor (PPAR) coactivator 1 alpha (PGC-1α).43, 44  
This master regulator of mitochondrial biogenesis, and its downstream targets were decreased 
following nerve denervation in rodents.  PGC-1α expression is known to influence fiber type 
phenotype and enhances the shift from fast to slow myosin heavy chain. Its expression is 
increased with increasing ATP cellular demands during exercise and GLUT-4 expression 
resulting in insulin sensitizing effects.54  PGC-1α is decreased in obese, diabetic individuals and 
following denervation in animal models. Denervation results in reduction in the size and the 
number of mitochondria as well as decreased electron transport chain (ETC) activity.45, 46   
Martin et al. reported a 48-67% lower SDH activity per unit fiber volume, complex II of the ETC, 
in tibialis anterior muscle fibers of patients 2-11 years after injury compared with AB controls.61 
 
Conclusion. Preserving skeletal muscle integrity is vital for several activities of cellular and 
whole body metabolism.48-50 Skeletal muscles serve as a large paracrine gland that controls the 
interplay between the musculoskeletal system and other physiological systems.48-50 Recent 
studies documented that skeletal muscle hypertrophy releases important myokines that may 
regulate atrophic pathways, bone and endocrine glands.49,50  Thus, it is crucial to maintain 
skeletal muscle vitality following LMN denervation to maintain the integrity of other physiological 
systems.  
 
Surface Neuromuscular Electrical Stimulation (NMES) after SCI. Recent guidelines 
recommend a minimum of twice weekly exercise for persons with SCI in order to ensure 
adherence and compliance.51 Previous studies have used surface neuromuscular electrical 

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stimulation (NMES) in individuals with chronic SCI to evoke exercise-induced resistance training 
(RT) using ankle weights.52-55 Eight weeks of twice weekly NMES-RT restored knee extensor 
muscle size to 75% of size at six weeks post-SCI.52  Twelve weeks of training increased skeletal 
muscle hypertrophy by more than 40% and improved glucose tolerance many years after 
injury.53 Ryan et al. noted an improvement in mitochondrial capacity by 25% following 16 weeks 
twice weekly NMES-RT.54 NMES-RT may increase mitochondrial capacity to utilize fat as a 
source of energy during exercise and further improve insulin sensitivity.55 Twelve weeks of twice 
weekly NMES-RT can elicit ~ 35% increase in skeletal muscle size, decreased IMF and VAT, 
increased insulin sensitivity and increased IGF-1 by 25%.55 The mechanisms responsible for 
protein turnover and its impact on muscle hypertrophy following resistance exercise training in 
persons with SCI are unknown.  An acute bout of NMES-RT has been shown to increase 
protein levels of phosphorylated- and total AMP-activated protein kinase (AMPK)-α and protein 
kinase B (Akt). This suggests that paralyzed muscle remains mechanically sensitive to triggers 
of cellular pathways that can increase protein synthesis via activation of IGF/AKT/mechanistic 
mammalian target of rapamycin complex (mTORC1)56-58; implying that muscle plasticity is still 
intact after years of SCI (see preliminary data).  
Singe-muscle stimulation has an impact on systemic physiological markers. Mahoney et 
al. previously noted that 12 weeks of NMES-RT resulted in enhanced glucose disposal. Another 
study noted that following 12 weeks of NMES-RT of the knee extensor muscle group, there was 
improvement in glucose area under the curve, serum insulin concentration and triglyceride 
profile in persons with chronic SCI. The same study noted a 35% increase in plasma IGF-1 that 
was negatively correlated to the decrease in VAT. Our preliminary data supported the notion 
that single muscle stimulation for 16 weeks in conjunction with TRT resulted in significant 
increase in BMR (see preliminary data). 
 
It is worth noting that training with surface NMES may not be possible for a large segment of the 
SCI population because of peripheral denervation. The increase in the muscle depth because of 
atrophy, increase of subcutaneous fat thickness and excessive infiltration of IMF may diminish 
the spread of the current density to activate the target muscles.24 Standard surface NMES 
(pulse width of 150-600 µs) fails to stimulate denervated muscles because of an increase in the 
minimum time required, chronaxie, as demonstrated on the strength-duration curve.24 This 
requires higher current for the direct depolarization of the muscle fibers. The limited pulse width 
is inversely associated with an increase in the magnitude of the current required to stimulate the 
muscle. Most commercially available stimulators have amplitudes that do not exceed 200 mA 
because of an increased risk of skin irritation and burns, especially in individuals with SCI. 
However, this low amplitude of the current is unlikely to cause muscle stimulation following 
denervation in persons with SCI. Despite the aforementioned benefits of NMES applications, 
25% of the SCI population cannot benefit from the standard NMES because of LMN 
denervation.24-25  
 
 
 
The PI has just completed a clinical trial (NCT01652040)  
entitled “Resistance Training and Testosterone after SCI”.  
During the course of the trial, the study team enrolled  
40 individuals with chronic (>1 year) motor complete SCI.  
Eight participants (20%) failed to respond to biphasic  
surface NMES and were excluded because of LMN  
denervation of the stimulated knee extensors (Figure 1).   
MRI revealed that the muscle fibers become significantly  
smaller and were replaced by fat as well as connective tissue. (Figure2). 
Figure1. A schematic diagram of the process of recruitment, notice 
8 persons were disqualified because of no response to NMES. 
Fig 1 

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Rationale for using long pulse width stimulation (LPWS) following denervation in 
persons with SCI. The European project, Research and Innovation Staff Exchange (RISE), has 
introduced long pulse width (LPW) NMES to restore muscle size following denervation in people 
with SCI.24-25 The effects of home based functional electrical stimulation (FES), introducing a 
LPW (120-150 ms) at an intensity of 250 mA for 5 days/week has been studied for two years in 
25 SCI persons with complete LMN denervation.59-62 The trial showed an increase (24%) in 
knee extensor cross-sectional area (CSA) following the first year and an additional 7% in the 
second year, respectively, with no changes in the hamstring muscles.59 In previous trials, the 
length of the training was extended for 2 years on a daily basis without incorporating additional 
benefits to the trained muscles.59  The technology of utilizing long pulse width stimulation 
(LPWS) has not been tested or approved for use in Veterans with chronic denervation after SCI.  
Successful completion of this study will lead to a new rehabilitation intervention to 
restore muscle size after denervation in persons with SCI. As the amplitude or pulse width 
increase, the nerve fibers nearest the electrodes are depolarized to activate the target muscle. 
All available NMES applications are based on direct excitation of neural structures and indirect 
activation of the target muscle. Due to the denervation, muscular contractions can only be 
elicited by depolarizing the cellular membrane of each single muscle fiber.  Biphasic rectangular 
impulses with duration between 30 and 150 ms may have to be applied with amplitudes higher 
than that of standard NMES (450 µs). This imposes direct activation of the myofibers 
independent of LMN denervation. The LPWS stimulation has the capacity to penetrate deeply 
and activate muscle fibers.  
 
Rationale for using testosterone replacement therapy (TRT) in persons with SCI. 
Testosterone (T) is an anabolic and androgenic hormone that is associated with growth.  The 
majority of testosterone production takes place in the Leydig cells of the testes. Approximately 
60-70% of testosterone is tightly bound to sex hormone binding globulin (SHBG), 30-40% is 
bound loosely to albumin, and 0.5-2% is free.63-67 Sixty percent of men with SCI have low T 
levels in the first six months after SCI.63  A previous study demonstrated a 37% lower level of T 
in men with tetraplegia compared to AB controls.65  Testosterone signaling through the 
androgen receptor also results in increased brain-derived neurotrophic factor expression and 
restored the withdrawn synapses in acute models with peripheral denervation. 68-69 The use of 
an androgen receptor antagonist blocks the effects of exercise on the regenerative capacity 
after LMN, emphasizing the significance of using testosterone replacement therapy (TRT) in 
promoting axonal growth and restoring muscle size.68-69 The effect of TRT on cardiovascular risk 
has been controversial.70,71  There are data showing that hypogonadism is a risk for 
cardiovascular disease.70  Some replacement studies show increased risk, but another study 
showed decreased mortality in veterans receiving testosterone.71 One study in older men 
reported that injectable testosterone may be associated with increased cardiovascular risk but 
topical testosterone was not. 72 Based on the available scientific evidence, we felt that 
application of transdermal patches is the more feasible and safe approach for persons with SCI.  
 
Rationale for using TRT following denervation. TRT is an FDA-approved therapy used to 
treat hypogonadism and often results in significant improvement of muscle strength and fat-free 
mass in hypogonadal men. In rats with complete SCI, TRT has been shown to attenuate muscle 
atrophy and the decline in oxidative and glycolytic enzymatic activities.66 Transdermal TRT of 5-
10 mg/day has been shown to increase lean mass and basal metabolic rate (BMR) in 
hypogonadal men with SCI.67 In an acute denervation model, TRT acts on the nervous system 
using two different mechanisms, genomic and non-genomic. The genomic mechanism involves 
binding of the hormone to its nuclear receptor. The non-genomic mechanism is fast-driven and 
involves interaction of the hormone with membrane or neurotransmitter receptors. This leads to 

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changes in cells of the nervous system and effects on neurotrophic factors and regeneration. 
However, applications of TRT in chronic models of denervation have not been established. The 
role of TRT on muscle size independent of the changes in the peripheral nervous system has 
not been investigated. The anabolic steroid nandrolone reduced denervation atrophy after 56 
days of sciatic nerve transection.73  Furthermore, TRT was shown to increase muscle size, 
strength and increase total body potassium.73 TRT increases skeletal muscle mass by inducing 
hypertrophy of both types I and II muscle fibers in men through its actions on androgen 
receptors. TRT promotes differentiation of a pluripotent mesenchymal cell line into myogenic 
lineage and inhibits differentiation into an adipogenic lineage. These effects were mediated 
through an androgen pathway. Androgen receptors are expressed in mesenchymal precursor 
cells within skeletal muscle (satellite cells). After 20 weeks of adding 100 nm of TRT to cultures 
of satellite cells and myocytes, the numbers of myonuclei per fiber increased from 3.2% to 4.2% 
and the percentage of myonuclei that tested positive for androgen receptors increased from 
51% to 78%. Furthermore, the number of satellite cells as a percentage of myonuclei increased 
from 3.3% to 5.6% and percentage of satellite cells that were androgen positive increased from 
89% to 96%.74  
 
Innovation and rationale for combining both TRT and LPWS following denervation. We 
hypothesize that 1 year of electrically evoked TRT+LPWS will result in a significant muscle 
hypertrophy of 25% or more. This will be associated with a significant increase in leg lean mass 
(>10%) and concomitant improvement in overall metabolic profile by 20%-30%. The rationale is 
that elevating levels of T and free T to the physiological level will optimize the outcomes on 
muscle mass and will render the LPWS protocol more effective.  Previous studies suggest that 
LPWS may require up two years of 5 days per week to restore muscle size in SCI persons with 
LMN denervation. Clinically, this is not feasible considering the barriers related to dressing, 
bowel and bladder movements, transportation, and loading and unloading of wheelchairs. 
These barriers would lead to decreased adherence to the protocol. Our preliminary data showed 
95% compliance when an NMES protocol is administered twice weekly for 16 weeks. We are 
hypothesizing that the addition of TRT to LPWS may facilitate the increase in leg lean mass and 
allow optimization of the stimulation protocol in 1 year compared to 2 years. Therefore, this 
approach of combining both physical and pharmacological interventions may allow twice weekly 
of LPWS to be highly effective in restoring muscle size. Administering TRT is necessary to 
maximize the outcomes of LPWS and provide balancing effects against several of the 
secondary health related complications after SCI.  
  
2. Significance of this research to the VA population.  
Currently, 46,000 individuals are listed in the national VAMC spinal cord dysfunction registry, 
and more than 50% of them have insulin resistance resulting in glucose intolerance or type II 
DM, dyslipidemia and cardiovascular disease. The Department of Veteran Affairs has made 
research designed to limit secondary complications of people with disabilities its primary goal. 
The health consequences of losing more than 25% of muscle mass has considerable impact 
after SCI. Furthermore, 20-25% of those with SCI may not benefit from standard 
rehabilitation techniques necessary to restore muscle size because of LMN denervation. 
Denervated muscles are 6 times smaller than innervated muscles (Figure 2). This special 
population already has significant functional deficits including reduced mobility, myocardial 
atrophy, restrictive lung disease, and bowel and bladder dysfunction. Failure to restore muscle 
size may lead to other serious secondary health complications including obesity, type II DM and 
cardiovascular diseases. This may limit benefits from advances in therapeutic interventions 
such as stem cell and gene therapy or exoskeleton training. Therefore, a complementary 
approach of LPWS and TRT may work as an effective rehabilitation strategy to counterbalance 
the deleterious effects of denervation on muscle size among Veterans and civilians with SCI. 

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3. Preliminary Studies 
 
a. Skeletal Muscle CSA in two persons with motor complete SCI  
 
Age 
(yrs) 
Weight 
(kg) 
Height 
(m) 
TSI 
(yrs) 
Level of 
Injury 
AIS 
classification 
Innervated 
45 
87 
1.88 
26 
C6 
A 
Partially 
denervated 
 
47 
 
67 
 
1.78 
 
25 
 
T11 
 
B 
 
Even though these individuals were matched based on age and time since injury (TSI), the two 
primary factors that likely to impact changes in lean mass and muscle size, note the dramatic 
muscle atrophy in the right thigh following SCI in a person with partial denervation (Figure 2). 
Contractile tissue is completely gone and muscle fibers were replaced with infiltrated IMF and 
connective tissues.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 3 shows that whole thigh muscle CSA and knee extensor CSA were 6 times smaller, 
respectively in individuals with denervation (Figure 3A and B). Percentage IMF was 50% 
greater in the denervated thigh compared to the innervated one (Figure 3C). These results 
highlight the need to establish an effective rehabilitation protocol that can restore muscle size 
and prevent excessive accumulation of IMF in persons with SCI who suffer from LMN 
denervation.  
b. Electrically Evoked Resistance Training.55 Nine individuals with motor complete SCI (C5-
T11) were randomly assigned into one of two groups; RT + diet (n= 5) or diet only (n=4). Weekly 
feedback was provided to maintain a standard diet at 45% carbohydrate, 30% fat and 25% 
protein. Figure 4 shows increased knee  
extensor muscle size in the RT+diet group.  
This hypertrophy was associated with a 25%  
increase in plasma IGF-1. This increase in IGF-1  
following training was negatively associated with  
ectopic adipose tissue accumulation. 
 
 
 
 
 
Fig 4 
Figure 2. Representative MRI of mid-thigh for two 
persons with innervated and denervated muscles after 
SCI. 
Figure 3. Skeletal muscle CSA of a) whole thigh, b) knee 
extensor and c) percentage intramuscular fat (IMF) between 
two persons with innervated and denervated SCI. 
Figure 4. Skeletal muscle hypertrophy as 
measured by magnetic resonance imaging (MRI) of 
the knee extensors before and after 16 weeks of 
NMES-RT 
Fig 3 
Fig 2 

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c. TRT & NMES-RT. The PI’s CDA2 career award findings support the view that twice weekly 
NMES-RT and daily TRT had adherence rates above 95% in persons with SCI. In this project 
22 participants were enrolled in NMES+TRT (n=11) or TRT (n=11) groups for 16 weeks. We 
have safely administered 2-6 mg of T daily for 16 weeks using patches for persons with SCI to 
improve body composition. Blood work was taken every 4 weeks and patch compliance was 
monitored every month (95-100% adherence). Our data showed that 18% and 55% of subjects 
had baseline serum T-level below 300 and 400 ng/dl, respectively. Transdermal patches were 
alternated daily between the right and left shoulders. Based on the T baseline level, participants 
were assigned the following dose (Table 2). Serum T level increased from 413±147 to 525±223 
ng/dl following 16 weeks of transdermal applications in NMES+TRT group. 
 
Table 2. TRT dose based on the serum T-level 
T- level 
(ng/dl) 
less 
than  
300 
ng/dl 
300-
600 
ng/dl 
greater 
than 600 
ng/dl 
Patches 6 
mg/day 
4 
mg/day 
2 mg/day 
 
 
 
 
Measurement of the T level was repeated every 4 weeks over the course of 16 weeks and the 
dose was adjusted accordingly. In the event of skin irritation or itching, subjects were prescribed 
topical hydrocortisone cream and the site of the patches was moved up or down on the shoulder 
away from the irritation point. TRT was prescribed for 7 days/week for 16 weeks. New patches 
were placed at night before going to bed. Each participant was asked to turn in a monthly log-in 
sheet to ensure adherence to the protocol and refill occurred every 30 days.  
Progression of electrically evoked RT 
RT constitutes four sets of 10 repetitions that was performed  
twice weekly for 16 weeks. The first week of RT was conducted 
with no ankle weights to ensure that the knee extensor muscles 
could extend the weight of the lower leg against gravity. Once  
full knee extension was achieved in a sitting position, two  
pounds were added on a weekly basis with the criteria that full  
knee extension was achieved before more weights were added. 
Surface NMES was applied to the knee extensor muscles via  
surface electrodes. Current from the stimulator (30 Hz, 450 µs  
pulses) was manually increased in 5-second intervals to evoke full knee extension with a 3-
minute rest between sets. Lifted weight significantly (P< 0.0001) progressed over training period 
for the right (19.6±6.5 lbs.) and the left (20.0±6.1 lbs.) legs (Figure 6). 
d. Changes in body composition as measured by dual energy x-ray absorptiometry (DXA) 
Sixteen weeks of NMES-RT+TRT 
increased leg lean mass by  
1.5 kg (P=0.003) and decreased 
leg %fat mass (FM) by 2% 
(P=0.037) (Figure 7a).  
 
 
BMR increased by 133 kcal/day (n=11, P = 0.2) or 218 kcal/day (n=8, P= 0.009; after excluding 
outliers) in the RT+TRT with no changes in TRT group. 
 
 
Figure 5. A) Transdermal patches applied daily 
and B) twice weekly of electrically evoked RT 
using ankle weights in persons with SCI. 
Figure 6. Progression of ankle weights 
over 16 weeks of training in the NMES-
RT+TRT group (n=11). 
 
Figure 7. Changes in a) leg lean 
mass and b) BMR in the NMES-
RT+TRT (n=11) and TRT (n=11) in 
persons with motor complete SCI. 
*
*
7a 
Fig 5a 
Fig 5b 
7b 
Fig 6 

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Association between the changes in lean mass and BMR 
The increase in whole body and leg lean mass drives the increase  
in BMR noted in Figure 7b. The increase in lean mass following  
NMES-RT explained 51% of the variance in BMR (n=22) 
The increase in BMR of 218 kcal/day may equate to FM loss of  
0.93 lb. per month or 11 lbs. per year. This highlights the  
significance of restoring lean mass on combating the increase in  
body FM, obesity and cardiovascular comorbidities after SCI.  
Preliminary MRI data showed 13% increase in whole muscle  
CSA after TRT. 
 
e. Protein expression following electrical stimulation training75  
In our previously published training studies, we have experienced wide variance in the primary 
outcome variables in response to electrical stimulation training. Studying molecular signaling 
pathways may provide insights on why skeletal muscle responds differently to FES protocols in 
persons with SCI. It is unknown why some individuals may respond well and experience large 
increases in muscle size while others do not. Understanding the variability in signaling pathways 
may help in the design of future clinical trials. To investigate the cellular changes, expression of 
three skeletal muscle proteins involved in glucose  
disposal, energy regulation and mitochondrial  
biogenesis (GLUT-4, AMPK, and PGC-1α, respectively) 
were measured. Participants underwent 16 weeks of 5  
days/week of FES cycling. Our results show that  
GLUT-4, PGC-1α and AMPK increased by 3.8, 2.3 and 
 3.4 fold, respectively, in the vastus lateralis (VL)  
muscle. There was no change in protein expression of  
untrained muscles (Triceps m.). The study  
demonstrates our successful collaboration with the  
James J. Peters VA Hospital (Dr. Cardozo).  
 
 
 
 
f. Mitochondrial Health after SCI76 
We also investigated the body composition factors that 
may influence mitochondrial density (citrate synthase)  
and activity (complex III) in the VL as measured by  
enzymatic assays.  The relationship between CS or CIII  
activity and thigh skeletal muscle CSA is shown in  
Figure 10 (n=16 for CS and n=14 for CIII). There was  
a positive correlation between CS activity and thigh  
muscle CSA (r=0.82, p=0.0001) and knee extensor  
(KE) CSA (r=0.74, p=0.001). Similarly, there was a  
positive relationship between CIII activity and thigh  
muscle CSA (r=0.84, p=0.0001) and knee extensor  
CSA (r=0.84, p=0.0002). 
 
 
 
 
 
Figure 8. Relationship between leg lean 
mass and BMR post-intervention in 22 
persons with SCI 
A
B
C
D
r = 0.82 
r = 0.84 
r = 0.84 
r = 0.74 
r = -0.58 
r = -0.50 
r = -0.56 
r = -0.60 
 
Figure 10. Citrate synthase (CS; n=16) and antimycin A-sensitive 
complex III (CIII; n=14) activity related to thigh muscle cross  
sectional area (CSA; A), knee extensor (KE) CSA (B), thigh  
intramuscular fat (IMF; C), and thigh %IMF (D). 
 
Figure 9. Immunoblots for protein levels of GLUT-4, AMPK, 
and PGC-1α in VL muscle following 16 weeks of FES training 
in persons with motor complete SCI. 
Fig 9 
Fig 10 
Fig 8 

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4. Research Design and Methods 
The goal of this randomized prospective controlled study is to investigate the effects of one year 
of TRT+LPWS versus TRT+standard NMES on muscle size (primary outcome variable), leg 
lean mass and percentage IMF, metabolic profile (BMR, carbohydrate and lipid profile) and 
protein synthesis and degradation pathways as well as mitochondrial health. The long-term goal 
is to develop a rehabilitation strategy to mitigate the deleterious changes in muscle size and 
lower leg lean mass in persons with denervation following SCI.  
Subjects. 24 chronic (1 year or more post-injury) individuals with motor complete SCI will be 
recruited from the Hunter Holmes McGuire VA Spinal Cord Dysfunction registry (n=~1,717-
1800) and Virginia Commonwealth University (n=750-1000) over 4 years. The Spinal Cord 
Injury and Disorders Outcomes (SCIDO) for FY2105 suggests that there are ~ 20% of our 
outpatient evaluation with LMN denervation as result of SCI. Approved flyers and 
advertisements will also be posted at the VAMC, VCU Hospitals and clinic sites. Training will be 
conducted twice weekly using a progressive RT model described in preliminary studies and 
previously by our group.55.  
Inclusion. All participants will be between18-70 years old, male, and greater than one-year post 
SCI. The age upper limit was set at 70 years to reduce the likelihood of developing any 
cardiovascular side effects from using TRT. Participants must have traumatic complete or 
incomplete T10 SCI or below (AIS A or B; i.e. motor deficit below the level of injury) with 
denervation of both knee extensor muscles and tolerance to the LPWS paradigm.  
Exclusion. Participants with the following pre-existing medical conditions will be excluded: 
cardiovascular disease, uncontrolled type II DM, (HbA1c >7.5), uncontrolled hypertension 
(resting blood pressure >140 /90 mmHg), and those on insulin, or who have pressure sores 
greater than stage 3, hematocrit above 50% or severe urinary tract infection. Those with a 
hyper-physiological testosterone level (above 800 ng/dl) will and those who fail to tolerate the 
LPWS paradigm will also be excluded.  Lower extremity fracture around the knee joint within the 
last 2 years will be excluded. After signing a consent form, all participants will undergo knee 
DXA scans and knee bone mineral density (BMD) less 0.6 gm/cm2 or hip BMD T-score below -
3.5 will result in exclusion from the study to prevent fracture at the distal femur or proximal tibia 
during training. 
After informed consent, each subject will undergo a complete physical examination by a 
physiatrist board certified in SCI medicine (Dr. Goetz or Dr. Lavis or Dr. Castillo), including 
neurologic assessment and American Spinal Injury Impairment Scale Classification (AIS) 
examination. Participants will be evaluated every 3 months after treatment initiation and then 
annually to assess any adverse effects and to check compliance. Testosterone measurements 
will be acquired every 4 weeks during the intervention to determine the serum level and the 
dose will be adjusted to allow ~30% increase from baseline (Dr. Adler). A prostatic abnormality 
on digital rectal examination will also lead to exclusion.  An increase in serum or plasma 
prostate specific antigen (PSA) of 1.4 ng/ml above baseline will result in immediate cessation of 
TRT.  
Measurements. All participants will undergo body composition assessments (specific aim 1), 
metabolic studies (specific aim 2) and muscle biopsies (specific aim 3). All testing procedures 
will be conducted one week prior to training (baseline), 6 months following training (mid-
intervention) and one week after the end of 1 year of training (post-intervention). At each time 
point, measurements will include estimation of body composition, anthropometry, and dual x-ray 
absorptiometry (DXA).  MRI scans will be obtained for thigh skeletal muscles to determine IMF 
and CSA.14-18 Participants will remain at the VA Medical Center for dinner, and overnight. After 
an overnight fast the subject will be gently awakened at 6 AM to measure BMR.  At 6.30 AM an 
IV line will be placed and blood will be drawn for serum total T and IGF-1 concentrations at 6.30, 
7.00 and 7.30 AM.  Resting blood pressure and fasting metabolic markers will be obtained 

12 
Gorgey-Verizon4-12312018 
including HbA1c, as well as lipid panels, CRP, IL-6, TNF-alpha, and free fatty acids (FFA).  This 
will be followed by a 3-hour intravenous glucose tolerance test (IVGTT) which will begin at 8 AM 
and terminate at 11 AM.  During the IVGTT, a dietitian will meet with each participant 
individually to ensure that they will follow a standard diet pattern during the 1 year-intervention 
(45% carbohydrate, 35% fat and 25% protein) to avoid any confounding effects on our 
measurements. All participants will be asked to maintain a 3 day food record monitoring their 
energy intake during the course of the study. The diaries will be evaluated weekly by the 
dietitian to provide monthly feedback.  All participants will meet with the dietitian three times 
during the study to ensure appropriate adherence to the diet pattern throughout the study. The 
vastus lateralis muscle will be biopsied to measure protein expression and to determine 
mitochondrial enzymatic activities.75, 76 
 
Twenty-four participants will be randomly assigned to either one year of TRT+LPWS (n = 12) or 
a TRT+ standard NMES (n = 12). Testosterone patches (Tp; 4 
-8 mg/d) will be re-placed daily on alternating skin sites at bedtime for 1 year.  Randomization 
will be done at the end of the two-day assessment period using a random number generator 
computer program (baseline). Participants will be block randomized based on the degree of 
denervation (lower or higher than 50% of compound muscle action potential (CMAP) of the 
standard normal femoral nerve values). Both groups (TRT+LPWS & TRT+ standard NMES) will 
undergo 1 year of supervised unilateral progressive RT, twice weekly, using ankle weights. The 
two-day assessment period will be repeated using the same sequence at 6 months and after 1 
year.  Prior to training, we will perform multiple neurophysiological tests to confirm LMN 
denervation of the knee extensor muscle group. The first technique is to place the surface 
NMES electrodes on knee extensor muscle group and increase the current (30 Hz, 450 µs) 
gradually up to 200 mA. If the knee extensors show visible elicited contraction, then the 
participant will be disqualified from the study. If there is no response, participant will then be 
escorted to the EMG lab and further testing for evidence documenting muscle denervation will 
be performed by a trained electromyographer. Briefly, participants will undergo a femoral nerve 
motor conduction study with recording of the CMAP from the vastus medialis (VM) with 
supramaximal femoral nerve stimulation just below the inguinal ligament.  The participant will 
undergo needle EMG of the vastus medialis to determine the presence and intensity 
of spontaneous muscle fiber fibrillation potentials to quantify the level of denervation.  A 
monopolar EMG needle electrode will be inserted into the VM muscle to record spontaneous 
intramuscular activity in the resting muscle. 
 
LPWS or Standard NMES. Training will be conducted twice weekly using a S88X dual output 
square pulse Grass Stimulator (for research use only) and the current will be set as shown in 
Table 3.22,25  According to the Food and Drug Administration (FDA), all functional non-invasive 
electrical stimulators are considered a non-significant risk device and do not necessarily need 
IDE application and only require IRB approval prior to the trial. Long pulse duration (120-150 
ms) is used to offset the low resting membrane potential of the denervated muscles.22-25 When 
tetanic contraction is achieved, the pulse duration will be shortened gradually by 5-10 ms/ 
month to reduce the likelihood of skin irritation (Table 3).  We will explore the best stimulation 
parameters necessary to evoke twitches/ tetanic contraction of the knee extensor as far as the 
frequency and amplitude of the current for each participant. Initially, we will set the pulse 
duration at 150 ms, frequency at 2 Hz and the amplitude of the current will be gradually 
increased from 0 mA by 10 mA intervals up to 200 mA. The current (mA) and the pulse duration 
(ms) that causes full knee extension will be recorded for each session. An example progression 
of the stimulation parameters is listed in table 3. Based on previous work, some participants 
may take up to 6 months to lift their legs against gravity.24, 62 Therefore, a one year intervention 
may be a reasonable duration to load the muscle and evoke hypertrophy especially after years 

13 
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of denervation. For the TRT+ standard NMES (control group) , a Theratouch 4.7 stimulator (0-
200 mA) or battery operated stimulator (0-100 mA) that elicits direct current, a 5 second/5 
second work/rest ratio will be used with a 3-minute rest between sets, 30 Hz, 450µs pulses.52-55 
For the control group over a 1-year period, participants will have the option to perform a home 
based training using our established videoconference telehealth system to monitor their training 
using a hand-held battery operated stimulator (see supplement). Study visits will be limited to 
once a month throughout the 1-year period to refill their 30 days stock of TRT patches. 
Training sessions will consist of 4 sets of 10 repetitions of LPWS NMES-induced knee 
extensions and will last for 30-40 minutes.  All training procedures will be conducted with the 
participants sitting in their wheelchairs with enough space to clear their foot off the ground.52-55 
Two large 8 X10 cm2 (Uni-Patch, Wabasha, MI, USA) adhesive carbon electrodes will be placed 
on the skin over the knee extensor muscle group.52-55 Once the participant completes 40 
repetitions of knee extension, ankle weights will be increased gradually by 2 lbs. per week (not 
to exceed 30 lbs.). In our prior work the maximum weight was below 30 lbs. because of 
concerns over the possibility of causing condylar fractures.  For the control group (TRT+ 
standard NMES), the direct current at 450 µs will be turned up to 200 mA for 10 times/set; which 
is unlikely to cause either twitches or tetanic contraction of the stimulated muscle.   
Table 3. Example of progression of the stimulation parameters over 1 year 24 
Months of 
Training 
Pulse Width 
(ms) 
Inter-Pulse 
interval 
(ms) 
Frequency 
(Hz) 
Amplitude of 
current (mA) 
Weights 
(lbs.) 
1-3 
120-150 
400 
2 
up to 200 
0 
4-6 
90-120 
400 
15-25 
up to 200 
0 
6-9 
60-90 
100-400 
25-30 
up to 200 
2 lbs./ 40 
reps/session 
9-12 
30-60 
10-12 
25-30 
up to 200 
2 lbs./ 40 
reps/session 
 
Testosterone replacement Therapy (TRT). Testosterone will be administered via transdermal 
patches (Androderm Corp., Palo Alto, CA) that will deliver between 4-8 mg/day.39 The 
Endocrine Society guidelines recommend one or two patches of 5 mg/day. Because 
Transdermal Androderm patches are either 2 or 4 mg we will proceed with 4-8 mg/day.  Two 
patches that deliver 4-8 mg/day initially will be worn at all times except when bathing. 
Participants will be instructed to change patches once a day before bedtime. Patches will be 
worn daily on a dry skin over the right or the left shoulder, abdomen or thighs and the 
application sites will be rotated to avoid skin irritation for 1 year.67 TRT will be administered for 1 
year because it has the maximum effects on lean mass after SCI. The dose will be decreased to 
2 mg/day if the serum T concentration is more than 1000 ng/dL (34.7 nmol/L) and the participant 
will be reeducated in the patch technique if the concentration is less than 250 ng/dL (8.7nmol/L) 
above the pretreatment concentration. Serum prostate-specific antigen (PSA) level will be 
measured to ensure normal concentration according the guidelines provided by the Endocrine 
Society.  Patch compliance will be monitored by inventory of the number of returned patches 
each month.78 Free T will be calculated using total T, sex hormone binding globulin (SHBG) and 
albumin equation.79 
Specific aim 1.  We will compare the effects of TRT+LPWS compared to TRT+ standard 
NMES (control group) on the size of thigh skeletal muscle, intramuscular fat (IMF) and leg 
lean mass. Both groups will receive TRT for 1 year. Anthropometrics, DXA and MRI will be 
performed at baseline, 6 and 12 months post-interventions to measure thigh skeletal muscle 
size, IMF and leg lean mass.  

14 
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Body mass index (BMI): Each participant will be asked to void his bladder and then will propel 
onto a wheelchair weighing scale. After weighing the participant and his wheelchair (1), he will 
be helped to transfer to an adjustable mat and his/her wheelchair will be weighted empty (2).  
The weight of each participant will be determined by subtracting (2) from (1) (kg).  The height 
will be determined in the supine position. Two smooth wooden boards will be placed at the 
participant’s head and heels and the distance between them will be taken as the height to the 
nearest cm. Every effort will be taken to maintain the knees in an extended position. BMI 
(Kg/m2) will be calculated as weight (Kg) divided by height2 (m2).15 
Dual energy x-ray absorptiometry (iDXA): iDXA will be used to measure body composition 
including regional and total FM, FFM and bone mineral density (BMD). Total body and regional 
scans will be performed using an iDXA scanner (Lunar Inc., Madison, WI) bone densitometer to 
determine regional bone mineral density and T-scores for hips and knees.  We will perform 
testing after lower extremity elevation for at least 20 minutes to minimize fluid shift.  All scans 
will be performed and analyzed by a trained, certified DXA operator. The subject will be assisted 
to lie on a padded table and both legs will be strapped proximal to the knees and the ankles. 
The arms and legs will be positioned to ensure proper alignment and the ability to lie still for 10 
minutes during the scan. Total and regional (%FM and FFM) will be determined using total and 
regional DXA software. The coefficient of variability of two repeated scans is less than 3%.15  
Magnetic resonance imaging (MRI): MRI will be performed using a 1.5 Tesla magnet (GE).14-
18 The skeletal muscle CSAs will be determined at baseline, 6 months (mid-intervention) and 1 
year after training (post-intervention). Both lower limbs will be strapped together using a soft 
Thera-band to avoid any movement inside the magnet. Participants will be instructed to lie still 
inside the magnet and they will be provided with earplugs to protect their ears against the 
magnet noise. The duration of the whole scan including the preparation time should not exceed 
10 minutes. Images of both thighs will be collected using the following scanning parameters 
(repetition time, 500; echo time, 14; field of view, 20cm; matrix, 256×256). Transaxial images, 8 
mm thick and 4 mm apart, will be taken from the hip joint to the knee joint using a localized coil.  
Images will be downloaded and analyzed using X-vessel software.17,19,20, 31,55 
Testosterone and PSA Concentration. The serum testosterone concentration and PSA levels 
will be measured at the beginning, every 4 weeks and 1 year after intervention. IV line will be 
placed after overnight fast, serum total T and PSA concentrations will be measured in 
duplicates.78 Samples will be sent for analysis using a standard procedure assays. 
Specific Aim 2. We will determine the association between the changes in skeletal 
muscle size, IMF, leg lean mass and the metabolic profile as determined by measuring 
basal metabolic rate (BMR), lipid panel and carbohydrate profile. Participants will undergo 
an array of metabolic measurements at baseline, 6 and 12 months post-interventions including 
BMR, fasting lipid panel and 3 hour IVGTT. Other metabolic and inflammatory biomarkers 
(plasma IGF-1, IGFBP-3, TNF-alpha, IL-6 and CRP) will also be measured at the 3 time points. 
We hypothesize that the increase in lean mass following TRT+ LPWS will increase BMR and 
improve both carbohydrate and lipid profiles as well as associated with decrease in FFA and 
inflammatory biomarkers. 
BMR and respiratory exchange ratio. After an overnight fast, participants will be kept in a dark 
room for 20-30 minutes to attain a resting state during which BMR will be measured by using a 
canopy. The gasses (VCO2 and VO2) collected will used to determine the respiratory exchange 
ratio.  This will help to determine the changes in the percentage of substrate utilization (% fat vs. 
% carbohydrate) after the interventions.15  
Serum total, free testosterone and IGF-1. The plasma T and IGF-1 will be measured in the 
morning (2 ml/ sample).78,79 The analysis of total T will be performed by radioimmunoassay after 
sample extraction and column chromatography. The interassay coefficient of variation (CV) is 
12.5% or less for all quality control samples analyzed. Plasma IGF-I and IGFBP-3, 
concentrations will be measured by immunoluminometric assay (Quest Diagnostics, Madison, 

15 
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NJ) and RIA (Diagnostics Systems Laboratories Inc., Webster, TX), respectively. Intra-assay 
precision of IGF-1 is 4.6% at 50 ng/ml and 3.6% at 168 ng/ml. 
Blood lipids. Each subject will have fasting lipid profiles (HDL-C, LDL-C, total cholesterol, and 
TG) assessed, with total cholesterol: HDL-C ratios utilized as the criterion variable.  Concurrent 
with the IVGTT and following a 12-hour fast, 10 ml of blood will be collected from the indwelling 
venous catheter and lipids determined by standard analyses procedures.15 
Inflammatory biomarkers. Before starting the IVGTT and following a 12-hour fast, 10 ml of 
blood will be collected from the indwelling venous catheter and CRP, IL-6, TNF- , and FFA will 
be determined by standard procedures using commercially available assay kits.21   
Intravenous Glucose Tolerance Test (IVGTT) An IVGTT will be used to determine insulin 
sensitivity and glucose effectiveness.  Each subject will undergo an IVGTT test 3 times.  After a 
10 to 12-hour fast, an indwelling catheter with an intravenous saline drip (0.9% NaCl) will be 
placed in an antecubital vein, and another intravenous line will be placed in a contralateral hand 
vein to facilitate infusion of glucose and blood sampling during the IVGTT.  Glucose samples will 
be taken at –6, -4, -2, 0, 2, 3, 4, 5, 6, 8, 10, 12, 14, 16, 19, 22, 23, 24, 25, 27, 30, 35, 40, 50, 60, 
70, 80, 90, 100, 120, 140, 160, and 180 minutes after the rapid glucose injection (0.3 gm/kg IV 
over 30 seconds at time zero).  Twenty minutes after the glucose injection a bolus of insulin 
(0.02 U/kg) will be injected to determine insulin sensitivity. Plasma glucose will be measured by 
the Autoanalyzer glucose oxidase method and plasma insulin concentrations will be determined 
by commercial radioimmunoassay using single-antibody kits.  The SI (glucose disposal rate per 
unit of secreted insulin per unit time) and SG (glucose mediated glucose disposal rate) will be 
calculated from a least-squares fitting of the temporal pattern of glucose and insulin using the 
MINMOD program.80  The coefficient of variation is approximately 15%.  KG, a measure of 
glucose tolerance, is calculated as the least square slope of the natural log of absolute glucose 
concentration between 5 and 20 minutes after the glucose bolus.80 The homeostatic model of 
assessment of insulin resistance (HOMA-IR) will be calculated and insulin sensitivity will be 
determined using Matsuda and Defronzo formula. 81,82 
Specific Aim 3. We will investigate the cellular mechanisms responsible for evoking 
skeletal muscle hypertrophy following TRT+LPWS compared to TRT+ standard NMES. 
Participants will undergo 3 muscle biopsies of vastus lateralis at baseline, 6 and 12 months 
post-intervention to measure gene and protein expression and perform mitochondrial enzymatic 
assays. Considering the limited muscle tissue in persons with denervation atrophy, four biopsy 
samples of the vastus lateralis muscle (total: 25-50 mg wet wt) will be obtained by a 14 gauge 
Tru-Cut needle using a sterile technique and local anesthesia (2% lidocaine). The biopsy 
samples will be frozen in liquid nitrogen and stored at -70C until further analysis. We 
hypothesize that the TRT+LPWS will upregulate protein synthetic and downregulate protein 
degradation pathways, gene expression and mitochondrial enzymatic ETC activities compared 
to the TRT+ standard NMES group.  
Protein content. Muscle biopsy samples will be homogenized on ice using the appropriate 
buffers. Equal amounts of protein will be resolved by SDS-PAGE after which proteins will be 
electrophoretically transferred to a PVDF membrane. Western blot analysis will then be 
performed to determine the protein concentrations as described in preliminary data and 
previously by our lab.75 After blocking, membranes will be probed with primary antibodies for 
activated pathways including AMPK, p-AMPK PGC-1α, IGF-1, Akt, p-Akt, mTOR and protein 
degradation pathways (FOXO1/3, atrogin-1, MURF). followed by incubation with the appropriate 
secondary antibody. Western blots will be quantified by scanning with A GS800 densitometer. 
Optical densities of the Western blots will be measured using image-analysis software 
(Molecular Analyst; Bio-Rad). 
Real-time quantitative PCR (qPCR).  Quantification of mRNA levels by RT qPCR (real-time 
PCR) in muscle biopsy samples will follow well-established procedures in our lab. Briefly, frozen 
muscle biopsy samples will be added to Trizol reagent and immediately homogenized then 

16 
Gorgey-Verizon4-12312018 
centrifuged to separate the chloroform and aqueous phases. mRNA will be extracted using 
commercially available kits. Residual genomic DNA will be removed by on the column DNAse I 
digestion. cDNA libraries will be synthesized by reverse transcription of total RNA using 
commercially available kits. Expression of individual target genes (IGF1, PGC1alpha, AMPK, 
Akt, mTOR) will be evaluated by qPCR using 18S RNA or housekeeping genes as loading 
controls. The effects of interventions on mRNA expression levels will be expressed as fold-
change where fold change is calculated using the 2-∆∆Ct method.74,83  
Mitochondrial ETC activities. The assays will be performed using fresh cholate-treated 
skeletal muscle homogenates. ETC complex activities will be measured spectrophotometrically 
as specific donor-acceptor oxidoreductase activities in 0.1M phosphate buffer (HP 8453 and 
Lambda 35 UV/VIS). Rotenone-sensitive NADH cytochrome c reductase will measure 
complexes I and III. NADH coenzyme Q reductase will be measured as the rotenone-sensitive 
oxidation of NADH with decylubiquinone as acceptor, and assesses complex I. NADH 
ferricyanide reductase measures NADH dehydrogenase in complex I. Cytochrome c oxidase will 
be measured as the oxidation of reduced cytochrome c and expressed as the first order rate 
constant.42,43 Flurometric measurements will be conducted to measure the oxidative and 
glycolytic enzymes’ activities including citrate synthase and SDH.42, 43, 76 
Statistical Analyses. Means and standard deviations or frequencies and percentages will be 
reported for all data. Similar summaries will be provided for all outcome and biomarker data 
separately at baseline, 6-, and 12-months. A repeated-measures ANOVA will be used to 
analyze the primary study outcome, skeletal muscle size, with treatment, time, and the 
interaction of these variables included in the model. A first order autoregressive correlation 
structure will be used to capture the dependency within subjects’ outcomes. A specific contrast 
will be used to determine if the change from baseline for the treatment group is different than 
that of the control group. A model selection procedure will be performed due to the relatively 
large number of predictor variables compared to the number of subjects for specific aims 2 and 
3. A penalized random effect model will be used to suggest the important predictors for each 
outcome separately. These include each specific predictor mentioned in the specific aims as 
well as injury characteristics.84 A parsimonious model will be chosen by the Bayesian 
information criterion. Since the aforementioned model is well-suited for model selection, but 
results in biased parameter estimates, an unpenalized random effects model will be fitted based 
on the parsimonious model and used for inference. Study period will be included in all analyses, 
and a time by group interaction will be included for the analyses associated with Specific Aim 3. 
All statistics will performed with R (3.3.0) with the ‘glmmLasso’ package. Prior to any statistical 
analysis, any of the biomarkers may be transformed to ensure all statistical assumptions are 
met. A simulation study was used to determine the power achieved from the proposed study if 
5% of subjects were assumed to drop out at the 12-month observation point. One thousand 
datasets were created with Cohen’s d varying between 0.5 and 2.0, with the anticipated 24 
subjects being equally allocated to the treatment and control groups and the subjects’ outcomes 
having a correlation of 0.25. A linear mixed-effects model was used to analyze the simulated 
data using a one-sided test at α=0.05. Results of the study show that this design will have the 
power to detect differences of d=1.28 with 80% power and d=1.48 with 90% power. An intent-to-
treat approach will be used to deal with missing data. If the missing data is due to drop-out, the 
statistical methods are valid as long as the data mechanism is considered missing at random or 
missing completely at random. 
 
Dissemination and Implementation Plan 
The target audiences for dissemination of the results from this study include the VHA and its 
practitioners, the national SCI/D Services Office, the general healthcare community, and the 
veteran population. We will share our findings with the SCI community. Our SCI/D Services and 
PVA publish a quarterly newsletter that is sent to SCI practitioners across the VA system. We 

17 
Gorgey-Verizon4-12312018 
will inform the VA community of the impact of these findings. We will report our findings to the 
scientific community via the American Congress of Rehab Medicine, American College of 
Sports Medicine and American Spinal Cord Injury Association (ASIA). We will target JAP, MSSE 
and SCI journals to publish our reports. 
 
 
5. Human Subjects 
I. Human Subjects Involvement and Characteristics: 
Twenty-four individuals with chronic (1-year post-injury) motor complete SCI will be recruited 
from the Hunter Holmes McGuire VA Spinal Cord Injury & Dysfunction (SCI&D) registry 
(n=1,800) over 4 years to participate in the study. The following table showed the primary 
reason for admission to the SCI&D at the McGuire VA Medical Center based on the 2015 fiscal 
year. 
 
Primary reasons for admissions 
Number of Patients 
Total number of SCI between 18-70 years 
1717 
1- Inpatient admission 
778 
 
- 
Acute rehab. CARF 
~ 58 
- 
Inpatient annual evaluations 
~337 
- 
Wound Care 
~350 
- 
Respite 
~ 88 
- 
Palliative and other chronic pts 
~ 47 
2- Outpatient visits 
939 
- 
Outpatient annual evaluations  
417 
- 
SCI walk-in Clinic 
400 
- 
Total Patients in Richmond 
250-275 
  
We are expecting that 20-25% of the entire 46,000 VA SCI population (~11,500 persons) and 
the entire 243,000-347,000 SCI civilians (60,750-86,750 persons) according to the 2016 SCI 
facts and figures in US may benefit from outcomes of the current study.  In our VA facility in 
Richmond and since the initial submission, there were additional 8 men with motor complete 
SCI who failed stimulation because of lower motor neuron (LMN) denervation (37.5±13 years 
old, 27±6 kg/m2, T10-L1 SCI).  All of them were interested in strategies that can help restoring 
their leg muscle.  This means that we currently have access to 16 participants (8 from 
applicant’s CDA2 study) with LMN denervation without even starting an active recruitment 

18 
Gorgey-Verizon4-12312018 
process ready to be contacted to participate in the study and this will ensure the recruitment 
target will be met. 
 
After informed consent, each subject will undergo a complete physical examination by a board 
certified physiatrist in SCI medicine, including neurological assessment and ISNCSCI 
examination to confirm their level of injury and determine if it is safe for them to participate.  The 
physical exam will include the measurement of body weight using a wheelchair weighing scale, 
and the performance of electrocardiograph (ECG) to rule any cardiac abnormalities including 
abnormal heart rhythms and myocardial infarction.  
All 24 participants will undergo body composition assessments (specific aim 1), metabolic 
studies (specific aim 2) and muscle biopsies (specific aim 3). IRB approved flyers and 
advertisements will also be posted at the VAMC and VCU hospitals and clinic sites.   
 
a. Inclusion: All participants will be between 18-70 years old, male, with traumatic motor 
complete SCI and level of injury of T10 and below, only participants with LMN denervation as 
determined by EMG testing (see research design section).  Participants must also have an 
absence of reflexes, denervation of both knee extensor muscles and tolerance to LPWS 
paradigm, both knee extensors will also have to be unresponsive (i.e. no observed tetanic 
contraction or twitches) to standard electrical stimulation procedures (stimulation frequency: 30 
Hz; pulse duration:450 µs and amplitude of the current:200 mA). All participants will undergo 
International Standards for Neurological Classification of SCI (ISNCSCI) examination for 
neurological level and function and only those with American Spinal Injury Classification (AIS A 
and B; i.e. motor deficit below the level of injury) will be included.  We have chosen to set 70 
years as the upper limit of the study, because individuals with SCI are living longer and baby 
boomers with SCI are likely to represent the majority of the VA population (age 60 and above). 
The study should be able to generalize the findings to the general population with LMN 
denervation, cardiovascular complications from TRT are also less likely to occur in individuals 
under the age of 70 years.  
 
b. Rationale for recruiting veterans and non-veterans for this trial 
The Hunter Holmes McGuire VAMC and the surrounding 13 spokes will be notified of the clinical 
trial once it is approved for imitation.  Despite the large Spinal Cord Dysfunction (SCD) registry 
(n=1,800), SCI persons with LMN denervation represent a small subgroup of the entire 
population and recruitment may be challenging. The primary focus will be to include Veterans 
with SCI and the Civilians with SCI will be only considered in case we fall short to complete our 
target sample size. The inclusion of Civilians with SCI will allow generalizing the findings of the 
current trial to the entire SCI population. 
 
c. Rationale for conducting the trial up to 1 year 
In the current trial, we will include SCI persons with different levels of denervation. It is clear that 
skeletal muscles with denervation atrophy may take 3-6 months to evoke a strong tetanic 
contraction that is capable of moving the leg against gravity. Our data showed that loading the 
muscle is the best approach to evoke muscle hypertrophy and therefore, adding another 6 
months may be a reasonable period to load the muscles. Besides the duration of the 
intervention has also considered the frequency (twice weekly) and not to overly stress the 
muscle to cause exercise induced muscle damage. Regarding applications of TRT, it is clear 
that using transdermal TRT patches may also need up to 1 year to induce a modest effect on 
lean mass. 
 
d. Inclusion of women and minorities: Women will not be included in the current study 

19 
Gorgey-Verizon4-12312018 
because administering TRT is neither appropriate nor safe.  Department of Veteran Affairs has 
limited access to Veteran women with motor complete SCI. They are also at risk of virilizing 
actions of testosterone, therefore, we were planning to limit this trial only to men with SCI. No 
vulnerable populations will be included and persons under 18 will be excluded.   
 
e. Exclusion:  Every effort will be made to ensure each subject’s safety or to exclude 
participants with current medical conditions that may confound the results. A conditional 
exclusion is those who will fail to tolerate the LPWS paradigm will also be excluded.  Pain 
tolerance will be examined by gradually increasing the current in 10 mA intervals starting from 0 
mA. If pain arises before a visible contraction, the subject will be automatically excluded from 
the trial.  
 
The list of exclusion criteria will include the followings 
1. Diagnosis of neurological injury other than SCI; 
2. Pre-existing medical conditions will be excluded (cardiovascular disease, uncontrolled type 
II DM and those on insulin requirements) or other concurrent medical conditions judged to 
be contraindicated by the site physician.  
3. Hematocrit above 50% and severe urinary tract infection or symptoms 
4. Those with hyper-physiological testosterone level above 800 ng/dl. 
5. Those who will fail to tolerate the LPWS paradigm 
6. Progressive condition that would be expected to result in changing neurological status; 
7. Lower extremity fracture around the knee joint (distal femur or proximal tibia) within the last 
2 years from enrollment in the study;   
8. Knee BMD < 0.60 gm/cm2;  
9. Total hip BMD T-scores < -3.5;  
10. Untreatable severe spasticity judged to be contraindicated by the site Physician;   
11. Untreated or uncontrolled hypertension (systolic blood pressure >140 mmHg; diastolic blood 
pressure >90 mmHg);  
12. Pressure ulcer of the trunk, pelvic area, or lower extremities of grade 3 or more 
13. Psychopathology documentation in the medical record or history that may conflict with study 
objectives  
  
f. Sources of Materials 
Existing electronic medical records will be reviewed for each subject enrolled by an IRB-
approved investigator (Dr. Gorgey). All research data (recruitment and collected) will be stored 
in the PI's locked office designated specifically for SCI Research. No VA research data will be 
destroyed. 
 
 
II. Study Procedures 
The study procedures will include assessment of vital signs, EMG to quantify level of 
denervation, anthropometry, body composition assessments including DXA, MRI, metabolic 
assessment and muscle biopsy.  These procedures will be performed by Dr. Gorgey in the 
McGuire SCI Exercise and Body Composition Research Lab except for muscle biopsies that will 
be performed at the minor procedure surgical room at the McGuire VAMC.  All supplies and 
equipment for completion of tests are available in the Research Lab and pose no cost to the 
hospital. The MRI will be completed at McGuire Radiology Department. A portion of the grant 
funds will be used to reimburse the hospital for the resources to complete the MRI. The MRI 
protocol has been successfully conducted in the applicant’s funded CDA-2 “Resistance Training 
and Testosterone after Spinal Cord Injury”. The total time to scan both thighs is less than 8 
minutes using an advanced localized coil.  

20 
Gorgey-Verizon4-12312018 
 
 
III. Recruitment and Informed Consent 
a. Plans for recruitment: 
1.      SCI & D providers along with staff will be briefed on the protocol by the PI at a routine 
monthly staff meeting. Providers will be updated and their support for recruitment 
reinforced at future routine staff meetings. Providers will refer patients who may be 
potential candidates. An opportunity will be made available to discuss the study in more 
depth if any provider wishes to learn more about the study. Upon notification, a review of 
the medical chart may be performed to determine if a subject is eligible to participate in 
the study.  
2. 
Recruitment Flyers will be distributed throughout the   VA Medical Center.  
3. 
SCI Research exhibits containing IRB approved literature for distribution to interested 
persons will be displayed in the VA Medical Center at monthly Paralyzed Veterans of 
America (PVA) meetings/events in addition to various VA Medical Center events.   
4. 
IRB approved literature will be published on PVA websites in addition to other VA 
websites. 
 
b. Detailed strategies for the Recruitment Plan 
Every effort will be made by the applicant to implement a successful recruitment plan, and to 
avoid any source of coercion during the actual process. 
The following timeline will be implemented to meet our recruitment goals, and determine 
screening failure using the following recruitment methods. Our goal is to recruit, train and test 8 
participants per year.  This is feasible considering our previous experience recruiting and 
conducting similar trials.  We plan to have 4 participants recruited in the first month of the trial in 
the first year and we will recruit an additional 4 participants every 6 months using the following 
timeline to meet our sample size. Approximately 2-3 subjects will be screened every other 
month.  They will then be randomized to either group.  The goal is to recruit 8 participants per 
year (4 participants every 6 months) and in order to finish data collection in 3-3.5 years. 
 
Research Activities 
Year 1 
Year 2 
Year 3 
Year 4 
Months 
1-6 
6-12 
 
1-6 
6-12 
1-6 
6-12 
1-6 
6-12 
Equipment & Supply 
Purchase 
 
 
 
 
 
 
 
 
Recruitment (n=4 per 
quarter) 
 
 
 
 
 
  
 
Screen and enroll 
subjects 
 
 
 
 
 
  
 
Data Collection 
 
 
 
 
 
 
 
 
Progress Report 
 
 
 
  
  
 

21 
Gorgey-Verizon4-12312018 
Data 
entry/coding/cleaning 
 
 
 
 
 
 
 
 
Data analysis and 
interpretation 
 
 
 
 
 
 
 
 
Presentation/Publications  
 
 
  
  
 
 
During the first 2 months of the trial, the investigators will purchase equipment and supplies, 
finalize data collection forms and procedures and begin subject recruitment.    Data analyses 
will be performed during the final six months of the trial.  It is anticipated that preliminary data 
will be presented at meetings of the American Spinal Injury Association, American Congress of 
Rehabilitation Medicine, American College of Sports Medicine, in addition to the VA RR&D 
Annual Conference.  Three manuscripts that address the primary specific aims will be submitted 
to the Journals of Spinal Cord, Archives of Physical Medicine & Rehabilitation and Applied 
Physiology.  
 
C. Feasibility of recruitment 
There is an emphasis on feasibility of the trial recruitment to ensure we reach our target sample 
size, especially considering the one year commitment necessary from participants. Below we 
provide a step-by-step description of our recruitment strategies to demonstrate feasibility  
- 
Prior to submission of the current work, eight participants were identified in our preliminary 
work. 
- 
After submission, eight additional participants were identified which already represents 33% 
of our target population. We have provided the physical characteristics of these participants. 
- 
We are planning to use both VCU and Sheltering & Arms as active recruitment sites for our 
trial. Currently, Sheltering and Arms is partnered with PMR-VCU under the leadership of Dr. 
David Cifu, Co-investigator. 
- 
We will contact every SCI physician, nurse and rehab. providers about our ongoing protocol 
through our weekly clinical rounds and grand rounds. 
- 
We will send an email blast through our secured network to our 13 Spokes sites and 
extended SCI Centers inviting out of state participants who may be eligible and offer them 
lodging opportunity during the course of the trial. 
- 
We will send electronic flyers as well as making our research coordinator available to 
present at our SCI meetings, PVA monthly meeting, SCI quarterly newsletters, hub and 
spoke conference, and SCI national Chief teleconference meeting. 
- 
We have been approved by our Service Chief to use one lodging room to house participants 
during the training period (see letter from Dr. Lavis). 
- 
We will provide the telehealth videoconference option to the control group (n=12), they will 
be likely to use standard NMES unit and we have tested the safety and the feasibility of this 
approach. This is likely to reduce the burden on the study resources and provide more focus 
on the TRT+LPWS group. We cannot offer the same option for the TRT+LPWS, because all 
training procedures have to be completed under full supervision. 
- 
Dropout is likely to happen with longitudinal interventions, in our CDA-2 trial, we had 26 
participants enrolled and 4 withdrew as previously highlighted. During the trial, we strived to 
replace them and we were very successful in accomplishing this goal. According to our initial 
power calculation, we require a sample size of 20 participants to achieve 80% power and we 
completed the trial with 22 participants.  

22 
Gorgey-Verizon4-12312018 
- 
Our SCI&D service has a designated wheelchair van that we have been using on a regular 
basis for transportation of our participants back and forth during the course of clinical trials, 
assuming they reside in the Richmond area. This accessible transportation has encouraged 
several participants to be enrolled in our previous VA trials. 
 
d. Recruitment Methods 
1. 
Flyers and brochures 
2. 
Annual health fairs at McGuire VA Hospital and VCU Medical Center 
3. 
Virginia local chapter of SCI (the applicant was previously invited to present in their 
monthly meetings). 
4. 
The PI will notify all the physicians, physician assistants and therapist working on the 
SCI service about the protocol and provide them with a print out of the 
inclusion/exclusion criteria.  The PI will plan to present quarterly at grand rounds to 
educate the staff and involve them in recruitment. 
5. 
All medical providers will be provided with an inclusion/ exclusion criteria that allows 
them to screen participants and to notify the PI about potential applicants. 
5. 
A letter with the inclusion/exclusion criteria will be mailed out to all potential applicants in 
the SCI registry, we will start first with the local participants (n= ~275) and we will 
subsequently include other participants in the registry. 
 
e. Process for obtaining informed consent: 
The PI will seek informed consent from subjects with an IRB approved consent form. 
Determination of a subject's capacity to consent will be made by the investigator.  Input may be 
solicited from an SCI primary provider who knows the potential subjects. Potential subjects will 
have the full study verbally explained to them by the PI.  If they voice an interest in the study 
they will have the written consent form provided and ample time to consider their participation.  
All concerns and questions will be answered. Emphasis will be placed on explaining all study 
procedures.  Family members will be included in the discussion as desired by the subjects. 
They will be told that participation is voluntary and can withdraw at any time with no impact on 
the care they receive from the VA.  They can discuss the study with their primary SCI provider.  
The subjects will be given a copy of the consent form once it is signed.  Potential subjects will 
be allowed sufficient time and opportunity to read the consent alone and have all questions and 
concerns answered.  They will be allowed to take consent home for additional time prior to 
making decisions. Voluntary participation and withdrawal will be reinforced. All aspects of the 
approved consent will be reviewed with all subjects. All signed consents will be scanned into 
CPRS attached to a CWAD note indicating enrollment in study. In addition to a consent note 
entered into CPRS for all subjects, progress notes of their active participation will also be 
entered. In summary, the following main points will be considered in this process 
1. 
The PI will approach all potential applicants, only after the provision of a written medical 
clearance from their primary provider stating their eligibility to participate in the study. 
2. 
The PI will discuss individually with the potential applicant and provide a detailed 
explanation about the study as well as offering the applicant sufficient time to consider 
reading the consent form, discuss with relatives and primary provider.  A list of study 
benefits/risks will be highlighted and the applicants will sign the consent in presence of a 
witness. 
3. 
Subjects will be allowed to withdraw from the study at any time without impacting their 
medical care or health benefits at the local VA facility. 
 
6. Limitations and Alternatives.   
The current interventions may not be applicable to those who have pain or intolerance to the 
stimulation parameters. 1) Only those with LMN denervation may benefit the current protocol. 2) 

23 
Gorgey-Verizon4-12312018 
Although LMN injury may evenly spread across different segments of the cord, we are 
interested in studying the large knee extensors because of its established metabolic activities.  
3) Every effort will be made to recruit individuals with TSI less than 5 years to ensure 
appropriate response to LPWS; however, the study will include others who have been injured 
for more than 5 years to ensure generalization to those with long-term LMN denervation. 4) The 
Grass S88X is intended for research use only and not for clinical applications. However, 
successful completion of this proposal will allow clinical translation and ensure safety of 
introducing these stimulation parameters to the clinical field. The unit does not require FDA 
approval to be used for human with SCI, it does only require IRB approval prior initiation of the 
trial. 
 
Other Limitations and Alternatives:  The current study is limited by  
1) The fact that the effects of training and increased muscle mass may be influenced by 
increased dietary intake, which may confound the primary outcome measures.  We will evaluate 
the caloric intake reports from our participants on a monthly basis.  This will allow us to closely 
monitor extra-caloric intake and we will regularly instruct our participants if the caloric intake 
exceeds 300-500 Kcal/week of their pre-measured BMR.   
2) Some individuals may complain of skin rashes when wearing the transdermal patches; 
glucocorticoid cream will be prescribed for use after each patch is removed and participant will 
be excluded if the problem is persistent.  
3) Concerns about frequent muscle biopsy samples and the size of the muscle biopsy. The 
muscle biopsy is performed by our Chief of Surgery, Dr. Rivers who has done more than 40 
subjects with no adverse events in different SCI clinical trials. She relies on making a tiny 
incision and she uses a 14 gauge Tri-Cut needle. Because we are aware that SCI persons with 
LMN denervation may have limited size muscle, we are planning to limit our analysis to specific 
proteins of interest and specific gene expression that helps elucidate pathways for triggering 
muscle hypertrophy.  For the ETC, we have proposed to study complex I and complex III as well 
as citrate synthase, this is likely to provide a clear indication of mitochondrial activity and size in 
persons with LMN denervation.    
4) Another concern is the ability to recruit the suggested sample size.  The PI has previously 
recruited and supervised 22 individuals during his CDA-2 award (see preliminary work).  We 
have also provided a plan to maximize recruitment (see human subject research plan for details 
about reasons for admissions and recruitment plan).  As we highlighted earlier, we currently 
have access to 16 participants who meet the study inclusion criteria without starting an active 
recruitment process. 
5) Concerns about frequent blood sampling, the procedure has been previously IRB approved in 
two funded grants and no single adverse incident has been reported.  
6) Concerns about retaining participants to finish the 1 year study; transportation is the 
greatest impediment to subject compliance for this population. Transportation will therefore be 
arranged in advance to allow for subjects personalized schedules and financial cost.  
a) The health benefits of actively enrolled in the trial will be clearly highlighted. 
b) A scheduled pick-up and drop-off time will be established to ensure subjects are more likely 
to attend all testing sessions.  
c) A portion of the budget will be dedicated for transportation using the CARE van, a 
transportation service for individuals with disabilities.  
d) Compared to our initial submission, we obtained an approval from our Service Chief (Dr. 
Lavis) to provide a lodging unit (1 bed room) to house our training group during the study 
(see the support letter from Dr. Lavis).  
e) A portion of $3000 subjects’ reimbursement fee will be dedicated to reserve a room for non-
veteran participants who may need lodging at Candlewood suites which is located 4.5 miles 
away from our center. 

24 
Gorgey-Verizon4-12312018 
f) For the TRT+ standard NMES (control group; n=12), we will provide the option to carry out 
the training at their home using our established videoconference telehealth system and 
monitor the training using a hand-held battery operated stimulator, which is pre-customized 
and ready to be used (see supplement). We have 5 Empi stimulators in our laboratory and  
do not need to buy any additional units. This will ensure subject retention at least in the 
control group and will allow the study team to focus on the retention of the other 12 
participants in the TRT+LPWS group. 
g) Providing financial reimbursement, social interaction during training sessions and access to 
the data at the conclusion of the study are additional methods to be utilized to reduce 
subject attrition.  
h) Dr. Gorgey will work closely with each participant to resolve any scheduling barrier and will 
allow morning and evening schedules.  
i) We will also provide a comprehensive team approach that will allow our participants free 
consultations with dietitian, psychologist and participation in our recreational activity 
program. 
 
7. Risk to Subjects 
 
Potential Risk                              Potential effects of risk                      Potential seriousness 
Anthropometrics  
Bruising, discomfort   
Occasionally  
Venous catheter insertion and 
blood draws 
Localized swelling, soreness, bruising, and 
chance of infection, bleeding, pain, 
lightheadedness or possible fainting. 
A total of 12 tablespoons will be collected. 
Occasionally  
IV line failure 
 Discomfort, swelling, redness over the IV  
line site causing failure to use the line.  
Another IV will need to be placed in  
another part of the arm. 
Occasionally  
 
Insulin Sensitivity Tests 
Hypoglycemia (low blood sugar)  
with occasional dizziness, sweating,  
and nausea, seizures, coma, or death 
Occasionally  
 
Unlikely 
Basic Metabolic Rate 
Anxiety, apnea, and claustrophobia 
Occasionally 
Autonomic Dysreflexia  
Slow heart rate, high blood pressure, 
headache flushing and sweating. 
 Unlikely 
DXA 
 
Fall during transfer 
This study will involve exposure to radiation 
from 3 whole body DXA scans and regional 
scans for hips and knees. This radiation 
exposure is not necessary for medical care 
and is for research purposes only.  All 
radiation increases the risk of developing 
cancer in the future.  The total amount of 
 Unlikely 

25 
Gorgey-Verizon4-12312018 
radiation in this study is equal to less than one 
day of exposure from natural background 
radiation. The McGuire VA Medical Center 
Radiation Safety Committee will review the 
use of radiation in this research study and will 
approve the use as involving acceptable risk 
and necessary to obtain the research 
information desired.  Physicians will be 
informed about the research to help their 
participants to make the correct decision.  
MRI 
Anxiety, dizziness, and claustrophobia 
Occasionally  
Muscle Biopsy 
 
 
 
Localized swelling, soreness, bruising, chance 
of infection, bleeding, pain, lightheadedness or 
possible fainting. 
 
The numbing medication can cause allergic 
reaction including local skin rash and rapid 
heart rate. 
Uncommon 
Resistance training and LPWS 
electrical stimulation 
1. Light-headedness, shortness of breath and 
altered heart rate& blood pressure leading 
to autonomic dysreflexia. Muscle soreness 
at your neck, upper back, shoulders, arms 
& hands 
2. Fracture  
3. Autonomic dysreflexia (slow heart rate,  
high blood pressure, headache flushing & 
sweating) which may be life threatening 
4. Pressure Ulcers 
5. Fainting, heart attacks or death 
 
Unlikely 
Testosterone Replacement 
Therapy 
Serious reactions 
Severe rash at site of the patches, worsening 
heart failure that may cause difficulty for 
pumping blood, swelling of the body, enlarged 
prostate causing difficulty in urination, increase 
in red blood cells which may cause blood clots 
in the legs (cause swelling), chest pain, 
shortness of breath and rarely death and brain 
damage (causing a stroke), infertility, prostate 
cancer, difficulty in breathing during sleep, 
blood in urine. 
Common reactions 
Application site reactions, back pain, enlarged 
prostate, headache, irritations of the skin, 
Occasionally occurs 

26 
Gorgey-Verizon4-12312018 
depression, enlarged breasts, increase 
cholesterol which may increase the risk of 
heart disease, chills, diarrhea, fatigue, frequent 
urination, pain during urination, reduced sex 
drive, inflammation of prostate, rash, acne, 
confusion 
 
a. Protection against Risk: 
Every effort will be made by the PI and the study team to minimize potential risks. Any 
procedures will be carried out in accordance with any standard operating procedures and study 
staff will receive the necessary training to mitigate risks. There will be strict adherence to the 
inclusion & exclusion criteria of the protocol. Appropriate health screening and strict compliance 
with the established exclusion criteria will minimize attrition due to medically related causes. 
Subjects will be closely monitored by study personnel at all visits.  All subjects will be provided 
with 24-hour contact information for the investigator and instructed to call for any concerns. 
Unscheduled visits may be performed if required for evaluation of safety. If a subject has an 
adverse event, more frequent visits may be necessary. 
 
b. Adequacy of Protection from Risk: 
Protection of skin integrity during Anthropometry:  
 Skin will be closely checked following each measurement to ensure no redness or scratches.   
 
Protection from risk associated with transfers: 
To minimize risk, an investigator will be available to assist in all transfers, and provide a slide 
board or any other assistive devices needed.  Our labs are equipped with ceiling lifts that 
facilitate the transfer process from wheelchairs to any other station.  
 
Protection against risk of autonomic dysreflexia (AD).  
Our sample is limited to T10 and below, we have developed a protocol by carefully monitoring 
blood pressure and heart rate every 2-3 minutes in persons with SCI. Moreover, our training 
protocol provide us with an opportunity to space out time between NMES repetitions in persons 
who are susceptible of developing AD risk. This ensures the participants can safely continue the 
training and reduce the potential risk. Following 4-8 weeks of training, participants’ free nerve 
endings become acclimatized to the electrical signals during NMES.  
 
Protection from risk associated with Dual Energy X-ray Absorptiometry (DXA) Scan: 
To minimize risk, only the required scans will be performed.  An overhead lift system has been 
installed to ensure safe transfers on and off scanner. All study procedures have to be approved 
by our Radiation Safety committee prior obtaining IRB approval.  
 
Protection from risk associated with MRI: 
To minimize risks an MRI safety checklist will be used to ascertain it is safe for subjects to have 
an MRI. Only board certified radiologists at McGuire VAMC will be utilized. 
 
Protection from risk associated with venous catheter insertion and blood draws: 
To reduce risk, all blood drawing will be performed by certified personnel using aseptic 
techniques and universal precautions.  All blood draws will be performed by well-trained certified 
nurses who are working in our SCI center. IVGTT dose calculation and test will be carried out 
and administered by a medical doctor and the participant will be under full medical supervision 
during the test. 
 

27 
Gorgey-Verizon4-12312018 
Protection from risk associated with muscle biopsy: 
The muscle biopsy will be conducted at the McGuire VA Medical Center. Three biopsy samples 
of the vastus lateralis muscle (25-50 mg wet wt.) will be obtained by a 14 gauge Tru-Cut needle 
by Dr. Rivers. Biopsies will be obtained before the trial (baseline), mid-intervention (6 months) 
and after 1 year of completing the trial (post-intervention) using a sterile technique and local 
anesthesia (2% lidocaine).  The skin overlying the muscles will be prepped and draped in a 
sterile fashion and 3cc 2% lidocaine will be locally administered. A 5 mm skin incision will then 
be made with a #10 scalpel. The biopsy samples will be obtained from one site incision, after 
which the site will be closed with Steristrips and an overlying sterile adhesive dressing. 
Furthermore, a pressure dressing will be administered for at least 10 minutes. Following the 
muscle biopsy, Dr. Gorgey will provide the participants with extra supplies in case the dressing 
needs to be changed. One of our SCI physicians will examine all the participants within 48 
hours after conducting the muscle biopsy. This procedure has been successfully completed in 
our previous CDA2 trial (n=22) without a single adverse event reported.  
 
Protection from risk associated with resistance training and LPWS neuromuscular 
electrical stimulation 
Dr. Adler will review all DXA scans to determine that participants can safely exercise without risk 
of fracture. Participants with knee BMD less than 0.6 g/cm2 and hip T-scores below -3.5 SD or 
previous bony fracture around the knee joint within the last 2 years will be excluded from the 
trial. Dr. Gorgey will supervise all aspects related to the protocol including proper ankle weight 
positioning, placement of the electrodes and monitoring vital signs during electrical stimulation.  
 
Protection from risk associated with Testosterone (T) Replacement Therapy (TRT) 
Dr.  Adler will clinically and medically supervise all our participants during the course of the 
study. Possibility of skin rashes will be treated with glucocorticoid cream after removal of T 
patches. The PI will supervise all the participants closely and provide a weekly call to identify 
any issues. Participants will be monitored for any changes in baseline health.  Participants will 
undergo blood work to determine serum T-level as well as their Prostate-specific antigen (PSA). 
There is no specific normal or abnormal level of PSA; however, a value above 1.4 ng/ml or 
increase of the PSA above 1.4 compared to baseline values will result in immediate cessation of 
TRT. We will also check the HCT every 4 weeks to ensure that hematocrit (HCT) is less than 
54%, value greater than 54 may result in polycythemia.  
Moreover, a staff physician who is board certified in SCI medicine will evaluate all participants 
who enroll in the study.  This physician is competent to assess for urologic irritative or 
obstructive voiding symptoms and for changes in erectile function.  This is a routine component 
of SCI medicine practice for patients with urologic symptoms related to both neurogenic voiding 
dysfunction and prostate hypertrophy.  The physician will assess each participant for new 
symptoms every three months. 
 
Study removal criteria may include: 
- 
Extensive skin irritation or rashes or itching as result of TRT applications 
- 
Medical history of carcinoma of the breast, carcinoma of the prostate, venous 
thromboembolism, pulmonary embolism, stroke, cholestatic jaundice, hypertension, serious 
heart problems, heart failure, myocardial infarction, ventricular arrhythmia, exertional chest 
pain, insulin dependent diabetes, hypercholesterolemia, hypertriglyceridemia, impaired liver 
function, or significant renal dysfunction. 
- 
cardiovascular events similar to acute myocardial infarction, acute coronary syndrome, 
congestive heart failure, any cardiovascular-related hospitalization, stroke, or cardiac arrest, 
and the development of new significant ischemic findings or symptoms during the course of 

28 
Gorgey-Verizon4-12312018 
the study (including development of new major abnormalities on serial EKGs or symptoms of 
typical angina) 
- 
Serum PSA >4.0ng/ml 
- 
Increase in serum PSA of >1.4ng/ml compared to baseline 
- 
HCT >54% 
- 
Liver enzymes (AST / ALT) >1.5 times normal upper limit 
- 
Hemoglobin >17.5 g/dL 
- 
Serum calcium between 10.5 – 11.2mg/dL with symptoms of hypercalcemia 
- 
Gynecomastia 
- 
Development of severe peripheral edema, as classified as 2+ or higher 
- 
Development of any other SAE that the Medical Director, Dr. Adler, feels necessitates study 
withdrawal for participant safety 
 
 
Protection against possible subjects’ coercion.  
The $3000 dollar amount dedicated as a reimbursement fee may create subject coercion. This 
amount reflects the cost of gas, transportation and commitment throughout the 1-year period. 
To protect against any coercion, the figure will be split into 6 payments ($500 every two months 
or 16 visits). This means that each participant will receive ~ $31.25 per study visit.  The $3000 
figure will be re-calculated incase participants decide to lodge at Candlewood suites or perform 
the study at home using our established telehealth system.  Finally, all our study procedures will 
be approved by the IRB and the PI will work closely with the IRB to avoid any coercive influence 
on any of our study participants.   
 
c. Adverse Events 
Participants will be monitored for any changes in baseline health.  Their SCI provider will be 
notified if this occurs. An adverse event is any experience that has taken place during the 
course of research project, which, in the opinion of the investigators, was harmful to a subject 
participating in the research, increases the risks of harm in the research, or had an unfavorable 
impact on the risk/benefit ratio.  Adverse events (AE) will be monitored throughout the study via 
exams, vital signs, laboratory tests, review of medical charts, and verbal concerns voiced by the 
participant or an associated friend or family member.  Any adverse event will be documented in 
their files. Files will be reviewed for adverse events, protocol violations, and reasons for 
dropouts/withdrawals every ten days.  The PI will provide the McGuire VA IRB & Office of 
Research Subjects Protections with an annual summary of adverse events. All serious adverse 
events (SAEs), such as those that are life-threating or involve hospitalization, s will be promptly 
reported to the McGuire IRB Research Subjects Protection Program.  Participants’ health 
conditions will be monitored during study visits. 
 
When study procedures begin, the importance of reporting any perceived problem, adverse 
event or change from baseline health will be stressed to the subjects. Examples will be given to 
the subject of potential problems requiring immediate medical attention and potential problems 
requiring a phone call to the investigator. Above all, it will be stressed to the subject that direct 
phone access to the study staff is available 24hrs/day and if there is ever any doubt or concern 
on the part of the subject a call should be made. At the completion of this study all subjects will 
continue to receive their health care from their assigned SCI provider or other provider of 
subjects' own choice. 
 
All subjects will be identified by an assigned number and their initials. Subjects' research charts 
will be kept inside a locked file in the PI’s locked office.  Only study staff listed on the Personnel 
List will have access to subject study records and medical information. A master sheet of 

29 
Gorgey-Verizon4-12312018 
participants’ full names will be kept in a locked file in the PI’s office.  All completed study files 
will be stored in the PI’s SCI research office 1V-129. At the end of the 4 year period, all records 
will either be stored in the SCI Research Exercise Laboratory, which is a locked room or sent to 
Dunmar Storage Facility per direction of McGuire IRB.  
 
8. Subjects' burdens 
 
The current study was designed to reduce and minimize subject burden including 
transportation and participation time.  Although participation may impose a significant burden, 
every effort will be taken by the study team to reduce the stressors and burdens of participation. 
Over the 1 year period, persons will be asked to visit the lab 4 times (1 visit for screening and 
consenting and 3 testing sessions for conducting outlined procedures) for testing.  All exercise 
training will be conducted twice weekly over 1 year. Each training session should not last more 
than 30 minutes. The current study design will allow each participant to serve as his own control 
over all the genomic, dietary, body composition, metabolic and SCI factors that are likely to 
impact the outcomes of any training study.  Every effort will be taken to retain participants in the 
study for 1 year. We have significant experience retaining participants up to 9 months that 
adhered to the applicant’s CDA-2 study protocol. In the applicant CDA-2, the study constituted 
of 3 phases; a delay entry approach phase for 4 weeks, 16 weeks training phase and 16 weeks 
detraining phase. Out of the 26 participants who completed the first 2 phases, the applicant was 
successful in retaining 13 participants for the 3 phases (50%).  The CDA2 study was designed 
to examine only 50% of the participants in the detraining phase (i.e. 6 participants/ group). 
Moreover, each participant is allowed to miss up to 10% (12 visits) of the scheduled visits 
without withdrawing from the study to consider unanticipated events similar to sickness, medical 
appointments and vacations.  We believe that we can retain participants for up to one year 
using similar strategies.   
 
a) Previously we provided transportation using our facility owned Van (free of charge) to allow 
transportation to and from the VA facility.  
b) We have allowed operation and training beyond regular business hours to accommodate 
education and work related schedules. 
c) Total time commitment is less than 2 hours/ week, twice a week. Compared to other 
longitudinal clinical trials this is considered by far the least training volume, which was 
adopted according to the American College of Sports Medicine guidelines. 
d) During data collection, we will provide sufficient time for participants to have their meals 
and use medications. 
e) Trained research staff will help in the process of testing and data collection. 
f) The SCI Exercise Physiology Laboratory is equipped with a sound system and is in the 
process of installing a flat screen TV that will allow participants to listen to music or watch 
TV during exercise providing an interactive and motivational environment. 
g) A comprehensive team approach will be adopted that will allow participants to engage in 
recreational activity programs and to consult with a psychologist, dietitian or other clinical 
staff (PT, OT, etc.) as needed. 
 
a. Benefits and Burdens 
Potential benefits of research to subjects and others: 
The risks associated with this study seem appropriate for the anticipated benefits. Study 
information will be under continuous review for any information that may impact on the 
risk/benefit ratio; i.e. adverse events, unanticipated problems, and complaints regarding the 
research. SCI persons with LMN denervation exhibit greater loss in muscle mass. The 
significant loss in muscle mass has been linked to several metabolic and cardiovascular health 

30 
Gorgey-Verizon4-12312018 
related consequences. Individuals with SCI are at increased risk for many chronic diseases 
such as type II diabetes mellitus, dyslipidemia, cardiovascular disease and osteoporosis; it is 
important to continue developing exercise interventions that benefit these individuals and 
thereby decrease their risk for chronic disease. This understudied population represents 25% of 
the whole SCI population and cannot benefit from the standard applications of surface NMES on 
restoring muscle size similar to persons with SCI with intact LMN system.  Results from the 
current investigation will facilitate a greater understanding of the methodology necessary to 
accurately determine the impact of long-term exercise on muscle hypertrophy, metabolic and 
local cellular adaptations.  SCI predisposes individuals with denervated muscle to extreme 
muscle atrophy, decreased BMR, glucose intolerance and insulin resistance.  Exercise has the 
potential to improve BMR, glucose effectiveness and insulin sensitivity in this population.  
Moreover, the benefits of long-term rehabilitation interventions are limited in individuals with 
lower motor neuron (LMN) denervation following SCI. The current proposal may provide a 
simple rehabilitation intervention to help restore muscle size and prevent heath related 
consequences. We hope findings from this application will help reduce the costs associated with 
managing secondary health related complications in Veterans and Civilians with SCI. The 
research team will extend every effort to disseminate the knowledge gained from this trial at 
various scientific meetings and journals to share nationally and internationally with other 
academics/clinicians. While there may be no direct benefit to the subjects besides the monetary 
reimbursement, the information learned in this study has the potential to help others in the 
future. 
 
b. Importance of knowledge to be gained: The prevalence of individuals with SCI has been 
estimated to be 250,000-400,000 with an estimated 14% growth in the prevalence since 1988. 
Of the more than 46,000 Veterans with SCI-related disability, more than 60% are overweight or 
obese, more than 50% are glucose intolerant and 20% are frankly diabetic. In the last two 
decades, the national aggregate direct costs of SCI in the United States have increased with a 
concomitant decline in mortality over the first year after SCI.6 Our preliminary data suggested 
that 20-25% experience SCI with LMN denervation. Currently, there is no available rehabilitation 
intervention following lower motor neuron (LMN) denervation.  Denervation to lower extremity 
muscles results in even more deleterious sub-lesional skeletal muscle atrophy and is 
accompanied with several SCI health-related consequences. The current proposal will provide a 
novel rehabilitation strategy, combining both TRT+LPWS to determine the effects of mitigating 
muscle loss following LMN denervation. Establishing the LPWS rehabilitation protocol is a 
rigorous process and may require several attempts to refine and establish the best stimulation 
protocol necessary for stimulation of LMN denervation. The addition of TRT may provide 
additional benefits of increasing lean mass and accelerate the actions of LPWS. Previous 
attempts indicate that TRT may increase lean mass and BMR. This will be the first clinical 
attempt to determine the role of TRT on muscle size and lean mass in persons with LMN 
denervation independent of neural structures. This is a promising combination of physical and 
pharmacologic therapy that is likely to improve body composition and other cellular functions 
which may improve other metabolic health biomarkers. Several of the mechanisms involved in 
increasing muscle size, including proteins and gene expression will be studied, which will allow 
us to design specific interventions that target specific abnormalities at the cellular level which 
have the potential to impact body composition and metabolic adaptations in future studies. 
 
9. Clinical Trials Requirements. This is a drug trial and registration with Clinical Trials is 
mandated. We are aware of this requirement and are experienced in complying with all 
regulatory requirements. The PI has previous experience working with Clinical Trials and he 
successfully registered two clinical trials. 
 

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10. Data Safety and Monitoring Board (DSMB): 
The Data Safety Monitoring Board (DSMB) will consist of Dr. Randall E. Merchant, PhD, Dr. 
Steven L. West, PhD, CRC, Dr. Carolyn W. Graham, PhD and Dr. Sean McAvoy, MD.  The 
DSMB will meet to review the protocol prior to data collection and will meet at least annually to 
evaluate subject safety, data quality, and study progress and execution. The DSMB will review 
protocol for any major concern prior to implementation. They will also evaluate safety, study 
conduct, and scientific validity and integrity of the trial. They will also assess the performance of 
overall study operations and any other relevant issues, as necessary.  Elements in the letter will 
include the followings:  
• 
Evidence of efficacy according to pre-established statistical guidelines, if appropriate;  
• 
Evidence of study-related adverse events 
• 
Data quality, completeness, and timeliness  
• 
Performance of the study  
• 
Adequacy of compliance with goals for recruitment and retention, including those related 
to the participation of women 
• 
Adherence to the protocol  
• 
Factors that might affect the study outcome or compromise the confidentiality of the trial 
data (such as protocol violations)  
• 
Factors external to the study such as scientific or therapeutic developments that may 
impact participant safety or the ethics of the study.  
 
DSMB will include the following members 
Randall E. Merchant, Ph.D. 
Professor of Anatomy & Neurobiology, Neurosurgery, Physical Medicine & Rehabilitation 
Executive Director of the Center for Rehabilitation Science & Engineering (CERSE) 
Virginia Commonwealth University 
 
Steven L. West, PhD 
Associate Professor in the Department of Physical Medicine and Rehabilitation and Associate 
Director of the Center for Rehabilitation Science and Engineering at Virginia Commonwealth 
University) Principal Investigator (PI): He has extensive experience in conducting research on 
substance abuse and disability related issues. 
 
Carolyn W. Graham, PhD 
Research Methodologist, Center for Rehabilitation Sciences and Engineering 
Director of Research, RRTC for Employment of Individuals with Physical Disabilities 
Associate Professor, Department of Physical Medicine and Rehabilitation 
Virginia Commonwealth University 
 
William McKinley, MD 
Professor in in the Department of Physical Medicine and Rehabilitation 
Director, Physical Medicine and Rehabilitation Residency Program  
Director of Spinal Cord Injury Services at the Rehabilitation and Research Center. 

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McKinley is a professor and director of the residency program in the Department of Physical 
Medicine and Rehabilitation with special interests and expertise in spinal cord injury, 
electrodiagnosis and musculoskeletal rehabilitation and has been active in clinical research in 
SCI and pain assessment.  
 
 
Sean McAvoy, MD 
Attending Physician, Spinal Cord Injury and Disorders 
Department of Veterans Affairs 
Hunter Holmes McGuire VA Medical Center 
Phone: 804-675-6227 
Email: sean.mcavoy@va.gov