Heat Shock Therapy to Improve Mitochondrial Function in Neuropathy
Phase: NA
Conditions: PreDiabetes, Neuropathy
Sponsor: University of Kansas Medical Center

 
KUMC – HRPP- 03/12/2015 
 
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University of Kansas Medical Center  
RESEARCH PROTOCOL INVOLVING HUMAN SUBJECTS  
TEMPLATE WITH GUIDANCE 
 
Version date: 08 June 2021 
Principal Investigator: Paige Geiger, PhD 
Study Title: Heat Shock Therapy to Improve Mitochondrial Function in Neuropathy (HOTFUN) 
Co- Investigator(s): Douglas Wright, PhD; Mamatha Pasnoor, MD; Andrea Nicol, MD 
 
I. 
Purpose, Background and Rationale 
A. Aim and Hypotheses  
1. Sensory dysfunction as a result of peripheral nerve damage is a significant problem that 
leads to reduced quality of life for patients. The prevalence of sensory dysfunction in 
peripheral neuropathy associates with epidemic increases in prediabetes and diabetes, 
but also is relevant to chemotherapy treatments and genetic disorders. Clinical 
approaches to treat peripheral neuropathy and to stimulate axon growth in settings of 
peripheral axon loss are limited. Although new drugs will hopefully be forthcoming, the 
most promising approaches likely involve behavioral and lifestyle interventions. 
Mitochondrial dysfunction is emerging as a key cellular contribution to peripheral axon 
health and peripheral neuropathy. Mitochondrial deficiencies contribute to neuropathy 
and include impaired mitochondrial problems with trafficking, mitophagy, fission, and 
biogenesis. All of these are thought to lead to a bioenergetic crisis, ending in distal 
axonal degeneration, sensory dysfunction and pain. Heat shock proteins play a critically 
important role in cellular homeostasis and increasing heat shock protein functions within 
cells leads to a range of positive improvements, particularly in mitochondria. In addition, 
new evidence suggests that increasing heat shock protein responses in peripheral nerves 
has powerful, positive impacts on sensory function and neuropathy. 
 
2. Our interdisciplinary team will investigate the role of mitochondrial dysfunction in 
peripheral neuropathy and translate these approaches to improve treatment for patients 
with peripheral neuropathy. We hypothesize that novel heat treatment interventions that 
improve mitochondrial function will improve metabolic symptoms and peripheral nerve 
mitochondria, leading to improvements in sensory function, via heat shock protein 
induction. We will employ immersion heat treatment to elevate heat shock protein 
responses that induce positive changes in peripheral nerve mitochondria. One aspect is to 
confirm the efficacy, safety, and potential for heat treatment to improve sensory 
dysfunction in human patients with prediabetes. The goal of this proposal is 1) to test the 
breadth of heat treatment on various forms of neuropathy, 2) identify mechanisms in 
which heat treatment improves mitochondrial function, and 3) test the efficacy, safety, 
and potential for heat treatment to improve sensory dysfunction in human patients with 
prediabetes.  
 
B. Background and Significance 
1. Study Significance: Diabetic neuropathy (DN) is a common prediabetic and diabetic 
complication and is a leading cause for disability due to foot ulceration and amputation, 
gait disturbance, and fall-related injury. Sensory dysfunction in peripheral neuropathy 
(PN) is also is relevant to chemotherapy treatments and genetic disorders. Compared to 

 
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diabetic patients without neuropathy, patients with DN experience a twofold increase in 
health-care costs, and those with severe painful peripheral neuropathy experience a 
fourfold increase. In addition, 25% of patients with prediabetes also develop PN1. 
Currently, there are no treatments for diabetic and prediabetic PN other than pain 
control. This problem must be addressed as our global population with diabetes increases 
in epidemic proportions. The scientific premise of our application is based on the 
evidence from both preclinical and clinical studies. 
 
2. The reliance of peripheral neurons on proper mitochondrial support for their maintenance 
has emerged as a key mechanism underlying neuropathy. In diabetic neuropathy, a 
number of recent studies have reported deficient mitochondrial support. Thus, 
approaches to improve mitochondrial function and stimulate new mitochondrial 
biogenesis are logical directions to treat peripheral neuropathy. Heat shock is one of the 
best-known interventions that lead to changes in gene expression known to improve 
mitochondrial function. New evidence is emerging that heat treatment leads to a 
significant enhancement of heat shock protein effects in a number of organ systems. A 
key step in leading to this proposal was the successful implementation of a hot tub in the 
CTSU that now allows us to heat treat patients and test the hypothesis that heat 
treatment stimulates heat-shock protein mediated mitochondrial improvements related to 
glucose control and nerve function. 
 
3. Literature Review: Peripheral neuropathy is strongly associated with metabolic 
syndrome and diabetes. Current strategies to prevent diabetic PN focus on glucose 
control and lifestyle modifications. Improved glucose control dramatically reduces the 
incidence of PN in type 1 and type 2 diabetes. Current clinical recommendations focus on 
optimizing glucose control to prevent or delay the development of diabetic PN. New 
approaches that contribute to better glucose control are needed2. 
 
Peripheral neuropathy is associated with mitochondrial dysfunction. 
Mitochondrial dysfunction is a key cellular contributor to peripheral axon health. 
Mitochondrial deficiencies contribute to neuropathy and include impaired mitochondrial 
problems with trafficking, mitophagy, fission, and biogenesis. Together, this leads to a 
bioenergetic crisis, ending in distal axonal degeneration and sensory dysfunction. Heat 
shock proteins play a critically important role in cellular homeostasis and increasing heat 
shock proteins improves neuronal health3. 
 
Heat treatment reduces abnormal metabolic changes in diabetes. Several studies 
have reported metabolic benefits in type 2 diabetes patients with heat therapy. In these 
studies, 3 weeks of heat treatment reduced plasma glucose and HbA1c levels. Additional 
studies using heat therapy in obese patients report improvements in quality of life and 
reduced weight and fat. Thus, an additional benefit of heat treatment may be to reduce 
detrimental metabolic changes that contribute to PN4. 
 
Heat treatment stimulates heat shock protein levels and improves mitochondrial 
function in patients. Ongoing studies are assessing the ability of heat therapy to 
impact mitochondria in human subjects (ages 28-45, n=5). A skeletal muscle biopsy was 
performed at the KU Clinical Research Center (CRC). One week later, subjects underwent 
60 min of heat exposure (hot tub) located in the CRC. Subjects then returned 24 h after 
the heat therapy for a second muscle biopsy. Muscle samples were analyzed for heat 
shock protein levels and respiratory measures. These studies reveal that skeletal muscle 
respiratory capacity increases following acute heat therapy. Moreover, these studies 
suggest that heat treatment increases heat shock proteins in muscle that positively 

 
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correlate with increased mitochondrial respiration. These findings are consistent with our 
preclinical studies of heat therapy in rodents. 
 
C. Rationale 
1. Literature from our own studies and others reveal that heat treatment leads to beneficial 
heat-shock-mediated improvements in glucose control and mitochondrial function.  
Studies now reveal that deficient energy support from mitochondria in peripheral nerves 
is a significant contributor to impaired nerve function and neuropathy. 
2. Success in this project will reveal a new intervention for patients suffering from nerve 
damage and sensory dysfunction. Currently, there are no treatments other than pain 
control for patients with peripheral neuropathy. Heat treatment likely can be combined 
with healthy lifestyle and exercise to benefit patients suffering from neuropathy. The 
project will also provide new information about how heat treatment may improve glucose 
control in humans with prediabetes or diabetes.  
3. The information gained in this research study will be useful in developing fundamental 
knowledge about heat therapy and determining if heat therapy can be a novel treatment 
of peripheral neuropathy related to prediabetes patients. 
 
II. 
Research Plan and Design 
A. Study Objectives: To see if heat therapy can be used to improve metabolic symptoms and 
peripheral nerve mitochondria, leading to improvements in sensory function. 
B. Study Type and Design: This prospective, observational cohort pilot study will recruit 20 
patients with prediabetes with or without peripheral neuropathy (painful and non-painful) to 
participate in a 4-week heat therapy intervention. After screening, informed consent, and 
enrollment into the study, subjects will undergo a pre-intervention evaluation that will assess 
metabolic biomarkers and heat shock protein levels (blood), peripheral neuropathy, and 
epidermal evaluation (skin biopsy). After the skin biopsy has the appropriate time to heal 
(approximately 7-14 days), the subjects will undergo 45-minute heat treatments in 40°C 
water, three times weekly, for 4 weeks. After completion of heat treatments, subjects will 
undergo a repeated post-intervention evaluation and skin biopsy. Statistical approaches will 
compare pre– and post-heat therapy measures. 
 
C. Sample size, statistical methods, and power calculation 
1. Subjects will not be randomized as our study is a pilot intervention of subjects with 
prediabetes and neuropathy. Analyses of pre- treatment vs. post-treatment outcomes 
will be performed using ANOVA. The primary goal of this pilot study will be to provide 
necessary data for a power analysis to estimate the effect size for design of a larger 
future study. 
2. N/A 
3. 20 subjects will receive intervention. As this is a pilot study which will be used to inform 
future, larger studies, power calculations will not be needed. Statistical approaches will 
compare pre- and post-heat therapy measures. 
 
D. Subject Criteria (See Vulnerable Populations appendix, if applicable):  
1. Inclusion criteria: Subjects will include both males and females, ages 45-75, that have 
suspected or diagnosed prediabetes with or without neuropathy (to be confirmed at pre-
intervention evaluation).  

 
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2. Exclusion criteria: (1) skin conditions, circulatory insufficiency, or open wounds in the leg 
that would interfere with healing from a biopsy; 
(2) stroke or other significant nervous system pathology; 
(3) lidocaine allergy; 
(4) anticipated difficulty with blood clotting due to disorder or use of a blood thinner such 
as Coumadin, Xarelto, or Eliquis; 
(5) use of any medication used to treat abnormal blood glucose such as Metformin; 
(6) body weight > 350 lbs.; 
(7) history of anemia or vitamin b12 deficiency; 
(8) clinical anemia (hematocrit <32 for women, <36 for men); 
(9) abnormal SPEP result; 
(10) history of cancer or chemotherapy treatment; 
(11) current or recent use (within the last 6 months) of artificial fingernails / nail 
enhancements that would interfere with quantitative sensory testing; 
(12) no special classes of subjects such as fetuses, neonates, pregnant women, 
prisoners, institutionalized individuals, non-English speaking individuals, or other who 
may be considered vulnerable populations will be included in this study. 
3. Withdrawal/Termination criteria: Prediabetes will be determined using the American 
Diabetes Association (ADA) Diabetes Management Guidelines. The subject will meet the 
criteria for a diagnosis of pre-diabetes if the subject has one or more positive test(s) for 
either A1c (5.7-6.4%), fasting glucose (100-125 mg/dl), or 2-hr oral glucose tolerance 
test (140-199 mg/dl). If at pre-intervention evaluation, the subject does not meet the 
criteria for prediabetes (lower than the above-mentioned range), meets the ADA criteria 
for diabetes (higher than the above-mentioned range), the subject will be considered a 
screen fail and will not progress to skin biopsy or intervention.   
4. Subject may participate in other observational studies but cannot participate in other 
studies in which they receive an intervention. 
 
E.  Specific methods and techniques used throughout the study  
 
1. After screening, informed consent, and enrollment into the study, subjects will be 
assessed for the following at the CTSU: 
 
Blood draw (approximately 8 tubes of blood): complete blood count, complete 
metabolic panel, lipid panel, inflammatory panel, fasting glucose, 1 hour and 2 hour 
glucose (oral glucose tolerance test), insulin, glycosylated hemoglobin (HbA1c), serum 
protein electrophoresis (SPEP), vitamin B12, point of care glucose finger stick (pre- and 
post-OGTT), heat shock protein (HSP) 72 and 90 
Urine Analysis: pregnancy test, if applicable 
  
2. Study Procedures: All study visits will be completed at the University of Kansas Clinical 
and Translational Science Unit (CTSU) by study personnel and CTSU staff. Prior to the 
first visit, the inclusion and exclusion criteria will be reviewed with a phone screen 
(included in appendix).  
 
Visit 1 (pre-intervention evaluation): During the pre-intervention evaluation (approx. 
3.5 hours), inclusion and exclusion criteria will be confirmed via medical history, 
medication review, and the above listed laboratory tests. Vitals, demographic 

 
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information, social and lifestyle information, and questionnaires on lifestyle will also be 
collected.  
 
Medical History: prediabetes diagnosis and duration, neuropathy diagnosis and 
duration, family history of diabetes or neuromuscular disorders, general medical 
history 
Medication Review 
Vitals: heart rate, blood pressure, height, weight, waist circumference, body mass 
index (BMI) 
Demographic Information: date of birth, sex, race, ethnicity, recruitment source, 
education level 
Social/Lifestyle: marital status, employment status, smoking history 
Questionnaires: PROMIS Emotional Distress and Depression, PROMIS Sleep 
Disturbance (included in appendix). 
 
Following an overnight fast, participants will have blood drawn (6 teaspoons) for analysis 
at Quest Diagnostics. After initial fasting blood samples (listed above), patients will drink 
a sweet and concentrated solution of glucose (Azer Scientific Glucola, 75 g) within 5 
minutes. After this, patients will wait for 1 hour and blood will be redrawn to test glucose 
and insulin levels (2 teaspoons). A final blood draw for glucose and insulin will occur after 
another hour (2 teaspoons). Patients will complete a point of care glucose finger stick to 
ensure blood glucose is within a safe range before start and after completion of OGTT for 
safety. 
 
Visit 2 (pre-intervention evaluation): Once inclusion and exclusion criteria are 
confirmed by laboratory results, the presence and type of neuropathy will be confirmed 
with a clinical examination and nerve function testing (Drs. Mamatha Pasnoor or Andrea 
Nicol, approx. 1.5 hours).  
 
Neuropathy and Pain Assessment: medical evaluation by Drs. Pasnoor and Nicol, 
Utah Early Neuropathy Scale (UENS), Quantitative Sensory Testing (QST). 
Questionnaires: Brief Pain Inventory (BPI), PROMIS Physical Function short form. 
Skin Biopsy: Patients will undergo a punch skin biopsy from the proximal thigh. 
Total dermal and epidermal innervation will be quantified from skin biopsies. The 
punch skin biopsy will be performed using a 3 mm disposable circular punch 
(Miltex, York, PA) after injection of 2% lidocaine under a sterile technique. No 
suture will be used. The skin will be placed in freshly prepared Zamboni's fixative 
for one hour. The tissue will be sectioned at 50 µm and processed for 
immunohistochemistry using rabbit anti-PGP9.5 primary antibody (1:3000; 
Chemicon, Temecula, CA). Sections will be coded in order to carry out the analysis 
in a blinded fashion and quantified. The biopsy will be used for quantification of 
GLO1 enzymatic activity. 
 
Visits 3-14 (heat therapy intervention x 12 treatments): After the skin biopsy has 
appropriate time to heal (approximately 7-14 days), the subjects will undergo 30-minute 
heat treatments in 40°C water, three times weekly, for 4 weeks (approx. 1 hour each). 
 
Subjects will be immersed up to the shoulder in a 40°C hot tub until rectal temperature 
(Tre) increases by 1°C (~20 minutes). Subjects will then remain in the water bath 
submerged to waist level to maintain Tre between 38.5 and 39.0°C for another 30 
minutes (approx. total time submerged ~50 minutes). Following hot water immersion, 
subjects will be monitored for another 10 min, or until Tre falls below 38.5°C. Core 
temperature will be monitored using either 1) a rectal probe with sterile disposable 
sheaths or 2) a sterile disposable rectal thermistor probe (401 A/C, Advanced Industrial 
Systems, Inc., Harrods Creek, KY) to be inserted ~1 inch past the anal sphincter 

 
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(inserted by participant). Heart rate and blood pressure will be monitored throughout the 
treatment. Subjects will be continually monitored and removed from the hot bath if Tre 
exceeds 39.5°C. 
 
Visit 
15 
(post-intervention 
evaluation): After completion of heat therapy 
intervention, subject will return to assess any change in fasting laboratory tests, oral 
glucose tolerance test, and questionnaires as listed in Visit 1 (approx. 2.5 hours). In 
addition to the two questionnaires completed at Visit 1, subject will also complete a 
Patient Global Impression of Change (PGIC) survey (included in appendix). A single 
question asks patients “After my treatment, my pain is:” with a 7-point scale ranging 
from -3 (very much worse) to 0 (no different) to +3 (very much improved). This 
measure will be a secondary determinant of analgesic response to treatment and will 
only be administered at the completion of heat therapy intervention 
 
Visit 16 (post-intervention evaluation): Subject will return for a final visit to assess 
any change in the presence or type of neuropathy by completing the same clinical 
examination and nerve function testing as in Visit 2 (Drs. Mamatha Pasnoor or Andrea 
Nicol, approx. 1.5 hours).  
 
3. All procedures will be performed solely for research purposes. None should be considered 
standard of care or billed to insurance. 
4. Blood will be processed at the CTSU and sent to Quest Diagnostics for resulting. Subjects 
will have the option to save leftover samples for future deidentified research. Otherwise, 
any leftover samples will be destroyed. Skin biopsy samples will be housed at the 
University of Kansas Medical Center in a secure laboratory for processing. Only the study 
team will have access to any samples. All samples will be marked only with subject ID 
and date.  
5. Timeline:  
 
 
Subjects are expected to complete the study in approximately 11-13 weeks. 
 
F. Risk/benefit assessment:   
1. Physical risk: Participants will be asked to fast overnight for the blood draw. The study 
visits will be scheduled in the morning when possible, and subjects will be provided with 
a snack immediately following testing. Risks of blood draws include temporary discomfort 
from the needle being inserted into the skin, bruising, swelling, fainting, or in rare cases, 
infection or blood clot at the injection site. 
 
During the oral glucose tolerance test, there is a very small risk of developing symptoms 
of low blood sugar, which include rapid heartbeat, sweating, and headache. Nausea and 
vomiting are also rare, but known, risks of the oral glucose tolerance test. Patients will 
complete a point of care glucose finger stick to ensure blood glucose is within a safe 
range before leaving the CTSU. 
 
Quantitative sensory testing (QST) may cause minor but temporary physical discomfort. 

 
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Study personnel will be trained by the investigators to be sensitive to participant 
discomfort and concerns. Participants will be instructed that they can stop any QST 
procedure anytime that the pain or unpleasantness of the task becomes unbearable. 
There have been no significant adverse events associated with any of these procedures in 
the experience of its use at the Chronic Pain and Fatigue Research Center at the 
University of Michigan. Specifically, MAST testing may cause some temporary physical 
discomfort on the thumbnail. The MAST System incorporates a series of redundant 
mechanical, electrical, and software safety features to prevent patient injury in the event 
of user error or device failure, including a safety pin that the subject can turn to 
immediately remove the pressure actuator from his or her thumb. The test is terminated 
at or before 10 kg/cm2 of pressure which is a commonly used maximum pressure level in 
human sensory testing and does not result in physical injury. Participants will always 
have personal control over the stimulus and can stop it at any time or express 
instructions to stop the stimuli. They can also withdraw their thumb from the device. 
However, these instruments may cause minor physical discomfort in the areas of testing 
that is expected to resolve within minutes of test completion. 
 
The 3mm skin biopsy procedure is not painful. However, when the Lidocaine is injected, 
there may be a brief pinprick pain followed by a few seconds of burning form the 
anesthesia. A small percentage of patients can have an allergic reaction to the Lidocaine. 
If an allergic reaction to the Lidocaine occurs, it will be treated immediately with 
medicines in the clinic. Following the biopsy there will probably be some soreness. There 
is a risk that the biopsy site will bleed or become infected. The risk for infection is low at 
the biopsy site. The biopsy will leave a small scar that will fade in intensity over time. 
There are some risks associated with heat exposure, including: fatigue, light-headedness, 
muscle cramps, dehydration, and neurological detriments (i.e. heat stroke). However, 
these symptoms do not typically occur until core temperature rises above 40°C. Core 
temperature (rectal thermistor) will be continuously monitored and recorded. Subjects 
will be removed from the hot bath immediately if either core temperature reaches 39.5°C 
or the subjects experience any symptoms of heat-related illness. All symptoms subside 
upon lowering core temperature. Ice packs will be on hand if rapid cooling is necessary 
(see Rapid Cooling SOP). Heart rate will also be continuously monitored and recorded 
throughout heating. If HR increases > 60 beats/min above resting or increases > 20 
beat/min with a 5 min time period, subjects will be moved to a seated position if they 
were previously fully submerged or removed from the hot tub if they were already sitting 
up. Additionally, heat exposure may have detrimental effect on a developing fetus in 
females. Thus, subjects who are pregnant or trying to conceive will be excluded from the 
study. This will be confirmed with a pregnancy test.  
 
2. Psychological risk: Some questions related to medical history, weight, or pain status may 
result in feelings of discomfort or embarrassment.  Participants may decline to answer 
any questions. 
 
3. Social risk: N/A 
 
4. Economic risk: N/A 
 

 
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5. Potential benefit of participating in the study  
a. Potential benefits for individuals including learning new information based on 
laboratory testing and medical examination, at no cost to the subject. This 
information may be of use to the participant and their physician by providing 
updated information on important parameters of prediabetes and/or neuropathy. 
Subjects will have the opportunity to receive heat therapy, which may offer 
multiple health benefits related to the cardiovascular system and metabolic 
health. Physiological benefits to the cardiovascular system in healthy subjects has 
been documented and those studies were performed by Dr. Chris Minson, from 
the University of Oregon. In addition, quality of life improvements have commonly 
been reported by patients undergoing chronic heat exposure (e.g. hot tub, sauna, 
etc.).  
b. The information gained in this research study will be useful in developing novel 
treatments of peripheral neuropathy in the future related to prediabetes patients. 
c. The proposed research will be helpful to develop fundamental knowledge about 
treatment approaches that will help reduce the burdens of disease and disability. 
This knowledge should offset the very minor risk to participation by individual 
subjects, given the protections that are in place and the low likelihood of a serious 
adverse event in this study. 
G. Location where study will be performed:  
Pre-screening data will be securely kept via REDCap.  
All study visits will take place at the University of Kansas Clinical and Translational Science 
Unit (CTSU) “Fairway” at 4350 Shawnee Mission Parkway, Fairway, KS or the CTSU 
“Rainbow” at 3901 Rainbow Boulevard, Kansas City, KS. 
Consent forms will be kept in a separate folder from subject study worksheets, and kept in a 
secure, locked location at the University of Kansas Medical Center - Hemenway. 
H. Collaboration (with another institution, if applicable): N/A 
I. Single IRB Review for a Multi-site study (if applicable):  N/A 
1. For which sites will KUMC serve as the IRB of record? N/A 
2. Indicate which study activities will occur at each site. If all study procedures will be 
identical across study sites, state this. N/A 
3. Describe how you will assess the capacity of each site to perform the research (e.g., 
expertise, staffing, space, equipment, etc.)  If applicable, include site evaluation tools in 
your IRB submission. N/A 
4. Describe how the lead investigators will ensure that all participating sites use the IRB-
approved version of the protocol, consent, recruitment materials and other study 
documents. N/A 
5. Describe how the lead investigators will communicate with and disseminate new 
information to other sites (e.g., training meetings, regularly-scheduled conference calls, 
notifications, etc.) N/A 
6. Describe how the lead investigator will assess protocol compliance, unanticipated 
problems and adverse events at other sites. N/A 
7. Name the member of the KUMC study team who will be the point of contact to coordinate 
oversight and communication with the sites. N/A 
 

 
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J. Community-Based Participatory Research (if applicable) 
1. Participants and the nature of their involvement: N/A 
 
2. Cultural issues:  N/A 
 
3. Origin of the research question: N/A 
 
4. Risks and Benefits:  N/A 
 
5. Study Description and Process:  N/A 
 
6. Return of results: N/A 
 
7. Sustainability: N/A 
 
K. Personnel who will conduct the study, including: 
1. Indicate, by title, who will be present during study procedure(s): 
a. Paige Geiger, PI 
b. Douglas Wright, co-I 
c. Mamatha Pasnoor, co-I 
d. Andrea Nicol, co-I 
e. Michelle Vitztum, regulatory and study coordinator 
f. 
Miranda McMillan, study coordinator 
g. Janelle Ryals, lab manager and study coordinator 
h. Josh Miller, study coordinator 
i. 
Daniel Elliott, lab technician and study coordinator 
2. Primary responsibility for the following activities, for example:  
a. Determining eligibility: PI, co-Is, and study coordinators 
b. Obtaining informed consent: PI, co-Is, and study coordinators 
c. Providing on-going information to the study sponsor and the IRB: Study 
coordinators 
d. Maintaining participant's research records: Study coordinators 
e. Completing physical examination: Co-Is and resident 
f. Taking vital signs, height, weight: CTSU Nursing Staff, PI, co-Is, and study 
coordinators 
g. Drawing / collecting laboratory specimens: CTSU Nursing Staff 
h. Performing / conducting tests, procedures, interventions, questionnaires: PI, co-
Is, and study coordinators 
i. Completing study data forms: PI, co-Is, and study coordinators 
j. Managing study database: PI, co-Is, and study coordinators 

 
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L. Assessment of Subject Safety and Development of a Data and Safety Monitoring 
Plan 
 
1. Elements of the plan include: 
a. Persons/groups who will review the data (study team; independent safety 
monitor, data monitoring committee or formal DSMB): The PI or Co-Is will 
monitor AEs monthly, grade them, and indicate if the AE is related to the study 
procedure (definite, probably, possible, unlikely, not related). For each AE, the PI 
will determine if the study procedure should be continued. Patients will be 
instructed to call the PI’s office (or on-call resident/coordinator if at night or on 
the weekend) to report events that occur between study visits. All SAEs will be 
reported to the HSC and Clinical Research Center (if applicable) and FDA 
guidelines, as soon as possible, but no later than five working days.  
b. Data/events that will be reviewed: Any serious adverse events (SAE) will be 
reviewed as soon as possible and reported to the IRB if applicable. 
c. Frequency of review: Data safety will only be monitored if necessary (unusually 
high frequency of adverse events (AE) or at any SAE). 
d. Types of analyses to be performed: N/A 
e.  Safety-related triggers that would cause the PI to stop or alter the study: N/A - 
Study activities are considered low risk and any adverse symptoms will be 
treatment promptly, including temporary removal from heat treatment. Will 
assess if further safety-related triggers need to be identified as needed.  
2. Nursing staff will continually monitor participants for adverse events.  Any adverse event 
will be immediately reported to the PI and study coordinator per KUMC Human Subject 
Committee reporting policies. AEs will be classified as follows: related to study procedure 
as determined by the PI or unrelated to study procedure (related instead to underlying 
disease, pre-existing conditions, or other factors), anticipated (included in consent form) 
or unanticipated (not included in consent form), serious (SAE, Grade 4 using CTCAE 
v3.0) or not serious (AE, Grade 1, 2 or 3 using CTCAE v3.0) 
3. AEs that are not related to study procedures or are otherwise considered anticipated, 
low-risk events (ie: bruising or bleeding at injection site) will be monitored and recorded, 
but not necessarily reported to the medical monitor or the HSC unless frequency of event 
is considered unanticipated. 
Any AEs that are related to study procedure, are unanticipated, and are considered 
serious will be reported to the medical monitor and to HSC. A report that summarizes the 
frequency of all AEs will be provided to the medical monitor as needed. If a patient 
experiences a serious adverse event, they will be discontinued from the study. 
 
III. 
Subject Participation 
 
A. Recruitment: 
1. Participants will be recruited for this study through flyers posted at the University of 
Kansas Medical Center, in the community, and electronically via websites and email 
(included in appendix). Subjects may also be recruited from Drs. Pasnoor’s and Nicol’s 
clinics. Michelle Nguyen will utilize the KU Diabetes Institute to identify potential 
participants from ongoing research studies. We will also utilize the Frontiers Research 

 
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Participant Registry after approval from the Data Request Committee (DRC). Participants 
will be offered a $25 for completing Visits 1, 2, 15 and 16; and $15 for completing Visits 
3-14; via ClinCard after completing each of the visits ($280 total) to aid with time and 
transportation. 
2. Michelle Nguyen and Miranda McMillan will perform the majority of recruitment. 
Individual mailings and phone calls will be made to applicable subjects from the Frontier’s 
Research Participant Registry. 
3. Attached. 
4. Attached. 
B. Screening Interview/questionnaire: Attached. 
C. Informed consent process and timing of obtaining of consent 
1 
PIs and/or study coordinators authorized to review Informed Consent 
2 
Subjects will be given a copy of the consent form when their first visit (pre-intervention 
evaluation) is scheduled. This will give them ample time to review and prepare questions 
for the study team before their visit. The consent form will be reviewed with the subject 
by the PI and/or study coordinator in a private room at the CTSU at the start of their first 
visit. The subject will have the opportunity to ask any and all questions to the 
coordinator, or an investigator if requested, before signing. A signed copy will be given 
back to the subject. 
3 
All subjects should be English speaking, of consenting age (> 18 years old) and of sound 
mind (no cognitive or decisional impairment). If there is any question of this, the study 
coordinator will have an investigator assess ability to consent.  
D. Alternatives to Participation: The consent form includes the following statement: 
“Research is voluntary, and you may change your mind at any time. There will be no penalty 
to you if you decide not to participate, or if you start the study and decide to stop early. 
Either way, you can still get medical care and services at the University of Kansas Medical 
Center (KUMC).  
 
The consent form explains what you have to do if you are in the study. It also describes the 
possible risks and benefits. Please read the form carefully and ask as many questions as you 
need to, before deciding about this research.  
 
You can ask questions now or anytime during the study. The researchers will tell you if they 
receive any new information that might cause you to change your mind about participating.” 
E. Costs to Subjects: There will be no cost to the subject for participation in the study, 
including all labs and procedures. 
F. How new information will be conveyed to the study subject and how it will be 
documented: Michelle Vitztum, Miranda McMillan and Josh Miller will review screening 
results (laboratory) with subject only to assess eligibility for continuation. Drs. Pasnoor or 
Nicol will further discuss screening results with the subject by request.  
G. Payment, including a prorated plan for payment: Participants will be offered a $40 for 
completing Visits 1, 2, 15 and 16; and $20 for completing Visits 3 - 14; via ClinCard after 

 
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completing each of the visits ($400 total) to aid with time and transportation. Subjects will 
not continue to receive payments after they’ve withdrawn from the study.  
H. Payment for a research-related injury: We will include the following text in the consent 
form: “If subjects have a serious side effect or other problem during this study, they should 
immediately contact Dr. Mamatha Pasnoor at (913) 588-6970. If it is after 5:00 p.m., a 
holiday or a weekend, subjects should call (913) 588-5000 [24-hour phone number], and 
this number will contact Dr. Pasnoor. A member of the research team will decide what type 
of treatment, if any, is best for them at that time. If the subjects have a bodily injury as a 
result of participating in this study, treatment will be provided for them at the usual charge.  
Treatment may include first aid, emergency care and follow-up care, as needed. Claims will 
be submitted to their health insurance policy, their government program, or other third 
party, but they will be billed for the costs that are not covered by the insurance. The 
subjects do not give up any legal rights by signing this form.” 
IV. 
Data Collection and Protection 
A. Data Management and Security:  
1. 
Paige Geiger, Douglas Wright, Mamatha Pasnoor, Andrea Nicol, Michelle Vitztum, Miranda 
McMillan 
2. 
Following a phone call pre-screening, potential subjects will be emailed or mailed the 
consent form prior to the first visit and the consent discussion. Pre-screening data will be 
securely kept via RedCAP. Consent forms will be kept in a separate folder from subject 
study worksheets, and kept in a secure, locked location at the University of Kansas. All 
subject study worksheets, labs, and biopsies will be de-identified and marked only with a 
subject ID. This information will be kept for 15 years according to the KUMC Records 
Retention Policy. 
3. 
Through coded information. 
4. 
Only the study team will have access to the key to the code.  
5. 
Subjects will be assigned a study ID and this number will be used to follow subjects 
throughout the study. Only the consent forms (housed separately from the study 
worksheets) will be able to link identifiable data to study IDs.  
6. 
Paper data (consents, study worksheets) will be stored in a designated and locked 
storage cabinet, to be overseen by the PI, co-Is, and study coordinators. No one except 
for the study team will have access to the storage cabinet. Electronic data will be stored 
on a KUMC-supported network drive (S- or P-drive) and in a RedCAP database.  
7. 
N/A 
8. 
N/A 
 
B. Sample / Specimen Collection: Blood will be collected at the CTSU by nursing staff and 
analysis of blood samples will be performed externally my Quest Diagnostics.  
C. Tissue Banking Considerations: N/A 
D. Procedures to protect subject confidentiality: Subject confidentiality will not be at risk 
during any time in the study. 
E. Quality Assurance / Monitoring 

 
KUMC – HRPP- 03/12/2015 
 
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1. 
The data to be collected in this study will be reviewed in a timely fashion by the study 
team.  We will provide self-assessments on a regular basis to determine that the data 
values are within normative values. 
2. 
No 
 
V. 
Data Analysis and Reporting 
A. Statistical and Data Analysis:  To understand how heat therapy impacts glucose control 
and sensory function in prediabetic patients with or without neuropathy, we compare pre-
treatment versus end-of-treatment measures of fasting glucose and neuropathy measures 
using intraepidermal nerve fiber (IENF) density as our two primary outcome measures. We 
will also make comparisons between secondary outcome measures such as the Utah Early 
Neuropathy Scale (UENS), Quantitative Sensory Testing (QST), blood and metabolic 
biomarkers. As pre- and post-treatment measurements are available for each patient, a two-
sided paired t-test will be used to test the null hypothesis of no difference in conductance 
between pre- and post- conductance measures. As the paired t-test assumes normally 
distributed data and because of the modest number of subjects in this pilot study (e.g., N = 
20), we will also explore the use of non-parametric methods for testing the aforementioned 
null hypothesis, such as a Wilcoxon signed-rank tests and/or a randomized-based test. We 
will also introduce variables for key clinical characteristics of the patient (e.g., patient age, 
sex, ethnicity, disease severity, etc.) into the linear mixed effects model and formally 
statistically test whether there is a significant interaction between these variables and time. 
In other words, if there a significant relationship between the temporal trajectory of 
conductance over the course of treatment and patient age at baseline. 
B. Outcome: The hypothesis will test whether prediabetic patients with or without neuropathy 
exhibit any improvements in metabolic symptoms and peripheral nerve mitochondria, 
leading to improvements in sensory function, via heat shock protein induction. 
C. Study results to participants: Laboratory results and medical evaluations will be given to 
the subject if they request it.  
D. Publication Plan: Data from this intervention will be published by Drs. Geiger, Wright, 
Pasnoor, and Nicol in appropriate journals, likely focusing on diabetes and/or neuropathy and 
pain. Publications will be developed in a timely fashion and are the responsibility of the PI 
and co-Is.  
VI. 
Bibliography / References / Literature Cited  
1. Juster-Switlyk K and Smith AG. Updates in diabetic peripheral neuropathy. F1000Research 
2016; 5(F1000 Faculty Rev):738. 
2. Rodica-Popsui et al. Diabetes Care 2017; 40:136–154 
3. Fernyhough P. Mitochondrial dysfunction in diabetic neuropathy: a series of unfortunate 
metabolic events. Curr Diab Rep. 2015; 15(11):89. 
4. Krause M, et al. Heat shock proteins and heat therapy for type 2 diabetes: pros and cons. 
Curr Opin Clin Nutr Metab Care. 2015; 18(4):374-80. 
 
APPENDIX I: VULNERABLE POPULATIONS 
 
I.     The recruitment plan will not include any of the vulnerable groups below, except possibly 
employees of the University or Health System. 

 
KUMC – HRPP- 03/12/2015 
 
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II.     Cognitively or decisionally impaired individuals: N/A 
 
III.     Children: N/A 
 
IV.     Pregnant women: N/A 
 
V.     Prisoners: N/A 
 
VI. 
     Students and/or Employees:  
A. N/A 
 
B. Our study will not specifically target employees of the University or Health System. 
However, it is not outside the realm of possibility that employees may contact the study 
team for pre-screening after having seen recruitment postings or that they are not 
consenting participants of the Frontiers registry. 
 
C. N/A