Skeletal Muscle Hypertrophy and Attenuation of Cardio-Metabolic Risk Factors (SHARC) Using Functional Electrical Stimulation-Lower Extremity Cycling in Persons with Spinal Cord Injury. Study Protocol for a randomized clinical trial

Abstract Background Persons with spinal cord injury (SCI) are at heightened risks of developing unfavorable cardiometabolic consequences due to physical inactivity. Functional electrical stimulation (FES) and surface neuromuscular electrical stimulation (NMES)-resistance training (RT) have emerged as effective rehabilitation methods that can exercise muscles below the level of injury and attenuate cardio-metabolic risk factors. Our aims are to determine the impact of 12 weeks of NMES+12 weeks of FES-Lower extremity cycling (LEC) compared to 12 weeks of passive movement+12 weeks of FES-LEC on 1) oxygen uptake (VO2), insulin sensitivity and glucose disposal in adults with SCI; 2) skeletal muscle size, intramuscular fat (IMF) and visceral adipose tissue (VAT) and; 3) protein expression of energy metabolism, protein molecules involved in insulin signaling, muscle hypertrophy and oxygen uptake and electron transport chain (ETC) activities. Methods/Design Forty-eight persons aged 18-65 years with chronic (> 1 year) SCI/D (AIS A-C) at the C5-L2 levels, equally sub-grouped by cervical or sub-cervical injury levels and time since injury, will be randomized into either NMES+FES group or Passive+FES (control group). The NMES+FES group will undergo 12 weeks of evoked RT using twice-weekly NMES and ankle weights followed by twice-weekly of progressive FES-LEC for an additional 12 weeks. The control group will undergo 12 weeks of passive movement followed by 12 weeks of progressive FES-LEC. Measurements will be performed at baseline (B; week 0), post-intervention 1 (P1; week 13) and post-intervention 2 (P2; week 25) and will include VO2 measurements, insulin sensitivity and glucose effectiveness using intravenous glucose tolerance test; magnetic resonance imaging to measure muscle, IMF and VAT areas; muscle biopsy to measure protein expression and intracellular signaling as well as mitochondrial ETC function. Discussion Training through NMES+RT may evoke muscle hypertrophy and positively impact oxygen uptake, insulin sensitivity and glucose effectiveness. This may result in beneficial outcomes on metabolic activity, body composition profile, mitochondrial ETC and intracellular signaling related to insulin action and muscle hypertrophy. In the future, NMES-RT may be added to FES-LEC to improve the workloads achieved in the rehabilitation of persons with SCI and further decrease muscle wasting and cardio-metabolic risks.