Effects of Electrical Stimulation and Vitamin D Supplementation on Bone Health Following Spinal Cord Injury
Phase: PHASE2
Conditions: Spinal Cord Injury
Sponsor: VA Office of Research and Development

Ifon-Version 2- 06222021                                                  1
 
 
 
Effects of Electrical Stimulation and Vitamin D supplementation on Bone Health 
Following Spinal Cord Injury 
 
 
Protocol-Version 2- 06222021 
 
PI: Dora E. Ifon, PhD, NP 
Co-investigators: Ashraf S. Gorgey, PhD, Robert A Adler, MD, Timothy Lavis, MD, 
Teodoro Castillo, MD, Rehan Khan, MD 
 

Ifon-Version 2- 06222021                                                  2
 
 
 
r 
Table of Contents: 
 
 
 
Contents 
Page 
Title 
1 
Table of Contents 
2 
Background and Rationale 
3-4 
Significance of this Research to the VA Population 
4 
Preliminary Study 
5-6 
Research Design and Methods 
7-15 
Human Subject Section 
15-22 
Limitations and Alternatives 
22 
Risks to subjects 
20-26 
Subject’s Burden 
27-28 
Clinical Trial Requirements 
28 
Data Safety Monitoring Board 
28-29 
References 
30-34 
Additional Items 
 
Appendix 1: WHO-QOLQuestionnaire 
 
Appendix 2:   Common data elements 
 
Appendix 3: 3 day dietary record 
 

Ifon-Version 2- 06222021                                                  3
 
 
 
 
Background and Rationale: Neurogenic osteoporosis is a well-known complication of 
spinal cord injury (SCI). It results from bone demineralization due to the inevitable 
mechanical unloading of paralyzed limb1-5.  Impaired skeletal muscle activity leads to 
muscle atrophy, loss of bone mass, bone porosity, fragility and increased incidence of 
fractures6-10  Bone health is maintained by a continuous cycle of bone formation and 
resorption. However, when the cycle is interrupted or uncoupled, as seen in certain 
conditions like estrogen deficiency, changes in levels of parathyroid hormone (PTH), 
glucocorticoids, serum calcium and growth hormone, there is significant loss in bone 
tissue.11 It is estimated that 200 million people worldwide are affected by bone loss or 
osteoporosis.12-13 Osteoporosis is defined as a T-score of <-2.5 standard deviations 
(SD) below the bone mineral density (BMD) of a healthy young female, as measured by 
dual x-ray absorptiometry (DXA)13.  In the United States, an estimated10 million 
Americans have osteoporosis and another 44 million more, have low bone mass or 
osteopenia.17-20 Among able-bodied individuals, about 1 in 3 women and 1 in 5 men, 
over age 50, will suffer an osteoporotic fracture.14-17    
Data from the Department of Veterans Affairs suggest that SCI affects an 
estimated 46,000 Veterans.18  With about 18,000 new cases of SCI every year,18-19 
including a significant number of Veterans, the risk of osteoporosis and fracture is worth 
addressing. The first 2 weeks of SCI is the most critical for bone loss.20 Thereafter, 
progression slows down and stabilizes in 2-5 years and in some cases, far beyond10 
years7,20-21 It is estimated that 50% -70% of individuals with SCI, will sustain a low 
impact fracture sometime in their lifetime.11,20 The sites commonly affected are the distal 
femur and proximal tibia21-22  Osteoporosis-related fractures involve significant health 
care expenditure.  The medical cost for managing Veterans with SCI alone in 2016 was 
estimated at $30,770 - $62,563 per Veteran23-24; while cost in the acute phase could go 
above $140,00025.  The cost of medical care for Veterans with SCI and osteoporosis-
related fractures will naturally therefore, have significant impact on the finances of the 
VA healthcare system and those of Veterans and their families. It is estimated that 
health care cost for managing osteoporosis-related fractures, as a whole, will reach $25 
billion by 2025 23,25.  Treating and preventing osteoporosis in persons with SCI is 
challenging. Anti-resorptive drugs (bisphosphonate and denosumab) and anabolics 
(PTH peptides), have been shown to reduce fracture risk at vertebral and hip sites11,21. 
However, there is no consensus on whether they reduce fracture risk at the femur; the 
site of greatest relevance for persons with SCI. In contrast to anti-resorptive agents, 
sclerostin, which inhibits bone formation by up-regulating receptor activator of nuclear 
factor-kappa B ligand (RANKL) and down-regulating osteoprotegerin (OPG), with a net 
result of increased bone resorption, is emerging as a therapeutic target.26  Anti-
sclerostin drugs (e.g. romosozumab), have been shown to stimulate bone formation, 
reduce resorption and ultimately increase BMD27.  Its use in the SCI population is 
however still being studied. It is only available in injectable form and has a black box 
warning for cardiovascular events/death, making it unattractive for use in a population 
already at high risk of cardiovascular events.  Very importantly, electrical stimulation 
(ES) has been shown to partly reduce BMD loss in the femur if initiated early in SCI28-29 
and it presents no systemic side effects.  Bélanger et al., observed that the distal femur 
and proximal tibia had almost 30% recovery after 24 weeks of daily one-hour ES 

Ifon-Version 2- 06222021                                                  4
 
 
 
treatment to the quadriceps muscles 5 days a week.30 However, there was no notable 
change in the mid-tibia.  In another study of 24 persons with acute SCI receiving 
functional ES cycling exercises for 3 months, the rate of depletion in BMD in the distal 
femur, was significantly less in the study population compared to controls.31  We 
recently adopted neuromuscular electrical stimulation (NMES) resistant training (RT) to 
evoke muscular activity in paralyzed lower extremity muscles.32 Our preliminary data 
showed that just 16 weeks of 2 times a week resulted in micro-architectural changes, 
suggesting that NMES-RT holds great promise as a therapeutic modality.  We anticipate 
that a longer duration of treatment would yield even better outcomes. We therefore 
propose using telehealth to administer NMES-RT interventions over a 9-month period to 
improve the bone health of Veterans with SCI. Telehealth is an emerging utility that is 
gaining popularity.  Using Telehealth for patient care has been shown to increase 
access and compliance.33-34  In a pilot study NMES-RT induced muscle hypertrophy by 
Gorgey et al., all participants were compliant with keeping their telehealth appointments 
and participation in the intervention activities.35  Additionally, vitamin D (Vit D) 
deficiency, defined as 25-hyroxyvitaminD 25(OH)D < 30ng/mL, has been implicated in 
decreased BMD, higher bone turnover, and higher incidence of bone fractures36, 
whereas supplementation reduces fracture risk11 when major circulation 25(OH)D is 
sufficient.   
Vit D depletion in persons with SCI was first observed in the early 90s, when 
Zhou et al.,37 compared serum levels of 25(OH)D of 92 individuals with SCI (50 
paraplegics and 42 quadriplegics) with those of 28 able-bodied persons. Serum 
25(OH)D was low in SCI participants compared to the control group. Ultraviolet radiation 
from sunlight is the primary stimulant for the elaboration of Vit D.  Deficiency can easily 
develop in SCI patients who have limited exposure to sunlight.  Bauman et al.  
demonstrated that a sizable proportion of Veterans with chronic SCI have Vit D 
deficiency compared to non-SCIs in the general population.38  Although, Vit D deficiency 
is prevalent in the SCI population, the requisite amount of Vit D supplementation for 
correction of the deficiency has not yet been established.  In a prospective drug 
intervention study, Bauman and Colleagues, used daily doses of 2000 IU of oral Vit D in 
Vit D deficient (< 20 mg/mL) subjects, plus 1.3 gram of elemental calcium to reach 
physiological levels of serum 25(OH)D, after 3 months39.  Another study used 6000 IU 
daily dose of Vit D in a double-blinded study, to achieve physiological range within the 
same time frame40. The lower therapeutic dose in Bauman et al.’s study39 may be 
explained by the fact that Vit D is only needed for control of body calcium 
homeostasis41, to improve calcium absorption for bone health.  Lani et al.42 observed 
that calcium supplementation along with Vit D supplementation was necessary to 
achieve significant increase in bone mineralization in rat models. The authors 
suggested that even at higher doses, Vit D supplementation does not stimulate bone 
mineralization. Caution is however advised in the use of calcium supplementation in the 
SCI population, because of the risk of renal lithiasis and increased cardiovascular risks.  
To our knowledge, no study has considered the combination of Vit D 
supplementation and NMES-RT for attenuation of bone loss after SCI.  Prevention of 
osteoporosis and associated serious complications in the SCI population remains a 
major challenge and implementation of early interventions to mitigate complications and 
reduce health care cost is a worthwhile endeavor.   

Ifon-Version 2- 06222021                                                  5
 
 
 
 
Significance of this research to the Veterans’ population: The lack of weight 
bearing amongst Veterans with complete spinal cord injury and the prevalence of Vit. D 
deficiency, due to limited exposure to sunlight, is a significant problem.  The 
consequence of these duo can result in low impact fracture leading to increased 
morbidity and mortality, as well as, high health care cost, increased care burden for the 
families and poor quality of life for the Veteran. The proposed study to use NMES-RT in 
conjunction with 2000 IU oral daily Vit D supplementation in Veterans with SCI of at 
least one-year post-injury, is a potential therapeutic strategy that may attenuate bone 
loss and decrease the frequency of low  impact fractures after SCI. The fact that 50% of 
individuals with SCI will sustain low impact mechanical fractures during their lifetime, 
with an even higher incidence in Veterans, validates the need for this study. 
Additionally, the findings may help the VA healthcare system in the development of 
clinical guidelines for the prevention of osteoporosis in Veterans with SCI.   
 
 
 
Preliminary Study: RT has been identified as a very important rehabilitation approach 
that increases lean mass and decreases fat mass42-43.  After SCI, RT has also been 
used to exercise both paralyzed and non-paralyzed muscles of lower extremities. NMES 
has been used in individuals with chronic SCI to evoke exercise-induced RT using 
standard ankle weights.  
 
 
 
Fig 1  
 
 
 
 
 
 
 
Mahoney et al.44 showed that 12 weeks of twice a week NMES-RT resulted in skeletal 
muscle hypertrophy by more than 40% and improved glucose tolerance years after 
injury. A follow-up study reported that fatigue resistance of the trained knee extensors 
increased by 33%. Gorgey noted that 12-weeks of twice weekly NMES-RT elicited 
more than 35% increase in skeletal muscle size, improved muscle quality, and 
increased insulin growth factor-1 (IGF-1) by 25%. The authors implemented 12 weeks 
of NMES-RT, 40 contractions per leg per session, in 9 individuals with motor complete 
SCI (C5-T11). Participants were randomly assigned into one of two groups; RT + diet 
(n=5; 4 tetraplegic) 

Ifon-Version 2- 06222021                                                  6
 
 
 
or diet only (n=4; paraplegic). Skeletal Muscle Cross-Sectional Area (CSA) was 
measured with T1-axial MRI at a) pre and b) post-12 week 
of NMES-RT. Thigh (28%) and knee extensor muscle CSA 
(35%) showed remarkable hypertrophy (Fig 2). Another 
study demonstrated the effects of NMES-RT and 
Testosterone on cardio-metabolic risk factors after SCI45. In 
an open-label randomized clinical trial, we examined the 
effects of complementary approach of 16 weeks of surface 
NMES evoked RT and testosterone (TRT+RT) compared 
to testosterone replacement therapy (TRT) only (2-6 mg) 
on skeletal muscle size, body composition, and peak 
torque (muscle quality) in persons with motor complete 
SCI. Twenty-two individuals with chronic motor complete 
SCI (ages 18-50 years) were randomly assigned to either 
TRT+RT (n =11) or TRT (n= 11) for 16 weeks (Fig3).  In 
fig. 3, we determined the effects of TRT+ NMES-RT on 
whole thigh muscle CSA and whole thigh absolute muscle 
CSA after accounting for intramuscular fat. Compared to 
TRT only, TRT+ RT showed delta increase > 20 cm2; 
demonstrating the efficacy of loading the paralyzed 
muscles in evoking muscle hypertrophy.  Effects of NMES-
RT with TRT on trabecular bone parameters of distal femur 
and proximal tibia were also measured.  Nine participants 
with SCI were randomized into TRT+RT group for 16-week 
intervention. Each participant underwent MRI prior to BL 
and following the intervention PI.  MRI microarchitecture 
techniques were used to evaluate trabecular bone quality, measured as plate width 
(PW; μm), trabecular bone thickness (TBTh; mm), trabecular bone spacing (TBSp; mm), 
and network area (NA; 1/mm) for the right proximal tibia (ProxT) and distal femur 
(DistF). Mixed models with random effects were used to calculate differences between 
BL and PI (MD ± SE) and were then transformed to effect sizes similar to Cohen’s d (d, 
95% CI [effect size]). Bar plots for trabecular measures of the distal femur depicting the 
difference for each measure across the intervention period. Small effect sizes were 
observed for distal femur TBTh variability, TBSp, and NA.  A medium effect size was 
observed for distal femur TBSp variability. Mean ±SE. Bar plots for trabecular measures 
of the proximal tibia depicting the difference for each measure across the intervention 
period.  A small effect size was observed for proximal tibia PW. Medium effect sizes 
were observed for ProxT, TBTh, TBSp, TBSp variability, and NA.  Mean±SE. Following 
the intervention, ProxT PW (MD: 30.56 ± 22.52; d: 0.48, -0.21 to 1.17 [small]), TBTh 
(MD: 0.02 ± 0.01; d: 0.70, 0.01 to 1.39 [medium], and  NA (MD:0.04 ± 0.02; d: 0.64, -
0.05 to 1.33 [medium]) all increased from BL measures.  In contrast, TBSp (MD: -0.25 ± 
0.17; d: -0.52, -1.22 to 0.17 [medium]) decreased from BL. The DistF similarly 
presented with increases in bone quality from BL for PW (MD: 11.7 ± 42.70; d: 0.10, -
0.60 to 0.79 [negligible], TBTh (MD: 0.01 ± 0.01; d: 0.29, -0.41 to 0.98 [negligible], and 
NA (MD: 0.03 ± 10/29/2019. Fig. 4 & 5: Due to the exploratory nature of the study on 
small sample size and short duration, we relied primarily in this trial on measuring the 
 
-5
0
5
10
15
20
25
30
Delta Changes in CSA 
(cm2)
16-Week Interventions
TRT+RT
TRT
R
R
Whole 
Thigh CSA
Whole 
Muscle 
CSA
Absolute 
Muscle 
CSA
R
L
L
L
Fig.3
0
5
10
15
20
25
30
35
40
45
Knee Extensors muscle 
CSA (cm2) 
Pre-intervention    Post-
intervention
RT+ diet
Diet
Fig. 2

Ifon-Version 2- 06222021                                                  7
 
 
 
effect size.  Our results support the fact that the TRT+RT has a small effect size (<0.3) 
on parameters of trabecular bone at the distal femur and moderate effect size at 
proximal tibia (>0.5-0.8) compared to TRT only.  Biostatistician advised that we should 
not run inferential statistics (Holman et al. under review, Ost. Int.-R2) 
Summary of preliminary data. There are two key questions that are yet to be 
answered before deployment of this intervention; 1) Would NMES+RT +Vit D drive 
improvement in trabecular bone parameters compared to passive movement + Vit 
D in persons with chronic SCI? and 2) does skeletal muscle hypertrophy induce 
improvement in biomarkers of bone formation over bone resorption?  Our 
preliminary data is limited; however, it highlights the benefits of evoking skeletal muscle 
hypertrophy on trabecular bone parameters in persons with chronic SCI. We therefore 
posit that a home-based approach of 9 mos NMES-evoked RT and Vit D 
supplementation will enhance trabecular bone parameters and markers of bone 
formation compared to passive movement and Vit D supplementation.  
 
 
 
 
 
Research Design and Methods: A 2-year single site randomized controlled trial to 
investigate the efficacy of NMES-RT + Vit D versus passive movement + Vit D 
supplementation on trabecular bone parameters of distal femur and proximal tibia and 
on biomarkers of bone formation and resorption in persons with chronic SCI. All 
Recruitment will be conducted at CVHCS  
 
Specific aims and Research Hypotheses:   
                                                                                               
 
Fig. 4 

Ifon-Version 2- 06222021                                                  8
 
 
 
Aim 1: To determine the impact of home-based NMES-RT protocol plus oral Vit D 
supplementation, compared to passive movement plus oral Vit D on bone micro-
architectural properties, as measured by MRI in Veterans with chronic SCI (> 
1year post SCI). Both groups will receive 9 mos of prescribed treatment. We 
hypothesize that NMES-RT+ Vit D supplementation will result in improved trabecular 
bone parameters after SCI. We plan to compare changes in bone composition including 
bone marrow fat (MBF) and cortical porosity, at the distal femur and proximal tibia, as 
measured by MRI and DXA in the two groups, at enrollment and end of intervention (9 
mos).  We will analyze the effect of Vit D based on levels of 25-(OH)D, at enrollment; 
mid-intervention (4.5 mos), and at 9 mos. Participants with > 40ng/mL of 25 (OH)D will 
be excluded from the study. 
Hypothesis: NMES-RT+ Vit D supplementation will result in improvement in trabecular 
and cortical bone parameters compared to passive movement and Vit D 
supplementation after 9 months in persons with SCI.   
Aim 2: To determine the impact of home-based NMES-RT protocol plus oral Vit D 
compared to passive movement and Vit D supplementation on biomarkers of 
bone formation and bone resorption in Veterans > 1-year post SCI. Both groups will 
also receive 9 months of therapy.  We hypothesized that NMES-RT will increase 
osteoblast activity and decrease bone demineralization compared to passive 
movements. We plan to measure serum 25(OH)D, PTH, Bone specific alkaline 
phosphatase ( BALP), Procollagen Type 1Intact N Terminal Propeptide (P1NP), 
Hydroxyproline (HYP), Carboxy-terminal Crosslinked Telopeptide of Type 1 collagen 
(CTX), in participants’ blood. The role of bone turnover markers in the evaluation of 
bone loss in persons with SCI has not been established.  In able-bodied persons, serum 
CTX and serum P1NP are considered the best markers of bone resorption and 
formation, respectively46-48.  Blood analysis will be done at enrollment, 4.5 mos and 9 
mos, for both groups. We plan to account for dietary intakes of protein, sodium, calcium, 
and phosphorous on BMD. Each participant will turn in dietary logs of 3-days per week 
on a weekly basis. The dietary log of each participant will be analyzed by our registered 
dietitian using Nutrition Data System for Research (NDSR) software49.  We will solicit 
the service of our dietitian who will contact participants once a month to advise them on 
balanced diet. Additionally, the World Health Organization quality of life (WHO-QOL) 
survey will be used to assess participants’ physical and mental domains after 
intervention. The WHO-QOL is a survey instrument that rates six broad domains on 
health (physical, psychological, level of independence, social relations, environment, 
and spirituality/religion/personal belief), using a five-point Likert scale (1-5) to produce a 
total of 100 items in assessment. This survey will be administered at enrollment and at 
the end of intervention. It takes about 15 minutes to complete the survey.  Data 
obtained from the survey will serve as preliminary data to  determine whether exercise 
programs  could also enhance the QOL  for persons with SCI.  It will be interesting to 
note any association between physical domain and bone parameters after SCI.   
Hypothesis: Osteoblastic and osteoclastic activities undergo obvious dynamic 
changes favoring bone loss after SCI. NMES-RT +Vit D supplementation increases 
osteoblastic activity and decreases bone demineralization as observed by decreased 
biomarkers of osteoclastic activity compared to passive movement and Vit D 
supplementation.  

Ifon-Version 2- 06222021                                                  9
 
 
 
 
Subjects: Twenty Veterans and non-Veterans with >1 year of SCI will be recruited from 
CVHCS and (VCU, if insufficient Veteran participants). The CVHCS SCI registry has 
~1,800 Veterans and more than 298 meet the inclusion criteria of C8-T10 level of injury.  
 
Inclusion Criteria:  Participants should be 18-65 years of age; male or female, with 
traumatic motor complete SCI (≥1-year)  and C8 to T10 neurological level of injury 
(NLI), by the International Standards for Neurological Classification (ISNCSCI) of SCI, 
serum 25(OH)D < 41ng/mL, be a wheelchair user for primary mobility, be able to 
receive written clearance from their medical Providers to ensure safety of participants, 
accessible caregiver capable of physically supporting participant throughout the trial and 
willing to be trained to apply intervention protocol in the home (placing weights and 
positioning the Veteran) throughout study duration, and have normal ECG. Participants’ 
knee extensors must respond to standard surface NMES procedures (frequency: 30 Hz; 
pulse duration:450 µs and amplitude of the current < 200 mA), to ensure intact neural 
circuitry below the level of SCI. All participants will undergo NLI examination. Only those 
with American Spinal Cord Injury Impairment Scale (AIS) A and B will be included.  Age 
limit of 65 years is to avoid cardiovascular challenges that could be provoked by 9 
months of strenuous physical activity in older persons.  Moreover, persons older than 
65, have more than 2-fold risk of osteoporosis related fractures, which may confound 
the trial50. 
Exclusion Criteria:  Participants with any of the following pre-existing medical 
conditions will be excluded from the trial: 1) neurological injury other than SCI,(e.g. 
cauda equina or distal conus injuries resulting in limb or sacral areflexia; 2) Unhealed 
fracture in either lower or upper extremities; 3) Severe scoliosis, hip knee range of 
motion (ROM) > 20 degrees. or flexion knee contractures 4) Uncontrolled hypertension 
(BP >140/90 mmHg) and severe orthostatic hypotension (BP drop > 20 mmHg) or 
inability to maintain a sitting position ; 5) Other medical conditions like cardiovascular 
disease, uncontrolled type II DM, insulin-dependent DM, or symptomatic urinary tract 
infection; 6) severe hypercalcemia (defined as Serum calcium >16 ng/mL)51; 7) anti-
coagulant or anti-platelet therapy, including aspirin.  8) pacemakers and/or defibrillator 
devices in place, metallic implants, shrapnel or bullets in the vertebral column, or other 
contraindications for MRI;  9) DXA total body-score < -2.5, knee BMD scores < 0.6 
g/cm2 ; 10) Participants with spasticity that is severe or adjudged a contraindication by 
the site Physician or limited ROM will be excluded. 11) Pressure ulcer of the trunk, 
pelvic area, or lower extremities of ≥ stage 3; 12) Psychopathology history that may 
conflict with study objectives; 13) Potential participants who are not wheelchair users 
and cannot transfer with sliding boards or portable lifts.14) serum Vit. D > 40 ng/mL; 15) 
abnormal/elevated calcium level 16) pregnancy (female participants). Medically 
accepted birth control is required to enter this study.  This may include, but is not limited 
to, birth control pills, IUD’s, condoms, diaphragms, implants, being surgically sterile, or 
being in a post-menopausal state.  A blood pregnancy test will be conducted to rule out 
any pregnancy before the study at the McGuire VAMC. The test will be repeated every 
month during the course of the study. The blood samples will be sent to the McGuire VA 
pathology lab for analysis. 17) Any condition that, in the judgment of the principal 

Ifon-Version 2- 06222021                                                  10
 
 
 
investigator or medical provider precludes safe participation in the study and/or 
increases the risk of infection. A large percentage of patients in the department of VA 
are males. Should female participants be found, in order to ensure heterogeneity of 
samples between the two groups, postmenopausal and estrogen deficient females and 
men undergoing anti-androgen therapy or post orchiectomy, will be excluded.  In 
addition, individuals with stage 3b or higher chronic kidney disease and those likely to 
have bone loss (age >65), will be excluded due to possible renal osteodystrophy and 
osteoporosis that may increase the risk of bone fractures from bone loading and ES to 
muscles. We will also exclude those with AIS C & D as they are already engaging in 
weight bearing activities which may confound the results of the trial. We have chosen 
inclusion and exclusion criteria for this study, to optimize homogeneity. Should the 
outcome be positive, it will be necessary to broaden inclusion criteria for future studies 
so that the methods can be used in a larger number of individuals with SCI.  
 
Intervention for 9 months:  
 
Vitamin D:  
Participants will receive a 30-day supply of 2000 IU vitamin D to take by mouth once a 
day at about the same time every day. If baseline Vitamin D is low, we will supplement 
with Cholecalciferol for two weeks as follows: 
Participants with Serum Vitamin D: 
 < 10 ng/mL, will receive 5,000 IU daily 
11-20 ng/mL, will receive 2000 IU daily 
21-40 ng/mL, will receive 1000 IU daily 
Then, all participants will receive 2000 IU daily through the period of intervention. 
Vitamin D will be refilled every 25 days to ensure the participants do not run out of the 
intervention drug. 
We will also call participants every 30 days for a pill count to ensure that they are taking 
the vitamin D.  
 
Resistance training (RT) and Rowing Exercise:   
Those assigned to the NMES-RT/Rowing with Vitamin D group will receive 4.5 months 
of electrical leg shocks with ankle weights (no ankle weights in the first week), twice a 
week. The intervention will be done while sitting in a wheelchair. Two adhesive patches 
(electrodes) will be placed on the skin over the knee muscles. Participants/caregivers 
will initiate and slowly increase electric current on the stimulator in 5-second intervals to 
cause full leg extension (leg straightens out). Once full knee extension is achieved in a 
sitting position, an extra 2 lbs. of weight will be added every week. Each session will 
consist of 4 sets of 10 knee extensions and will last for 30-40 minutes. Training will 
alternate between the right and left leg. In addition, the participant and a caregiver will 
train on how to set up the device for use at home. 
After 4.5 months, each participant will receive a rowing machine (Murtisol Magnetic 
Rowing machine) to use twice weekly. The participant will be asked to transfer to the 
rowing machine (with assistance or supervision from a caregiver) for the intervention, 
using a sliding board or a portable lift. Participant/caregiver will place patches for NMES 
on both knee extensors (muscles that straighten out the legs) and flexors (muscles that 

Ifon-Version 2- 06222021                                                  11
 
 
 
bend the knee) and initiate the electrical current. They will alternate the current 5 
seconds on, then 10 seconds off on both muscle groups. Participants with upper body 
strength will be encouraged to use their arms to initiate the extension and flexion of both 
legs. If they do not have full trunk control, they will be provided with an adhesive belt to 
secure their trunk during an exercise and a special hand mitten to secure their hands to 
the rowing machine, if needed. Each session will consist of 4 sets of 10 knee extensions 
and flexions, and it will last for 30 - 40 minutes. Training will alternate between the right 
and left legs on the same day. 
 
Passive range of motion or passive stretching:   
Participants assigned to the passive exercise and Vitamin D group will have their 
caregivers perform passive ROM. Caregivers will be instructed to sit on a stool, cup the 
participant's leg above the ankle joint, and move it from 90-degrees of knee flexion to 
full knee extension. The leg will be maintained in extension for 5 sec and returned to 
flexion for 5 sec. The passive actions are repeated in the manner described in the RT 
protocol; 10 reps on the right leg followed by 10 reps on the left leg for 4 sets x 10 reps. 
This exercise training will take place twice a week. Each training exercise will last 30 – 
40 minutes each day of the exercise. 
 
Blood Pressure (BP) Monitoring: The caregiver will measure the participant's BP 
before starting the exercise, record the reading and leave the BP cuff in place. About 15 
to 20 minutes into the exercise, another BP reading will be taken and the final reading at 
the end of the exercise to safeguard against Autonomic Dysreflexia (AD). Most 
individuals with high cervical and thoracic levels of SCI own BP machines.  However, if 
they do not own one, they are eligible to get one from their Providers.  
 
Caregiver Role  
Caregivers will train on the use of neuromuscular electrical stimulation and passive 
range of motion (ROM). After the training, the caregivers will be responsible for placing 
and removing skin electrodes (patches) and checking the skin afterward for skin 
breakdown. The caregivers will also be responsible for adjusting the stimulator current. 
For those undergoing passive ROM, the caregivers will be responsible for moving the 
paralyzed legs (one at a time) while holding them above the ankle, from 90 degrees of 
knee flexion (bent knee) to full knee extension (straighten out). They will also be 
responsible for adding ankle weights during the exercise every week. 
Additionally, the caregivers will assist with transfers (if participants were unable to do 
so). We will review transfer techniques with a sliding board or portable lift with 
caregivers if the participant or caregiver requests us to do so. Caregivers and persons 
with SCI are usually skilled in the use of these types of transfer equipment. 
 
Home Video Telehealth Service:  
Telehealth is a service offered by the VA for use to provide virtual care. Telehealth uses 
video conference calls. Suppose participants are not already enrolled in the VA 
Telehealth program. In that case, they will be given a registration form to complete to 
provide us permission to use VA Telehealth before they can participate. The 
participants will need to have a smartphone, a tablet, or a computer with a webcam and 

Ifon-Version 2- 06222021                                                  12
 
 
 
internet access to be able to participate. However, if they not have one of these, they 
will be provided a tablet with a web camera and internet access, and we will help them 
create an e-mail account if they do not already have one.  
 
The participants will need a quiet space in their homes for the training. The study team 
will make sure that the address is accessible to EMS in an emergency. If it is not 
accessible to EMS, they may not participate in the study. At the start of each session, 
the PI will verify the address and telephone number and an alternate contact person, 
and a phone number for use in emergencies or communication failure. Should the need 
arise, the study team will contact EMS or the National VA Telehealth Crisis Line for 
additional help.  
 
Before starting the exercise training session, the microphone, speakers, and web 
camera will be tested to ensure things are working fine from both ends. We will request 
participants to be ready 20-30 min before the video call by asking the caregivers to 
place the electrodes on their legs, make sure the batteries of the stimulator are fully 
charged, electrodes are connected to the stimulator, and the ankle weights are 
positioned. Once the setup is completed, and the Telehealth connection is established, 
the training will begin.  
 
All training sessions will be conducted twice weekly. At the end of each session, the PI 
will confirm the next appointment and request that the participant confirms his/her next 
appointment online 24 hours before the next session. If unable to keep the next 
appointment for any reason, we can reschedule the appointment for another day and 
time so long as participants can have two sessions in a week. 
   
WHO-Quality of Life (QOL) Survey: 
Participants will be given a survey regarding their health, wellness and QOL to 
determine whether exercise programs could enhance QOL after SCI.  The WHO-QOL is 
a survey that rates six broad domains on health (physical, psychology, level of 
independence, social relations, environment, and spirituality/religion/personal belief), 
using a five-point scale (1-5) to produce a total of 100 items in the assessment.  
Participants will be given the survey at the beginning and at the end of the study.  The 
survey takes about 15 minutes to complete.  
 
 
Measurements: All training aspects and measurements will be conducted at the 
Central Virginia VA Health Care System (CVHCS) SCI Exercise Physiology & Body 
Composition Laboratory.  All participants will undergo bone assessment measurements 
with MRI and DXA (specific aim 1); measurements of bone biomarkers and weekly 
dietary recalls (specific aim 2). All testing procedures will be conducted a week to 
training (baseline) and post-intervention for Aim 1 and baseline, 4.5 mos and 9 mos 
for Aim 2.  Will get MRI of thigh skeletal muscles to determine muscle CSA, trabecular 
bone parameters (including BMF), cortical porosity and CSA. To ensure consistency of 
dietary intake for protein, sodium, calcium, and phosphorous, team dietitian will contact 
participants once a month to advise on diet. Evaluation of participants will involve 

Ifon-Version 2- 06222021                                                  13
 
 
 
cardiovascular assessments (EKG), heart and carotid auscultations, assessment of 
jugular venous pulse, peripheral pulses to identify any significant factors that may 
impact cardiovascular health, respiratory assessment (inspection, palpation, percussion, 
lungs auscultation, pulse oximetry and respiratory rate), and assessment of pain. Blood 
analysis will include: BALP, P1NP, CTX, 25-(OH)D, PTH, complete renal panel, 
calcium, magnesium and Hemoglobin A1c.  While previous work from our institution 
used urinary NTX, the current standard for bone resorption test is considered to be 
serum CTX48.  These markers will be obtained fasting at baseline, 4.5 months and 9 
months; and would require no more than 10ml of blood sample (each time) from study 
participants.  
Vit D:  Each participant will be prescribed a 30-day supply of oral 2000 IU of 
Cholecalciferol (Vit D3), daily. The Endocrine Society guidelines recommend treating 
Vit D deficiency with Vit D3 to achieve a target 25(OH)D goal of 30 ng/mL52.  Vit D 
deficiency is defined as 25(OH)D <20 ng/mL and insufficient as 25(OH)D 21 ng/mL to 
29 ng/mL53.  Participants with insufficient 25(OH)D3 will receive Vit D3 supplementation 
for 2wks as follows: Vit D < 10:  5000 units daily for 2 weeks; Vit D 11-20: 2000 units 
daily for 2 weeks; Vit D 21-40: 1000 units daily for 2 weeks. All participants will then 
receive 2000 units of Vit D for the rest of the study period. We chose to use 2000 IU of 
daily Vit D3 supplementation because prior studies have reported physiologic levels of 
25(OH)D with this dose. Participants will be instructed to take their Vit D3 at about the 
same time every day. The prescription will be renewed every 25 days to allow for early 
mailing to participants. To monitor compliance, study participants will be called every 30 
days for pill counts. Pre-treatment levels of 25(OH)D, will be measured at 
commencement of treatment and post treatment at 4.5 months and 9 months; 
participants with Vit D insufficiency will receive higher doses of Vit D3 supplement for 2 
weeks prior to intervention. The values obtained will be entered in a spread sheet.   
Resistance training (RT): Participants and caregivers will be trained on RT (application 
of electrodes, initiating and adjusting currents and the application of ankle weights). 
Resistant Training will be performed twice weekly in an open-chain format 
(resistance is placed at the distal part of an extremity in a fixed position) in the 
first 4.5 mos, followed by 4.5 mos in a closed-chain format using surface NMES. 
Initial open-chain format ensures muscle hypertrophy that is likely to cause modest 
bone adaptations54, prior to it being subjected to significant loading during closed-chain 
format. This would ensure bone safety during the close kinematic exercise. No ankle 
weights in the first week to ensure full knee extension against gravity. Weekly 
increments of 2 lbs. will be used on the condition that full knee extension is achieved 
before any increase in load. NMES of the extensor muscles of the knee, for concentric-
eccentric actions will be by surface electrodes as shown in fig 1. Two 8 X10 cm2 (Uni-
Patch, Wabasha, MI, USA) adhesive carbon electrodes will be placed on the skin over 
the knee extensor muscle group. Current from the stimulator will be increased at 5-
second intervals to evoke full knee extension against gravity followed by the lengthening 
action during relaxation. The current (mA) that causes full knee extension will be 
recorded. Training will be performed remotely, twice weekly for 4 sets of 10 repetitions 
under full supervision from the PI by telehealth. Each RT session will consist of 4 sets 
of 10 repetitions of NMES-induced knee extensions for 60 min. A 5 sec/5 sec work/rest 
ratio will be used with 3 min rests between sets, 30 Hz, 1 ms pulses and current 

Ifon-Version 2- 06222021                                                  14
 
 
 
sufficient to evoke full knee extension. To perform a closed kinematic chain exercise, 
participants will use a commercially available rowing machine (Murtisol Magnetic 
Rowing machine) to perform 4 sets x 10 reps twice weekly. NMES rowing has been 
shown to provide compressive loading on both distal femur and proximal tibia, further 
enhancing trabecular bone health in persons with chronic SCI.  Participants will transfer 
to the rowing machine with assistance by the caregiver or significant other, using a 
sliding board or a portable lift if available at home. Most Veterans have a portable lift in 
their homes as part of their clinical care. Additionally, persons with paraplegia are 
trained to manage fall risks and get back to their manual wheelchair with minimal 
assistance from caregiver. This will provide them with an opportunity to transfer to and 
from their manual wheelchairs and rowing machine.  Surface NMES will be applied to 
stimulate knee extensors for extension, alternating with the hamstrings for flexion, 
assisted by the upper extremities, with progression under full supervision by the trained 
caregiver. Electrodes will be placed bilaterally on both knee extensors and flexors and 
the current will be alternated 5 sec on/10 sec off on both muscle groups with frequency 
set at 30 Hz, pulse duration at 1 ms and reasonable amplitude to cause 
flexion/extension. This approach was previously adopted for our lab. 
Passive range of motion (ROM) or passive stretching for the control group: 
Participants and caregiver will be trained on passive ROM.  A trained caregiver sits 
on a stool and cups participant’s leg proximal to the ankle joint and move it from 90-
degrees of knee flexion to full knee extension. The leg will be maintained in extension 
for 5 sec and returned to flexion for 5 sec. The passive actions is repeated in the 
manner described in the RT protocol; 10 reps on the right leg followed by 10 reps on left 
leg for a total of 4 sets x 10 reps. This will help to balance the design between the two 
groups and training will be conducted twice weekly.  
Home Video Telehealth Service: Home exercise training will be conducted using 
Video Telehealth services, (known as, VA Video Connect (VVC)), under guidance from 
the Office of Connected Care with management and oversight from the VISN Telehealth 
Manager and Facility Telehealth Coordinator. The telehealth Program is located in the 
SCI&D service. The applicant is versed in the use of Telehealth for patient care as this 
has been the primary mode of patient evaluation and treatment during this COVID-19 
pandemic. After obtaining participant’s consent, the  PI, together with the Telehealth 
Coordinator, will conduct a selection-consideration review for all participants, to ensure 
they agree to VVC for training, review clinical “video into home” worksheet and 
availability of appropriate technology. Participants without appropriate technology will be 
issued a tablet with web camera and internet access and assisted to create an e-mail 
account if they do not already have one. All participants who agree to provide a private, 
conducive environment for in-home training at addresses accessible to EMS, in 
emergency situations, will be enrolled. At the start of a session, the PI will obtain the 
address and telephone numbers of participants for use in emergency situations during 
VVC.  Should the need arise, the PI can contact the local medical/telehealth emergency 
resources for back-up or contact the National Study Participant’s Crisis Line for 
additional help. Before starting the exercise training session, the microphone, speakers 
and web camera are tested for efficacy in the home for both study participant and PI.  
The PI will ensure the availability of a telephone backup in the event of a 
communication failure via VVC. Participants will be advised to be ready 20-30 min prior 

Ifon-Version 2- 06222021                                                  15
 
 
 
to the VVC by placing electrodes, ensuring the batteries of the stimulator are charged 
overnight, connecting the electrodes to the stimulator and positioning the ankle weights. 
Once the setup is completed and internet connection established, the participant is 
instructed to increase the current to bring the leg into full knee extension and then report 
the current in milliamps (mA) to the PI. The goal is for each participant to perform 4 sets 
of ten repetitions. Each exercise training session will be conducted for at least 30 min 
with 2-3 min of rest periods between each set and 5 sec between each repetition. At the 
end of each session, the PI confirms the next appointment, reminds participant to 
confirm next appointment online 24 hours before, and access their log in password.  
Our telehealth platform is well established with strong support from our IT department. It 
is unlikely to fail but should it fail, participant will be rescheduled for the next day. 
Measurements: Specific aim 1.  MRI: MRI with no contrast will be performed using a 3 
Tesla magnet (GE). The skeletal muscle CSAs will be determined at baseline and 9 
months, respectively. Both lower limbs will be strapped together using 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. Duration of the whole scan including preparation time should not exceed 
10 min. Images of both thighs will be obtained with 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. A specific knee coil will be used to capture trabecular bone 
parameters of the distal femur and proximal tibia.  Images will be downloaded and 
analyzed using X-vessel software for muscle/cortical bone CSAs, as previously 
conducted by our group.   
Trabecular Bone Assessment: A 3D fast gradient-echo sequence will be used to 
obtain the high-resolution images (10 cm FOV), with a spatial reconstructed resolution 
of 195·195·1000 lm. A bilateral phased array coil (USA Instruments) will be used to 
obtain 30 contiguous1mm slices in the axial plane, starting with the distal end of the 
femur, and another block of 30 starting with the proximal end of the tibia. A 3-D low-
pass filter will be applied to correct for heterogeneous signal across the phased array 
surface coil. Regions of interests will be manually identified, and a set of parallel lines 
rotated by 5 through the slice to determine mean intercept length. Parameters 
measured will be apparent trabecular bone volume to total volume (app.BV/TV) and 
apparent trabecular thickness (app.Tb.Th, mm), from which apparent trabecular number 
(app.Tb.N, mm) and separation (app.Tb.Sp, mm) will be derived.  
Assessment of Trabecular Microarchitecture: Within manually drawn regions of 
interest with the distal femur and proximal tibia trabecular bone, we will apply digital 
topological analysis and volumetric topological analysis to compute metrics of bone 
microarchitecture including trabecular thickness, trabecular separation, trabecular plate 
width, and network area density (1/mm) as in prior work, as well as BMF. In digital 
topological analysis, local connectivity and topological metrics are used to characterize 
different topological structures in a skeletal surface representation of a three-
dimensional trabecular bone network. Volumetric topological analysis extends digital 
topological analysis and, through fuzzy skeletonization and unique manifold distance 
analysis approaches, will allow assessment of trabeculae on a continuum of plates to 
rods, permitting computation of individual trabecular plate width.  

Ifon-Version 2- 06222021                                                  16
 
 
 
Dual energy x-ray absorptiometry (iDXA): iDXA will be used to measure bone 
composition including regional and total Fat Mass (FM), Fat Free Mass (FFM), cortical 
porosity, and BMD. Total body and regional scans will be performed using an iDXA 
scanner (Lunar Inc., Madison, WI) bone densitometer to determine regional BMD and 
total body T-score, Total hip BMD and knee BMD scores (Total body T-score less than -
2.5. Total hip BMD T-scores < -3.5 and knee BMD scores of less than 0.6 g/cm2, will be 
excluded). Testing is performed after lower extremity elevation for at least 20 min to 
minimize fluid shift. Scanning and analysis is certified by DXA operator. The participant 
is assisted to lie on a padded table with both legs strapped proximal to the knees and 
ankles. The arms and legs are properly aligned to allow participant to lie still for 10 min 
during the scan. Total and regional FM and FFM are determined with DXA software in 
order to control for confounding variables; fat mass and BMF may influence bone 
health55. The coefficient of variability of two repeated scans is < 3%.  
 
Specific aim 2: We will assess bone remodeling with the following bone biomarkers: 
BALP, P1NP and CTX,  25(OH)D, PTH, renal panel, magnesium and calcium levels at 
baseline, 4.5 mos and 9 mos. HgbA1c will be obtained prior to and post intervention to 
determine glucose uptake benefit resulting from the intervention. Blood samples not 
exceeding 10 mls will be obtained after 8-10 hours overnight fasting. Samples will be 
processed at CVHCS Clinical Pathology Laboratory or Quest diagnostic depending on 
negotiated cost. All tests will be performed at the VAMC and participants transportation 
to and from test will be sponsored.  
 
Pilot exploratory work for Both Groups 
We will investigate the effects both groups on Toll-like receptors (TLRs), and Natural 
killer (NK) on T cell functionality (CD4+ T cells), cytokines, interferons, or chemokines, 
including IL-6, IL-10, IFN-α, IFN-γ and IP-10 in persons with chronic SCI. Peripheral 
Blood Mononuclear Cells (PBMCs) will be collected from all participants at three time 
points and isolated by Ficoll gradient centrifugation for immune analyses. For immune 
alternation of myeloid cells, the phagocytic and bactericidal function of circulating 
neutrophils in response to Staphylococcus aureus will be analyzed as described 
previously. Impairment in recognition of pathogen-associated molecular patterns by toll-
like receptors (TLRs) and subsequently declining immune responses have been 
associated with immune dysfunction, PBMCs will be incubated with various ligands for 
TLRs, followed by assessment of production of cytokines, interferons, or chemokines, 
including IL-6, IL-10, IFN-α, IFN-γ and IP-10. To assess T cell functionality, PBMCs will 
be cultured in the presence of phorbol 12-myristate 13-acetat plus ionomycin and 
subjected to assays of IFN production by intracellular staining and flow cytometry. 
Natural killer (NK) cells represent the main components of lymphocyte-mediated innate 
immunity and play an indispensable role in combating bacterial and viral infections. 
These cells have been reported to be associated with SCI-induced immune deficiency. 
Expression of CD107a, the marker of NK cell cytotoxicity, as well as production of 
effector cytokines TNF-α and IFN-γ by NK cells will be examined. NK cell cytotoxicity 
will also be assayed using the target cell line K562 on the basis of lactate 
dehydrogenase release assay as described. Additionally, plasma collected from 
patients will be analyzed for immune-related cytokines including IL-10, which has been 

Ifon-Version 2- 06222021                                                  17
 
 
 
identified to be a common candidate for immune suppression induced by stress and 
injury, including injury in the central nervous system.  Samples will be analyzed at the 
VCU Immunology Department. 
 
Pitfalls and Alternatives: Changes in trabecular bone parameters may be 
indeterminate because of the smallness and heterogeneity of sample size.  We will rely 
on previous experience to calculate the effect size, and on that basis, adequately power 
future trials. Failure to recruit proposed sample size: The applicant’s primary mentor 
(Dr. Gorgey) successfully conducted similar clinical trials in the past and demonstrated 
that use of telehealth facilitated recruitment and compliance among Veterans with SCI. 
Additionally, we may recruit non-Veterans to ensure completion of the study within the 
proposed timeline. Dr. Gorgey has a dual appointment with VCU and can successfully 
collaborate with VCU to ensure recruitment of the target sample size.   
Statistical Analyses. After signing consent, the PI will randomly assign a number from 
1-20 to participants using a computer program (nQuery). The order of enrollment will 
determine the participant’s number based on level and 
duration of injury. Summary of information, including means 
and SD, frequencies and percentages, for all study variables 
will be calculated at all-time points. T-tests and Pearson chi-
square tests will be used to compare characteristics that may 
act as confounders, including age, level and time since injury.   
 
Sample Size Justification: Being a pilot study, consideration 
of sample size is just to allow determination and examination 
of preliminary evidence of efficacy and effect size estimation 
towards a larger future randomized trial. The proposed sample size of 10 per group is 
adjudged sufficient to accomplish these goals. Although Julious recommends a sample 
size of at least 12 per group on the basis that gain in precision for estimates of variance 
becomes relatively small on reaching a sample size of 12,56 we are unable to meet that 
target because of cost of the intervention and testing. Our sample size still allows for 
adequate accuracy. As shown in Fig 6, the gain in precision is still limited with a sample 
size of 10 per group. Although testing efficacy is not the primary goal, we will have 80% 
power to detect a standardized mean difference of d=0.9 using an alpha of 0.25 
corresponding to a large effect size. Type I error rates larger than 0.05 are often used 
and recommended for pilot studies where tests of efficacy are not the primary aim.   
 
Data Analysis Plan: IBM SPSS statistical software version 26 will be used. Being a 
pilot study, primary analyses will be mainly descriptive. Means and SD will be estimated 
for utilization (number of sessions completed), with each outcome. Finally, analysis of 
covariance (ANCOVA) will be used to test differences between groups post intervention 
for each outcome, using the baseline score as a covariate. If normality of groups 
appears to be violated in the sample normalizing transformations or non-parametric 
statistics will be considered.  
 
 
Human Subject Section: 
Fig 6 

Ifon-Version 2- 06222021                                                  18
 
 
 
 
I. 
Human Subjects Involvement and Characteristics: 
Twenty (20) individuals with chronic (>1-year post-injury), motor complete Spinal Cord 
Injury (SCI) with American Spinal Injury Association Impairment Scale (AIS) score A or 
B will be recruited to participate in the proposed Telehealth study.  Participants will be 
recruited from the Central Virginia VA Health Care System (CVVHCS) Spinal Cord 
Injury & Disorders (SCI&D) registry.  The SCI&D registry has approximately 1,800 
Veterans (men and women), with more than 298 of the Veterans meeting the criteria for 
neurological level of injury (NLI) of C8-T10 and AIS A or B, which is our target study 
population.  The SCI population is however, predominantly male based on natural 
disposition, since men tend to join the military than do women.   
The SCI service at CVVHCS offers inpatient and outpatient services. The inpatient 
service provides acute rehabilitation services for Veterans with new SCI, annual 
evaluation for those with motor complete injury who are unable to use outpatient level of 
care, Veterans with pressure ulcers that are not responding to outpatient level of care and 
those requiring respite care to relieve caregivers of care burden.  Veterans needing minor 
surgical procedures are also admitted for short inpatient stay, for example, for cystoscopy 
or colonoscopy procedures.  In 2019 fiscal year, there were a total of 1022 Veterans, 
ages 18 to 70 years, within the Richmond catchment area and 298 reside in Richmond.  
Over 800 were admitted to SCI inpatient service for various reasons and over 600 
Veterans used outpatient level of care.  The tables below show some of the common 
reasons for inpatient and outpatient care, by number of Veterans, for fiscal year 2019: 
Common reasons for Inpatient Admission for fiscal year 2019:  
Reasons for Admission 
Number of Veterans 
Acute Rehabilitation 
~87 
Annual Evaluation (chronic SCI) 
~368 
Wound Care 
~269 
Respite Care 
~154 
Common reasons for outpatient visits in fiscal year 2019:  
 
Reasons for Visit 
Number of Veterans 
Annual or new evaluation (chronic SCI)  472 
The recruitment for the proposed study will be drawn from the SCI population within the 
Richmond catchment area (this includes Veterans who live outside Richmond but use 
CVVHCS for their SCI yearly evaluation).  After informed consent, each participant will 
undergo a complete physical examination to be done by the PI or a board-certified 
Physiatrist.  The physical examination will include: 
1. General: Race, gender, mood 
2. Vital signs: 

Ifon-Version 2- 06222021                                                  19
 
 
 
a. Temperature 
b. Pulse 
c. Respiration rate 
d. Pulse oximetry 
e. Blood Pressure 
f. Pain level 
g. weight 
3. Skin inspection for: 
a. Rashes 
b. Eruptions 
c. Pressure sores 
4. Head, Eyes, Ears, Nose, and Throat (HEENT) 
a. Head-size and shape; tenderness 
b. Eyes-conjunctiva; sclera, pupil size, shape and reactivity; extraocular 
muscle movements; visual fields 
c. Ears-hearing test, tenderness, discharge, external canal, tympanic 
membrane. 
d. Nose-symmetry; palpation of sinuses for tenderness; flaring; grunting 
e. Throat-lips, teeth, gums, tongue, pharynx  
5. Neck: 
a. Range of motion; tenderness, jugular vein distension, lymph nodes, 
thyroid, carotid bruits, Hepatojugular reflux  
6. Chest: 
a. Symmetry of movement with respiration 
b. Palpation for tenderness 
c. Breath sounds 
7. Heart: 
a. Rate 
b. Palpation of precordium for point of maximal impulse and thrill 
c. Auscultation for heart murmurs 
8. Abdomen: 
a. Shape 
b. Auscultation for bowel sounds and bruits 
c. Percussion for tympanic masses 
d. Palpate for tenderness/guarding; organomegaly 
9. Genitalia: 
a. Inspect for lesions, swelling, masses, hernias 
10. Rectal: 
a. Inspect/palpate for hemorrhoids, fissures, tags, sphincter tone 
b. Note presence or absence of stool 
c. Male- prostate size and texture, nodularity, tenderness 
11. Musculoskeletal:  
a. Range of motion 
b. Absence of limbs/deformities 
c. Swelling 
d. tenderness 

Ifon-Version 2- 06222021                                                  20
 
 
 
12. Neurological assessment:  
a. Mental status 
b. Cranial nerves  
c. motor strength and sensory level based on the International Standards for 
Neurological Classification of Spinal Cord Injury (ISNCSCI), to determine 
level of motor and sensory impairment. 
d. Reflexes 
e. Modified Ashworth scale (measure of spasticity) 
f. Penn Spasm Frequency Scale (self-reported measure of perceived frequency 
and severity of spasticity). 
Eligibility to participate will be based on physical examination findings.  Body weight will 
be measurement using a wheelchair weighing scale and subtracting the wheelchair 
weight from the total weight to obtain participants’ absolute weight. A baseline 
electrocardiogram (ECG) to rule out any concerning abnormal heart rhythm or 
myocardial ischemia will be obtained.  All participants will also undergo bone mineral 
density (BMD) measurements using Dual-energy X-ray absorptiometry (DXA) focusing 
on the distal femur and proximal tibia and MRI using a 3 Tesla magnet (GE) to 
determine skeletal muscle and cortical bone CSAs (specific Aim 1) and fasting blood 
work (specific Aim 2), at no cost.  
Inclusion criteria. To be included, participants will have to: 
1. Be 18-65 years of age 
2. Have history of traumatic SCI (≥1-year) with NLI of C8-T10 and AIS A or B 
(confirmed by AIS examination performed by PI or a qualified Provider. 
3. Have a caregiver who is available and willing to be trained to apply intervention 
protocol in the home (placing weights and positioning the Veteran) throughout 
study duration  
4. Be a wheelchair user for primary mode of mobility 
5. Have Knee extensors that must respond to standard surface electrical stimulation 
procedures (stimulation frequency procedures, 30 Hz; pulse duration:1 ms and 
amplitude of the current of less than200 mA)). 
6. Be able to receive written clearance from their medical Providers to ensure safety 
of participants.   
7. Be a Veteran (male or female), however, the Department of Veteran Affairs has 
limited number of female Veterans, especially those with motor complete injury at 
level C8-T10 (currently, there are only 3 female Veterans with the target NLI in our 
SCI registry).  Hence, inclusion of women Veterans may be challenging due to this 
disparity in the SCI population. If we fail to recruit 20 Veterans, we may seek an 
IRB approval to recruit non-Veterans to meet our target sample size.  
8. Have normal ECG 
9. Commit to undergo 9 months of trial; 4.5 months of open-kinematic chain 
resistance training followed by 4.5 months of closed-kinematic chain using simple 
rowing approach + Vit. D supplementation (Experimental group) or 9 months of 
passive movement +Vit D supplementation (control group). 
 

Ifon-Version 2- 06222021                                                  21
 
 
 
Rationale for conducting the trial up to 9 months: 
The preliminary study of Veterans with motor complete injury demonstrated that 16 
weeks (i.e. 4 months) of surface Neuromuscular electrical stimulation (NMES) evoked 
resistant training (RT) impacted skeletal muscle size positively, which will convey 
skeletal loading benefits to the bones.  Additionally, the increase in muscle mass has 
the potential to increase peripheral blood flow and increase blood glucose uptake that 
may delay the onset of Type 2 diabetes or/and improve diabetes control for those who 
are already diabetic.  However, the 16 weeks study was only exploratory and bone 
adaptation are likely to take longer time period, especially in persons with SCI. The 
primary rationale was that the duration of previous work that effectively used either 
electrical stimulation or Vit D ranged from 6 to 12 months.  Since we are unaware of any 
study that has determined the combined effects of both interventions, we chose to 
average 6 and 12 months to arrive at a 9 months trial. We believe that compared to the 
initial exploratory trial for 4 months, the proposed 9 months trial will set the basis for 
future clinical trials that are adequately powered to enhance bone parameters in 
persons with chronic SCI.   
 
Rationale for recruitment outside Richmond and non-Veterans: 
The target population for this study is Veteran with SCI but are no different than SCI 
individuals in the general population.  Therefore, in the event, that we are unable to 
meet the target sample size within study period, we may reach out to Virginia 
Commonwealth University (VCU), as previously discussed. 
 
Inclusion of women Veterans:  
There is inherently gender disparity in the Veteran population based on the fact that 
more men than women tend to join the military.  However, the study team will make 
every effort to recruit female Veterans but may be limited due to scarcity of female 
Veterans with SCI.  
 
Exclusion criteria: Every effort will be made to ensure participants’ safety and any 
participant with active medical condition that may confound the result of the trial will be 
excluded from participation. 
 Potential participants will be excluded if they exhibit any of the following:  
1. Neurological injury other than SCI  
2. Older than 65 years of age as they may likely have considerable amount of 
bone loss at that age.  
3. Have severe osteoporosis because loading porous/fragile bone by electrical 
stimulation may result in bone fracture.  
4. Those classified as AIS C & D, as they may already be engaging in weight 
bearing activities that may confound the results of this trial. 
5. Unhealed or unstable fractures in either lower or upper extremities.  
6. Severe scoliosis, deformities in the hip, knee, or ankles OR impaired range-of-
motion, as these could be a barrier to safe positioning on the rowing machine, 
and on MRI or DXA tables.   
7. No caregiver or family member/significant other, willing to help with placing 
weights and positioning participants’ lower extremities on the rowing machine.   

Ifon-Version 2- 06222021                                                  22
 
 
 
8. Untreated or uncontrolled hypertension (systolic blood pressure (BP) > 140 
mmHg; diastolic BP > 90 mmHg), and/or sudden hypotension upon transferring 
from bed to wheelchair, characterized by a drop in BP by 20 mmHg (especially 
in persons with tetraplegia) or heart rate > 100 beats per minute. 
9. Anti-coagulation or anti-platelet therapy (including aspirin) 
10. Implanted pacemakers, implanted defibrillator devices or any metallic implants 
including knee or hip implants.  
11. Presence of bullets in vertebral column or shrapnel anywhere in the body that 
may interfere with MRI procedure. 
12. Other medical conditions including cardiovascular disease, uncontrolled type II 
DM, active deep vein thrombosis (DVT), uncontrolled autonomic dysreflexia, use 
of  insulin for DM management, pressures injuries of stage 3 or higher, or active 
urinary tract infection.  
13. Severe hypercalcemia (serum calcium > 16mg/dl), stage III-V kidney disease, 
post-menopausal or estrogen dependent female, and men undergoing anti-
androgen therapy or are post orchiectomy.  
14. DXA total body T-score less than -2.5. Total hip BMD T-scores < -3.5 and knee 
BMD scores of less than 0.6 g/cm2.  
15. Untreatable severe spasticity bearing on potential participants’ activities of daily 
living, such as transfers from bed to wheelchair or maintaining position in 
wheelchair.    
16. Any psychiatric illness confounding judgment or cognitive impairment in 
participant or caregiver who is expected to help participant in the trial. 
17. Those with prosthetic lower limbs  
18. Any condition that, in the judgment of the PI or other medical Providers, 
preclude safe participation in the study and/or has the potential to 
expose/increase participant’s risk of infection. 
19. Unable to tolerate increasing either electrical stimulation current or weights to 
the lower legs for any reason. 
Sources of Materials:  
Electronic medical records (EMR) will be reviewed for each potential participant enrolled 
by IRB-approved investigators (PI or Co-PI; Dr. Ifon and Dr. Gorgey, respectively). All 
research data will be stored in the PI's office in a locked cabinet.  No VA research data 
will be destroyed. 
 
II. 
 Study Procedures:  
The study procedures include: consenting process, description of study activities and 
expectations. Consent to participate will be obtained as described under process of 
obtaining informed consent. Informed consent will be obtained prior to enrollment in the 
study.  After consenting, the participant will undergo 1-hour of history and physical 
examination that will be done by the PI or a certified SCI physician (Dr. Timothy Lavis) 
at CVVHCS. The screening examination will include history and physical examination 
and assessment of inclusion/exclusion criteria previously stated.  
Detailed Strategies for the Recruitment Plan.  
Efforts will be made by the applicant (PI), to implement a successful recruitment plan, 
and to avoid any source of coercion during the actual process. Twenty Veterans (10 in 

Ifon-Version 2- 06222021                                                  23
 
 
 
intervention group vs. 10 in control group) with motor complete SCI involving C8-T10 
and AIS A or B classification, will be recruited to participate in a 9 months trial.  The 
primary goal of this work is to ensure that our procedures are safe and effective for 
persons with motor complete SCI. 
The following timeline will be implemented to meet our recruitment goals. We plan to 
recruit 20 Veterans/non-Veterans over a 2-year period (24 months).  We plan to start 
participants enrollment in the 1st quarter of year-1 and finish in 1st quarter of year-2 
(see recruitment table below).  We will continue to collect data and finish analysis by the 
4th quarter of year two. This is feasible considering our previous experience recruiting 
for the parent study.  Also, we do not anticipate attrition due to prior established 
compliance with telehealth home-based study.  We plan to offer resistant training to 
participants on a flexible schedule so as to accommodate their lifestyle, to avoid 
attrition.  Participants will be randomized to either intervention or control group.  
Recruitment Table: 
 Research 
Activities Year 
2021 
2022 
2023 
Months 
A
p
r 
M
a
y 
J
u
n 
J
u 
l 
A
u
g 
S
e
p 
O
c
t 
N
o
v 
D
e
c 
J
a
n 
F
e
b 
M
a
r 
A
p
r 
M
a
y 
J
u
n 
J
u
l 
A
u
g 
S
e
p 
O
c
t 
N
o
v 
D
e
c 
J
a
n 
F
e
b 
M
a
r 
A
p
r 
M
a
y 
J
u
n
IRB process 
x x x  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Purchase of 
Equipment & 
Supplies 
 
 
 
 
 
 
x 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dissemination of 
recruitment 
flyers 
 
 
 
x x x x x x x x x x x x x  
 
 
 
 
 
 
 
 
 
 
 
Participants 
enrollment (from 
start to finish) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2 
 
 
 
 
 
 
2 
 
 
 
 
 
 
2 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2 
 
 
 
 
 
 
 
 
 
 
2 
 
 
 
 
 
 
 
 
 
 
 
 
2 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Ifon-Version 2- 06222021                                                  24
 
 
 
2 
 
 
Data Collection 
 
 
 
 
 
x x x x x x x x x x x x x x x x x x x x  
 
Progress Report 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Data 
entry/coding/cle
aning 
 
 
 
 
 
x x x x x x x x x x x x x x x x x x x x  
 
Data analysis 
and 
interpretation 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x x x x x x x x x x x x x 
 
Feasibility of recruitment:  
There is an emphasis on feasibility of the trial recruitment to ensure we reach our target 
sample size, especially considering the 9-months commitment requirement for each 
participant. Below is a step-by-step description of our recruitment strategies to 
demonstrate feasibility:  
- 
Prior to submission of the current application, 3 participants were already 
identified and were willing to participate in our preliminary work. 
- 
We will contact every SCI physician, nurse and rehabilitation staff (including 
those at the Spokes sites) about our ongoing protocol through our weekly clinical 
rounds, grand rounds, and friendly e-mail reminders. 
- 
We will send an email blast through our secured network to our 13 Spokes sites 
and encourage them to refer potential participants to our research team.  
- 
We will send electronic flyers and the PI will present at our SCI monthly 
meetings, PVA monthly meeting, SCI quarterly newsletters, hub and spoke 
annual conferences, and SCI national Chief teleconference meetings.  
- 
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 
previous VA trials and we plan to use this method too to encourage participation 
in the proposed trial; they will only need to come to the center at the beginning of 
the trial, mid-term and at the end of the trial for imaging and blood work. 
- 
 
Process for obtaining informed consent: 

Ifon-Version 2- 06222021                                                  25
 
 
 
The PI will seek informed consent from eligible participants with an IRB approved 
consent form. Determination of a participant’s capacity to consent will be made by the 
PI. Input may be solicited from participant’s SCI Provider on record, who knows the 
potential participant well. Potential participants will be given full verbal explanation of the 
study protocol by the PI. If they voice an interest in the study, they will receive the 
written consent form and will be provided ample time to consider their participation. All 
concerns and questions will be answered by the PI.  The PI will place emphasis on 
explaining all study procedures. Family members will be included in the discussion as 
desired by the participants. Participants will be made aware that participation is 
voluntary and that they can withdraw at any time with no impact on the care they 
currently receive or future care from the VA. Participants will be made aware that they 
can discuss the study participation with their primary SCI Provider, if they chose.  
Potential participants who take the consent forms home will be given a returned 
addressed envelope with postage paid in which they can mail back the consent form 
once signed. All signed consents will be scanned into the VA Computerized Patient 
Record System (CPRS); a warning note indicating participation in an ongoing research 
study will be enter in the “Crisis Notes, Warning Notes, Directives (CWD),” section of 
CPRS to alert CPRS users of participants’ enrollment in an ongoing study. In addition to 
a consent note entered into CPRS for all participants, progress notes of their active 
participation will also be entered. 
 
Limitations and Alternatives:  
 
1) Those with incomplete SCI (AIS C or D) as they may already be engaging in some 
weight bearing activities that convey some benefits of bone health, hence may confound 
the results of the study.  
 2) Those with marked osteopenia and severe osteoporosis as electrical stimulation and 
loading to already weakened limbs may increase the risk of sustaining stress fractures.   
3) It may be difficult to recruit female Veterans because of limited access as they are 
fewer in number compared to male Veterans.  
4)  Ability to recruit and retain the required sample size from current SCI & D registry. 
However, since the primary mentor had previously recruited and retained almost half of 
the proposed sample size in the parent study, we anticipate similar success rate.  
5) Frequent blood sampling; this procedure has been previously used in IRB approved 
funded studies without recorded incidence.  
6) concerns about retaining participants to finish the 9 months study; transportation 
could be a major impairment to participants’ compliance in the SCI population. 
Fortunately, the study involves limited travel since we are going to use Telehealth (a 
home-based) approach for the intervention and participants would only be required to 
travel at enrollment, mid-term and at the conclusion for testing procedures at no 
financial cost to them. Participants affiliated with the Spokes site can complete these 
tests at their local VAMC.  
 

Ifon-Version 2- 06222021                                                  26
 
 
 
 
 
Risk to Subjects. 
Every effort will be made to minimize potential harm to individuals during the study. 
There will strict adherence to the protocol’s inclusion/exclusion criteria.  However, the 
following may pose potential risk to study participants:  
  
Potential source of risk  
Potential Risk 
Possibility of 
occurring 
Pressure to skin from 
weights or    skin irritation 
from weights or during 
exercise 
Pressure injury (break to skin) 
Occasionally 
but no more 
than usual from 
daily activities 
DXA/MRI 
No significant risk  
This research study will involve 
exposure to radiation from 2 whole 
body DEXA scans and MRI with no 
contrast.  This radiation exposure is not 
necessary for medical care and is for 
research purposes only.  All radiation 
exposure increases the risk of 
developing cancer in the future.  The 
total amount of radiation that would be 
used in this study is equal to less than 
one day of exposure from natural 
background radiation. Permission 
would be obtained from the CVVHCS 
Radiation Safety Committee, who will 
review the use of radiation in this 
research study, involving minimal risk 
and necessary to obtain the desired 
research information.  Participants will 
be instructed to tell their Providers if 
they have participated in other research 
studies or received any other medical 
care involving radiation in the recent 
past. 
Unlikely 
Phlebotomy 
Phlebotomy can cause pain, bruising at 
the site of the venipuncture, nerve 
damage, hematoma or infection 
Rare 
Electrical 
stimulator/weights 
(Risk of fracture) 
 SCI is commonly associated with 
bone weakness and weight bearing o n 
t he participant’s limb s while exercising 
on the rowing machine may increase 
risk of fracture to already weakened 
bones. 
Rare 

Ifon-Version 2- 06222021                                                  27
 
 
 
Autonomic Dysreflexia 
(AD) 
Weights and exercise to limbs of 
participants may pose as noxious 
stimuli that may lead to symptoms of 
AD (headache, pounding in the head, 
ringing in the ears, dizziness, blurry 
vision, sweating, anxiety, flushing, 
tightness in the chest, stuffy nose, 
heart flutters, or difficulty breathing), 
especially in those with cervical level of 
injury and high thoracic level of injury 
(T6 and above). 
Rare 
Falls 
Falls could occur during training or 
transfer unto testing equipment 
(MRI/DXA table or in the home during 
transfer to/from wheelchair unto rowing 
machine. 
Rare 
Risk of Fracture 
SCI is commonly accompanied by bone 
weakness and weight bearing on the 
participants’ limbs may increase their 
risk of sustaining stress/low impact 
mechanical fracture. 
 
Medication (Vitamin D)  
Vitamin D toxicity can lead to 
hypercalcemia and kidney stones.  To 
reduce this risk participant’s serum 
level of 25(OH)D will be monitored 
closely and re-assessed at mid-term 
and at end of intervention. 
Hypercalcemia is usually not seen 
unless the D level is > 100 ng/ml. 
 
 
Rare 
Rowing equipment 
It is possible that the rowing machine 
may malfunction or cause stress injury 
to the weakened limbs   
Rare 
Implanted device 
malfunction due to use of 
MRI  
Implanted metallic device may pose 
risk for using MRI device, for example, 
implanted stimulator or intrathecal 
pump device may malfunction following 
MRI exposure.  These are 
reprogrammable if they occur. 
Rare 
  
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 established standard operating 
procedures and necessary precautions will be taken to mitigate any potential risk. There 
will be strict adherence to the inclusion & exclusion criteria for the protocol. Appropriate 

Ifon-Version 2- 06222021                                                  28
 
 
 
health screening and strict compliance with the established exclusion criteria will 
minimize attrition due to medical reasons. Participants will be closely monitored by the 
PI at all visits.  All participants will be provided a 24-hour contact information for the PI 
and instructed to call for any concerns. Unscheduled visits may be performed if required 
for evaluation of safety. If a participant exhibits an adverse event, more frequent visits 
may be necessary. 
• Protection of skin integrity during intervention 
Skin will be closely inspected with the help of the caregivers for dose with caregivers, 
otherwise, by the PI via the webcam during each intervention session to ensure 
maintenance of skin integrity.   
• Protection from risk associated with transfers 
To minimize risk, a caregiver will be available to assist in all transfers and provide a 
sliding board or any other assistive devices needed for those without good upper body 
strengths.  For those without caregivers, safe transfer techniques would have been 
validated prior to enrollment.  
• Protection from risk associated with radiation exposure 
To minimize risk, only the required scans will be performed.  Testing will be performed 
early in the day and after lower extremity elevation for at least 30 minutes to minimize 
lower extremity edema. An overhead lift system is installed in the exercise lab to ensure 
safe transfers on and off the DXA scanner.  
A possible health problem seen with radiation exposure is the development of cancer 
later in life. This extra cancer risk is higher at younger ages and for girls and women. 
The extra lifetime risk of dying of a fatal cancer due to the radiation exposure from this 
research is very low.  At such low radiation exposures, scientists disagree about the 
amount of risk. These estimates are very uncertain, and there may be no extra risk at 
all. 
• Protection from falls during transfers 
Falls could occur during transfers with sliding board or portable lift from bed to 
wheelchair and from wheelchair unto intervention equipment (rowing machine).  This 
requires careful use of equipment.  To avoid this kind of accident, transfer techniques 
will be reviewed with participants and caregivers (where applicable) at the beginning of 
the study.  However, this rarely occurs after a Veteran has successfully completed 
rehabilitation treatment post injury.  
• Protection against risk of fracture 
Every effort will be taken to minimize possible bone fracture; DXA scan will be 
performed as detailed earlier prior to enrollment in the trial. Persons with T-score less 
than -2.5 SD at the hip joints or with bone mineral density less than 0.6 gm/cm2 at the 
knee joints will be excluded from the trial.  
• Protection from autonomic dysreflexia 

Ifon-Version 2- 06222021                                                  29
 
 
 
Blood pressure (BP) will be monitored closely during the entire intervention and 
established AD protocol followed should participant experience AD symptoms (patients 
and caregivers usually receive training on AD management at home, during their 
rehabilitation course).  Any significant rise in BP greater than 20 mmHg above resting 
BP, the intervention will be suspended immediately and AD protocol instituted. The PI 
will remain on video connection until AD symptoms resolved and participant returns to 
normal state. 
• Protection against medications adverse effects  
Medication associated with the current trial can cause allergic reactions, such as, 
rashes, nausea, vomiting, and hypercalcemia. The PI will obtain allergy history (prior 
reactions) and monitor the patient and blood parameters closely during the course of 
the trial to avert any serious drug reaction.  
Study removal criteria may include: Participants may be withdrawn from the study by 
the research team for the following concerns: 
1. 
New medical diagnosis of carcinoma of the breast or prostate as these would 
may have bone health implications. Deep venous thromboembolism as this will 
hinder intervention and may increase risk of  pulmonary embolism; stroke, 
hypertension, serious heart problems, heart failure, myocardial infarction, 
ventricular arrhythmia, exertional chest pain, insulin dependent diabetes, 
hypercholesterolemia, hypertriglyceridemia, impaired liver function, 
hypercalcemia, or significant renal dysfunction. 
2. 
Hospitalization for acute medical problems (e.g. Liver enzymes (AST / ALT) >1.5 
times normal upper limit). 
3. 
Serum calcium greater than 16mg/dL or symptoms of hypercalcemia 
4. 
Severe peripheral edema, classified as 2+ or higher 
5. 
Any SAE that the SCI physician, Dr. Lavis, deems necessary for withdrawal for 
participant’s safety. 
 
Protection against possible participants’ coercion:  
The $300 paid to each participant is to compensate for time and inconveniences 
associate with the commitment to participate in a 9 months trial and would be paid in 2 
installments ($150 will be disbursed at the end of the 4.5 months testing and the end of 
the study, respectively)  to protect against coercion.  Furthermore, the PI will work 
closely with the IRB to avoid any coercive influence on any of our study participants.   
Adverse Events:  
All participants will be monitored for any changes in health status from baseline. The 
SCI Provider on record for each participant will be notified of any changes that may 
require attention. An adverse event is any experience that has taken place during 
research project, which, in the opinion of the investigators, was harmful to the research 
participant, increased the risks of harm in the research, or had an unfavorable impact on 

Ifon-Version 2- 06222021                                                  30
 
 
 
the risk/benefit ratio.  Adverse events will be monitored throughout the study period via 
physical examinations, vital signs, laboratory tests, review of medical charts, and 
verbalized concerns by the participants, caregivers, significant other or family member.  
Any adverse event will be documented in each participant’s file.  Files will be reviewed 
for adverse events, protocol violations, and reasons for dropouts/withdrawals every ten 
days. The PI will provide CVVHCS IRB an annual summary of adverse events.  All 
serious adverse events (SAEs), such as those that are life-threatening or involve 
hospitalization, will be promptly reported to CVVHC IRB Research Subjects Protection 
Program. Serious adverse event is defined as the unexpected medical occurrence 
associated with the research procedure that may lead to death, life-threatening medical 
condition, inpatient hospitalization for or longer than 24 hours, persistent or significant 
incapacity or substantial disruption of the ability to engage in normal activities of daily 
living.   
During the study period and at the completion of the study, all participants will continue 
to receive their usual health care from their assigned SCI Provider and/or other 
Providers within and outside VHA health care system. When study procedures begin, 
the importance of reporting any perceived problem, adverse event or change from 
baseline health will be stressed to the participants. Examples of potential problems 
requiring immediate medical attention or a call to the PI will be described to the 
participants. Above all, it will be stressed to the participants that direct phone access to 
the PI is available 24hrs/day, 7 days a week  and in the event of any questions or 
concerns, they are to call the PI with the phone number that they were given.  All 
participants will be identified by an assigned number. Participants' research charts will 
be kept in the PIs office which is locked inside a locked file cabinet. Only the PI and Co-
PI will have access to participants’ study records and medical information. A master 
sheet of the full names will be kept in the locked file in the PI’s office. All completed 
study files will be stored in the mentor’s SCI research office 1V-129.  At the end of 4-
year period, all records will either be stored in the SCI Research Exercise Laboratory 
locked room or sent to Dunmar Storage Facility based on space needs.  
 
Subject’s burden:  
The current study was designed to reduce and minimize participants’ 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 burden associated with study participation over the study period. Each intervention 
session would last approximately 60 minutes. The current study is designed to allow 
participants to participate from the comfort of their homes using video telehealth 
technologies.  This should provide some level of control over most SCI factors that may 
otherwise impact the outcome of the study, for example, stress associated with travel 
burden that could lead to attrition.  Each participant will have the liberty to miss up to 

Ifon-Version 2- 06222021                                                  31
 
 
 
15% of scheduled Telehealth visit, due to unanticipated events, such as, short duration 
of acute illness, medical appointments, or vacation, without being asked to withdraw or 
disenrolled from the study.  We believe that we can retain participants through the 
duration of the study (9 months) by: 
a) Providing free transportation for tests at the medical center (most Veterans already 
have this benefit).  
b) Providing flexible hours to accommodate education and work-related schedules. 
c) During data collection, we will provide sufficient time for participants to have their 
meals and use medications. 
d) Using a comprehensive team approach that would allow participants to engage in 
recreational activities and avail themselves of Psychology (if desired) and 
Nutritional services. 
 
Benefits: 
 Potential benefits of research to Veterans and others: 
The proposed study is geared towards improving both bone and muscle strengths and 
will benefit the participants in increasing muscle blood flow, blood glucose uptake as 
well as decrease bone demineralization. The anticipated benefits of the current trial 
should be viewed in the light that the proposed work will serve as a pilot work for future 
protocols by providing supporting preliminary data to adequately power future clinical 
trials. 
We hope findings from this work will provide supporting evidence to establish the 
resources necessary to accelerate research and development of therapies for bone 
loss 
      attenuation and improved functionality and quality of life for persons with 
chronic SCI.  It is anticipated that this will reduce the costs associated with managing 
low impact fractures secondary to bone loss after SCI. The PI will make every effort to 
disseminate the knowledge gained from this trial through presentations at local, national 
and/or international scientific meetings.  And also, by manuscript preparations and 
submission to high impact peer-reviewed journals for publications. The intervention in 
this study may directly benefit participants physiologically, aside from the financial 
compensation, by increasing muscle mass and improving blood flow.  However, if there 
are no direct benefits to participants, the information gained, has the potential to help 
others in the future. 
 
Importance of Knowledge to be gained 
The prevalence of individuals with SCI has been estimated to be 250,000-400,000 with 
an estimated 18% growth in the prevalence since 1988. Of the more than 46,000 
Veterans with SCI-related disability, more than 50% will develop osteoporosis in the first 
year of injury if the process is not mitigated. The incidence of osteoporosis in this 
population gets even higher and exceeds 80% with increased years since injury and 
predisposes persons with SCI to low impact mechanical fractures.  In fact, 50% of 

Ifon-Version 2- 06222021                                                  32
 
 
 
individuals with SCI will sustain low impact mechanical fractures during their lifetime.  It 
is worrisome that the cost of managing osteoporosis-related fractures may cost about 
$25 billion by 2025.  Fortunately, mechanical loading of paralyzed limbs has been 
shown to attenuate bone loss providing hopes for mitigation of bone loss after SCI, 
thereby slowing down progression to osteoporosis and associated complications.  In 
addition, electrical stimulation has been shown to partly reduce the loss of bone mineral 
density in the femur when treatment was initiated early post SCI.  Therefore, this study 
proposes to combine loading and electrical stimulation in addition to vitamin D 
supplementation, in an attempt to attenuate bone loss in persons with SCI. Considering 
the time, cost and potential associated-risks, we are proposing the use of both electrical 
stimulation and paralyzed limb loading strategy plus vitamin D supplementation to 
achieve bone attenuation.  Assuming that our protocol is successful in attenuating bone 
loss, many of the 46,000 Veterans with SCI stand to benefit as does VHA in health care 
costs savings.   
 
Clinical Trial 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. 
 
Data and Safety Monitoring Plan.  
The PI will monitor and review the protocol as well as data collection every month to 
evaluate participants’ safety, data quality, and study progression and execution.  The PI 
will review the protocol for any major concerns prior to implementation. The local data 
monitoring board will meet every 6 months to review/discuss the study.  The data 
monitoring board will have the option to request stopping or cessation of participants’ 
enrollment and all research procedure, if deemed necessary.  It is unlikely that they 
would find significant improvement in collected bone parameters at mid-intervention (4.5 
months) in the intervention group because bone requires a longer time for adaptation, 
especially in persons with SCI.  However, should there be significant  improvement (s) 
in the intervention group compared to the control group, the data monitoring team could 
terminate the study early. The PI will also assess the performance of overall study 
operations and any other relevant issues, as necessary. The Data and Safety 
Monitoring Board (DSMB) is responsible for overseeing the safety of the research and 
report observations/findings to the IRB on an annual basis.  The data monitoring team 
will review all unanticipated problems involving risks to subjects or others associated 
with the protocol and provide an independent report of the event to the IRB. They may 
discuss the research protocol with the investigators; shall have authority to stop a 
research protocol in progress, remove individual human subjects from a research 
protocol, and take whatever steps necessary to protect the safety and well-being of 
human participants until the IRB can assess the monitor's report; and shall have the 
responsibility to promptly report their observations and findings to the IRB. A letter will 
be drafted from the DSMB and will be attached with the annual summary report to the 
IRB. Elements in the letter will include the followings: 
• 
Evidence of study-related AEs  

Ifon-Version 2- 06222021                                                  33
 
 
 
• 
Evidence of efficacy according to pre-established statistical guidelines, if 
appropriate;  
• 
Data quality, completeness, and timeliness  
• 
Performance of the specific research center  
• 
Adequacy of compliance with goals for recruitment and retention 
• 
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. 
 
The Data Safety Monitoring Board (DSMB) will include 
 
Sean McAvoy, MD 
SCI Physician 
Hunter Holmes McGuire VA Medical Center, Richmond VA 
(804) 675-5586 
Sean.McAvoy@va.gov 
 
 Jeffrey Tubbs, MD 
 SCI Physician 
 Hunter Holmes McGuire VA Medical Center, Richmond VA 
 (804) 675-5455 
  Jeffrey.Tubbs@va.gov  
 
 Lance Goetz, MD 
 SCI Physician 
 Hunter Holmes McGuire VA Medical Center, Richmond VA 
 (804) 675-5000 ext. 2475 
  lance.goetz@va.gov  
 
 
 
 
 
 
 
 
 
 
 
 
 References  
 

Ifon-Version 2- 06222021                                                  34
 
 
 
1. Tan, C. O., Battaglimo, R. A. & Morse, L. R. (2013). Spinal cord injury and 
osteoporosis: Causes, Mechanism and rehabilitation strategies.  International 
Journal of Physical Medicine and Rehabilitation, 1, 127 
2. Bethel, M., Weaver, F. M., Bailey, L., Miskevics, S., Svircev, J. N., Bums, S. P. 
…Carbone, L. D. ( 2016).  Risk factors for osteoporotic fractures in persons with 
spinal cord injuries and disorders. Osteoporosis International, 27(10), 3011-3021. 
3. Jiang, S. -D., Dai, L. -Y., Jiang, L-S. (2006).  Osteoporosis after spinal cord 
injury.  Osteoporosis International, 17, 180-192 
4. Otom., A.,  &  Al-Ahmar, M. R.  (2014).  Bone loss following spinal cord injury.  
Journal of Neuorestoratology, 81-84.  
5. Maimoun, L. Fattal, C. Mccallef, J-P, Perucheon, E., & Rabischong, P.  (2006).  
Bone loss in spinal cord injured patients: from physiopathology to therapy. 
Spinal Cord, 44, 203-210 
6. Gao, Y., Arfat, Y., Wang, H., & Goswami, N. (2018). Muscle Atrophy Induced by 
Mechanical Unloading: Mechanisms and Potential Countermeasures. Frontiers 
in physiology, 9, 235. doi:10.3389/fphys.2018.00235 
7. Frotzler, A., Cheikh-Sarraf, B., Pourtehrani, M. l.,& Lippuner, K.  (2015).   Long-
bone fractures in persons with spinal cord injury. Spinal Cord 53, 701–704 
doi:10.1038/sc.2015.74 
8. Haider, I. T., Lobos, S. M., Simonian, N., Schnitzer, T. J., & Edwards, W. B. 
(2018). Bone fragility after spinal cord injury: reductions in stiffness and bone 
mineral at the distal femur and proximal tibia as a function of time. Osteoporosis 
international : a journal established as result of cooperation between the 
European Foundation for Osteoporosis and the National Osteoporosis 
Foundation of the USA, 29(12), 2703–2715. doi:10.1007/s00198-018-4733-0 
9. Varacallo, M., & Pizzutillo, P.  (2019).  Osteoporosis in spinal cord injury: In 
StatPearls publishing [Internet]  Treasure Island, FL.  
10. Ensurd, K. E., & Crandall, C. J. (2017).  Osteoporosis.  Ann Intern Med. 163(3), 
ITC17-ITC-32 
11. Coughlan, T. & Dockery, F. (2014).  Osteoporosis and fracture risk in older 
people.  Clinical Medicine, 14(2), 187-191. 
12. International Osteoporosis Foundation (2019). Facts and statistics. Retrieved 
from https://www.iofbonehealth.org>facts-statistics 
13. Sözen, T., Özışık, L., & Başaran, N. Ç. (2017). An overview and management of 
osteoporosis. European journal of rheumatology, 4(1), 46–56. 
https://doi.org/10.5152/eurjrheum.2016.048 
14. Wright, N. C., Looker, A. C., Saag, K. G., Curtis, J. R., Delzell, E. S., Randall, S., 
& Dawson-Hughes, B. (2014). The recent prevalence of osteoporosis and low 
bone mass in the United States based on bone mineral density at the femoral 
neck or lumbar spine. Journal of bone and mineral research : the official journal 
of the American Society for Bone and Mineral Research, 29(11), 2520–2526. 
doi:10.1002/jbmr.2269 
15. Pisani, P., Renna, M. D., Conversano, F., Casciaro, E., Di Paola, M., Quarta, E., 
… Casciaro, S. (2016). Major osteoporotic fragility fractures: Risk factor updates 
and societal impact. World journal of orthopedics, 7(3), 171–181. 
doi:10.5312/wjo.v7.i3.171 

Ifon-Version 2- 06222021                                                  35
 
 
 
16.  Vijayakumar R, Bu¨sselberg D.  (2016).  Osteoporosis: An under-recognized 
public health problem. Journal of Local and Global Health Science 2016:2 
http://dx.doi.org/10.5339/jlghs.2016.2   
17. Screening for Osteoporosis to Prevent Fractures US Preventive Services Task 
Force Recommendation Statement. (2018).  Journal of American Medical 
Association, 2521-2531 
18. U S Department of Veterans Affairs.  (2009). VA and spinal cord injury: Fact 
sheet.  Retrieved from 
https://www.va.gov/opa/publications/factsheets/fs_spinal_cord_injury.pdf 
19. National Spinal Cord Injury Statistical Center.  (2017).  Spinal cord injury facts 
and figures at a glance.  Retrieved from 
https://www.nscisc.uab.edu/Public/Facts%20and%20Figures%20-%202017.pdf 
20. Troy, K. L., & Morse, L. R. (2015). Measurement of Bone: Diagnosis of SCI-
Induced Osteoporosis and Fracture Risk Prediction. Topics in spinal cord injury 
rehabilitation, 21(4), 267–274. doi:10.1310/sci2104-267 
21. Gifre, L., Vidal, J., Carrasco, J., Portell, E., Puig, J., Monegal, A., Guañabens., 
N., & Peris,  P. (2014).  Incidence of skeletal fractures after traumatic spinal cord 
injury: a 10-year  
follow-up study. Clinical Rehabilitation, 28(4):361-9. doi: 
10.1177/0269215513501905. 
22. Gifre, L., Vidal, J., Carrasco, J. L., Muxi, A, Portell, E., Monegal, A. …Peris, P.  
(2015).  Risk factors for the development of osteoporosis after spinal cord injury.  
A 12 month follow-up study.  Osteoporosis International, 26(9), 2273-2280. doi: 
10.1007/s00198-015-3150-x 
23. Morse, L. R., Battaglino, R. A., Stolzmann, K. L., Hallett, L. D., Waddimba, A., 
Gagnon, D., … Garshick, E. (2009). Osteoporotic fractures and hospitalization 
risk in chronic spinal cord injury. Osteoporosis international : a journal 
established as result of cooperation between the European Foundation for 
Osteoporosis and the National Osteoporosis Foundation of the USA, 20(3), 385–
392. doi:10.1007/s00198-008-0671-6 
24. Furlan, J. C., Gulasingam, S., & Craven, B. C. (2017). The Health Economics of 
the Spinal Cord Injury or Disease among veterans of War: A systematic Review. 
The Journal of Spinal Cord Medicine, 649-664. 
25. Merritt, C. H., Taylor, M. A.,  Yelton, C. J.  & Ray, S. K. (2019).   Economic 
impact of traumatic spinal cord injuries in the United States.  Neuroimmunol 
Neuroinflammation, 2019;6:9. 
26. Battaglino, R. A., Lazzari, A.A, Garshick, E. and Morse, L. R. (2012). Spinal Cord 
Injury-Induced Osteoporosis: Pathogenesis and Emerging Therapies. Curr 
Osteoporosis Rep., 278-285 
27. Kerschan-Schindl K. (2020). Romosozumab: a novel bone anabolic treatment 
option for osteoporosis?. Romosozumab: eine neue Therapieoption bei 
Osteoporose mit anaboler Wirkung auf den Knochen. Wiener medizinische 
Wochenschrift (1946), 170(5-6), 124–131. https://doi.org/10.1007/s10354-019-
00721-5 
28. Paillard, T. (2018).  Regular muscle electrical stimulation could act favorably on 
bone mineral density in healthy aged subjects. Front. Physiol. 9: 1035 

Ifon-Version 2- 06222021                                                  36
 
 
 
29. Almstedt, H. C. (2017). Whole body vibration training Attenuates Bone loss in 
Osteoporosis: A Case Report. Journal of Osteoporosis & Physical Activity, 1-4. 
30. Bélanger, M., Stein, R. B., Wheeler, G. D., Gordon, T., & Leduc, B.  (2000). 
Electrical stimulation: Can it increase muscle strength and reverse osteopenia in 
spinal cord injured individuals? Achieves of Physical Medicine and 
Rehabilitation,81(8), 1090-1098. 
31. Lai, C. H., Chang, W. H., Chan, W. P, Peng, C. W., Shen, L. K., Chen, J. J., & 
Chen., S. C. (2010).   Effects of functional electrical stimulation cycling exercise 
on bone mineral density loss in early stages of spinal cord injury. Journal of 
Rehabilitation Medicine, 42(2),150-154.  doi: 10.2340/16501977.0499 
32. Gorgey, A. S., Khalil, R. E., Davis, J. C., Carter, W., Gill, R., Rivers, J., … Adler, 
R. A. (2019). 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. Trials, 20(1), 526. doi:10.1186/s13063-019-3560-8 
33. Young, J. D., & Badowski, M. E. (2017). Telehealth: Increasing Access to High 
Quality Care by Expanding the Role of Technology in Correctional Medicine. 
Journal of clinical medicine, 6(2), 20. doi:10.3390/jcm6020020 
34. De Lusignan S, Wells S, Johnson P, Meredith K, Leatham E.  (2001). 
Compliance and effectiveness of 1 year’s home telemonitoring. The report of a 
pilot study of patients with chronic heart failure. Europ J of HF, 3, 723–730. 
35. Gorgey, A. S., Mather, K. J., Cupp, H. R., Gater, D. R. (2012).  Effects of 
resistance training on adiposity and metabolism after spinal cord injury. Medicine 
& Science in Sports & Exercise, 44(1), 165-174, doi: 
10.1249/MSS.0b013e31822672aa  
36. Lips, P., & van Schoor, N. M. (2011). The effects of Vitamin D on bone and 
osteoporosis.  Best Practice & Research Clinical Endicrinology & Metabolism, 
585-591. 
37.  Zhou, X. J., Vazirin N. D., Segal, J. L., Winer, R. L. , Eltorai, I. & Brunnemann, S. 
R.  (1993). Effects of Chronic Spinal Cord Injury and Pressure Ulcer on 25(OH)-
Vitamin D Levels.  The Journal of The American Paraplegia Scociety, 16(1), 9-
13. 
38. Bauman, W. A., Zhong, Y. G., & Schwartz, E. (1995). Vitamin D Deficiency in 
Veterans with Chronic Spinal Cord Injury. Metabolism, 1612-1616 
39. Bauman, W. A., Emmons, R. R., Cimigliaro, C. M., Kirshblum, S.C., & Spungen, 
A. M. (2011).  An effective oral vitamin D replacement therapy in persons with 
spinal cord injury.  The journal of spinal cord medicine, 455-460 
40. Flueck, J. L., Schlaepfer, M. W., & Perret, C. (2016). Effect of 12-Week Vitamin D 
Supplementation on 25[OH]D status and performance in athletes with a Spinal 
Cord Injury. Nutrients, 8(10), 586. doi:10.3390/nu8100586. 
41. Fleet J. C. (2017). The role of vitamin D in the endocrinology controlling calcium 
homeostasis. Molecular and cellular endocrinology, 453, 36–45. 
doi:10.1016/j.mce.2017.04.008 
42. Lai, C. H., Chang, W. H., Chan, W. P, Peng, C. W., Shen, L. K., Chen, J. J., & 
Chen., S. C. (2010).   Effects of functional electrical stimulation cycling exercise 

Ifon-Version 2- 06222021                                                  37
 
 
 
on bone mineral density loss in early stages of spinal cord injury. Journal of 
Rehabilitation Medicine, 42(2),150-154.  doi: 10.2340/16501977.0499 
43. Shields, R. K.,  Dudley-Javoroski, S., & Frey Law, L. A. (2006).  Electrically 
Induced Muscle Contractions Influence Bone Density Decline After Spinal Cord 
Injury. Spine, 31(5): 548–553. doi:10.1097/01.brs.0000201303.49308.a8. 
44. Mahoney, E.T., Bickel, C.S., Elder, C., Black, C., Slade, J. M., Apple ,D., Jr,  & 
Dudley, G. A. (2005).  Changes in skeletal muscle size and glucose tolerance 
with electrically stimulated resistance training in subjects with chronic spinal cord 
injury. Arch Phys Med Rehabil. 86(7),1502–1504 
45. Gorgey, A. S.,  Khalil, R. E., Gill, R., Gater,  D. R., Lavis, T. D., Cardozo, C. P., 
Adler R. A. (2019). Low-Dose Testosterone and Evoked Resistance Exercise 
after Spinal Cord Injury on Cardio-Metabolic Risk Factors: An Open-Label 
Randomized Clinical Trial. J Neurotrauma. Sept. 15;36(18):2631-2645. doi: 
10.1089/neu.2018.6136. Epub.,  Mar 28. PMID: 30794084. 
46. Sigh, R., Rohilla, R. K., Saini, G., Magu, N. K., & Kaur, K.  (2014).  Bone mineral 
density and biochemical markers of bone turnover during the first year of injury in 
patients with spinal cord injury.  Journal of Orthopaedics, Trauma and 
Rehabilitation, 18(1), 2-6 
47. Kučukalić-Selimović, E., Valjevac, A., & Hadžović-Džuvo, A. (2013). The utility of 
procollagen type 1 N-terminal propeptide for the bone status assessment in 
postmenopausal women. Bosnian journal of basic medical sciences, 13(4), 259–
265. doi:10.17305/bjbms.2013.2337 
48. Vasikaran, S. D., Chubb, S. A., Schneider, H. G. (2014). Towards optimizing the 
provision of laboratory services for bone turnover markers. Pathology. 46(4):267-
73. doi: 10.1097/PAT.0000000000000092. PMID: 24798169. 
49. Nutrition Data System for Research. Retrieved, April 17, 2021 at 
www.ncc.umn.edu/products/ 
50. Lee, J., Lee, S., Jang, S., & Ryu, O. H. (2013). Age-Related Changes in the 
Prevalence of Osteoporosis according to Gender and Skeletal Site: The Korea 
National Health and Nutrition Examination Survey 2008-2010. Endocrinology and 
metabolism (Seoul, Korea), 28(3), 180–191. 
https://doi.org/10.3803/EnM.2013.28.3.180 
51. Guimard C, Batard E, Lavainne F, Trewick D. (2018). Is severe hypercalcemia 
immediately life-threatening? Eur J Emerg Med. 25(2):110-113. doi: 
10.1097/MEJ.0000000000000462. PMID: 28338532. 
52. Pilz, S., Zittermann, A., Trummer, C., Theiler-Schwetz, V., Lerchbaum, E., Martin 
H Keppel, M. H., Grübler, M. R., März, W. and Pandis, M. (2019).  Vitamin D 
Testing and Treatment: A Narrative Review of Current Evidence.  Endocrine 
Connections 8, no. 2  R27–43. https://doi.org/10.1530/EC-18-0432. 
53. Holick, M. F., Binkley, N. C., Bischoff-Ferrari, H. A., Gordon, C. M., Hanley, D. A., 
Robert Heaney, R. P., …Weaver, C. M. (2011).  Evaluation, Treatment, and 
Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice 
Guideline. The Journal of Clinical Endocrinology & Metabolism, 96, 7(1), 1911-
1930, https://doi.org/10.1210/jc.2011-0385 

Ifon-Version 2- 06222021                                                  38
 
 
 
54. Holman, M.E., G. Chang, M.P. Ghatas, P.K. Saha, X. Zhang, M.R. Khan, A.P. 
Sima, R.A. Adler, and A. S. Gorgey (2021). Bone and Non-Contractile Soft 
Tissue Changes Following Open Kinetic Chain Resistance Training and 
Testosterone Treatment in Spinal Cord Injury: An Exploratory 
Study. Osteoporosis International, January 14, 2021. 
https://doi.org/10.1007/s00198-020-05778-2 
55. Cordes, C., Baum, T.,  Dieckmeyer, M.,  Ruschke, S.,  Diefenbach, M. N., 
Hauner, H.,  Kirschke, J. S., and Karampinos. D. C. MR-Based Assessment of 
Bone Marrow Fat in Osteoporosis, Diabetes, and Obesity. Frontiers in 
Endocrinology 7 (June 27, 2016). https://doi.org/10.3389/fendo.2016.00074. 
56. Julious, S. A. (2005).  Sample size of 12 groups rule of thumb for a pilot study.  
Pharmaceutical Statistics, 4, 287-291.