Effects of Remote Ischemic Conditioning on Hand Use in Individuals With Spinal Cord Injury and Amyotrophic Lateral Sclerosis: A Preliminary Study
Phase: NA
Conditions: Spinal Cord Injuries, Amyotrophic Lateral Sclerosis
Sponsor: Bronx VA Medical Center

Effects of Remote Ischemic Conditioning on Hand Use in Individuals With 
Spinal Cord Injury and Amyotrophic Lateral Sclerosis: A Preliminary Study  
NCT03851302 
Study Protocol and Statistical Analysis Plan
24 November 2023 

 Research Strategy 
Significance 
 
Between 250-350,000 individuals live with spinal cord injury (SCI) in the United States. Among this 
population, ~ 60% have injuries at the cervical level1. Impairments of arm and hand function in individuals with 
cervical SCI (cSCI) greatly reduce quality of life and adversely impact the level of independence2. Previous 
research on the needs of individuals with cSCI has shown that the improvement of hand function is as important 
as regaining bladder and bowel function, and more important than walking3. Most spinal cord injuries are not 
fully transected, indicating that there are residual nerve circuits after injury4. Rehabilitation interventions such as 
physical training and neural stimulation have been shown to reorganize motor pathways in the brain, 
corticospinal tract, and at the spinal level, a process called neural plasticity5–8. Thus, neural plasticity after SCI 
could improve function by enhancing the excitability of residual neural circuits9–14. 
However, both physical training and neural stimulation require a large number of repetitions, and even so, 
the retention of the intervention effects may be fleeting. To enhance the magnitude and duration of 
neuroplasticity, investigators are supplementing physical training with methods that augment training effects and 
lengthen the retention of functional gains. Transcranial direct current stimulation (tDCS) and acute intermittent 
hypoxia (AIH) are two such approaches. Some preliminary research has shown that either tDCS or AIH coupled 
with task-oriented physical rehabilitation enhances the learning effects of task-specific motor training after 
SCI15,16. However, tDCS requires not only an electrical stimulation device but also the optimization of electrode 
placement, which is controversial. AIH requires an hypoxicator system to provide prolonged systemic low oxygen 
exposure.  Further both tDCS and AIH are costly, demand highly trained staff and require sophisticated 
technological devices. Therefore, the need remains for a simple, effective approach to synergistically 
improve neuroplasticity in combination with physical rehabilitation.  
In this proposed study, we will investigate a potential approach called remote ischemic conditioning (RIC).  
Ischemic conditioning occurs when a specific organ or tissue is exposed to one or more transient events of 
sublethal ischemia. This leads to several protective reactions against subsequent ischemia on that organ or 
tissue17–19. Studies have demonstrated that those endogenous protective effects are not limited to ischemic 
organ/tissue alone – they are transferrable to other organs or tissues20–22. This phenomenon is called remote 
ischemic conditioning23,24. For example, cardioprotective effects can be provoked simply by transiently restricting 
blood flow of one limb using a tourniquet. This simplicity makes RIC more attractive, less expensive and practical. 
The mechanisms of cardioprotection induced by RIC are not entirely clear, but evidence suggests that RIC has 
extensive effects via humoral and neural factors that may aid in cardioprotection24. Among the potential 
mechanisms supporting the cardioprotective benefits of RIC, two effects might potentially promote 
neuroplasticity: induction of hypoxia-inducible factor 1a (HIF-1a) and anti-inflammatory factors. H1F-1a may 
have neuroprotective effects via triggering the expression of genes related to oxygen transport, glycolytic 
metabolism, and apoptosis25. Albrecht and colleagues found that upper limb RIC induced H1F-1a accumulation 
and activation in the right atrial tissue in patients undergoing cardiopulmonary bypass26. Whether the activation 
of H1F-1a induced by RIC extends to corticospinal areas and regulates neural excitability is unknown. Also, it 
has been speculated that H1F-1a expression helps to overcome the negative environment for transplanted 
neural stem cells due to ischemia and inflammation after SCI27. On the other hand, RIC also reduces 
inflammation28,29. Inflammation has been shown to attenuate expression of brain-derived neurotrophic factor 
(BDNF) in the brain30–33. Since individuals with SCI show signs of chronic systemic inflammation34,35, we 
hypothesize RIC’s ability to dampen inflammation could improve the expression of BDNF, which might further 
promote neuroplasticity. 
Cherry-Allen and colleagues recently published the first study testing the synergistic effects of RIC on motor 
task learning36. Able-bodied adults (n=18) were randomly assigned into active or sham RIC groups to undergo 
seven consecutive weekday sessions of RIC followed by stability platform balance training or training of a 
cognitive task dependent on the hippocampus. One active or sham RIC (5 cycles of 5-min inflation and 5-min 
deflation) was conducted before training each day. The authors noted significantly improved performance on the 
stability platform task in the active RIC group compared to the sham group, immediately after the completion of 
seven-day training sessions and even at the 2- and 4-week follow-up visits. The mechanism of improvement was 
unclear in their study, since they did not find any significant changes in serum BDNF, cognitive learning, or 
generalized muscle activation measured by finger flexor EMG activity and grip force. However, their study did 

not investigate changes of corticospinal excitability. We will focus on the acute effects of RIC on 
corticospinal excitability and systemic inflammatory mediators in this proposal.  
 
Innovation 
 
We propose a proof of concept study to investigate the acute synergistic effects of active versus sham RIC 
on motor task training, especially in persons with chronic cSCI. The primary outcome measure will be change 
in corticospinal excitability after RIC combined with a single bout of isometric hand exercise. The 
advantage of RIC compared to other current modes of inducing neuroplasticity, such as tDCS and AIH, is that 
RIC is a more approachable application, because RIC is simple and low-cost. Yet, published studies of RIC 
regarding neuroplasticity do not exist for populations of individuals with neurologic injury or disease. If 
synergistic effects of RIC with physical training can be demonstrated in this study, then effects of RIC coupled 
with various other rehabilitation interventions can be tested in future studies. In addition, we expect the analysis 
of neurophysiology and inflammatory mediators before and after RIC to provide some preliminary information 
regarding the mechanism by which RIC promotes neuroplasticity and improves effects of training. Finally, as a 
safety precaution, we will monitor beat-to-beat changes in heart rate (HR), blood pressure (BP) and oxygen 
saturation (SaO2) during RIC, since damaged autonomic nervous system (ANS) in individuals with SCI might 
dysregulate those hemodynamic responses toward the ischemic stimulation. As far as we know, this will be 
the first study in the SCI population (1) to investigate the synergistic effects of RIC with physical training 
on corticospinal excitability, (2) to measure changes in inflammatory mediators after RIC, and (3) to 
observe in real time the responses of HR, BP and SaO2 during RIC.  
 
Approach 
Overview 
 
We propose a randomized crossover study to compare active versus sham RIC combined with one bout of 
isometric hand exercise. Participants will be randomly assigned the order of the two experimental sessions: active 
or sham RIC. The isometric hand exercise will be performed in both sessions. The washout period between the 
two experimental sessions will be two to three weeks to prevent any carry-over effects. Figure 1 outlines the 
experimental protocol. Each session will consist of a pre-test measurement (baseline), active/sham RIC, post-RIC 
measurement, an isometric hand exercise and a post-exercise measurement. The total time in each session is 
around 3 hours including preparation. At the beginning and end of active/sham RIC, blood samples will be collected 
to measure changes in inflammatory mediators.  
Participants with chronic cSCI (n=8, ASIA Impairment Scale 
(AIS) A-D) and age-matched (within ±5 years) able-bodied 
controls (n=8) will be recruited. Participants with cSCI must 
have at least partial ability to make volitional finger opposition 
movements (thumb and index finger) in at least one hand. 
Participants will be excluded if they have concurrent serious 
medical illness, traumatic brain injury, cardiovascular or 
pulmonary 
complications, 
seizure 
history, 
deep 
vein 
thrombosis, or any other issues that would increase risk of 
magnetic or electrical stimulation required for outcome measure 
assessment. We will also document medications that 
participants are currently using for systemic inflammation, 
spasticity, anxiety, or depression, which could affect nervous system excitability. One screening session will be 
conducted to confirm eligibility and determine the target arm in each participant. The arm with consistent responses 
on abductor pollicis brevis muscle (APB) induced by magnetic or electrical stimulation will be the target arm. 
Transcranial magnetic stimulation (TMS) will be performed to determine each subject’s optimal scalp location for 
hand motor cortex stimulation, and to determine resting motor threshold for the APB muscle. Participants will be 
withdrawn if TMS-induced motor evoked potentials (MEPs) are unable to be detected at the APB muscles on either 
hand at stimulus intensity below 90% of maximal stimulator output. More details regarding inclusion and exclusion 
criteria are listed in the human subject section.  
Figure 1. The experimental protocol. 

 
The RIC protocol involves 5 cycles of 5-min inflation and 5-min deflation on the non-target arm. RIC will be 
achieved via blood pressure cuff inflation to 200 mmHg for active RIC37–40 and 10 mmHg below the subjects’ 
diastolic blood pressure for sham conditioning. This method replicates RIC as it has been applied in many other 
studies23,38,41.  
The primary muscles assessed in this study are APB and the first dorsal interosseous (FDI) muscle on the 
target arm. The electrophysiological variables include intra-cortical facilitation/inhibition, corticospinal excitability 
and peripheral nerve conduction profile. Electrophysiological variables will be measured at pre-test measurement 
(baseline), post-RIC measurement (post-RIC), and post-exercise measurement (immediately after the isometric 
hand exercise (post-RICx-0) and 15 minute later (post-RICx-15)). The blood samples will be collected at baseline 
and post-RIC to measure gene expression for inflammatory mediators related to Toll-like receptor (TLR) signal 
pathway.  
For the isometric hand exercise, subjects will be instructed to pinch a dynamometer (Anyload) with thumb 
and index finger at different intensities and durations. Performing volitional movements at varying intensities 
stimulates corticospinal circuits42,43. The intensities of pinch force will be 10%, 25%, and 50% of the maximal 
voluntary contraction (MVC). For each intensity, durations of 2, 4, and 6 s will be employed, which resulted in 
nine different combinations delivered in pseudorandom order. Participants will perform 2 sets of the isometric 
hand exercise (18 pinches in total). The interval between each pinch will be 2 seconds, with 30 second intervals 
between each set.  
 
Aim 1: To determine the effects of active versus sham RIC prior to one bout of muscle contraction 
exercise on motor corticospinal excitability.  
Hypothesis 1A: Motor evoked potential (MEP) amplitudes at the APB muscle (Primary Outcome) will 
significantly increase after active RIC plus isometric hand exercise compared to sham RIC plus isometric 
hand exercise. Active RIC alone will not significantly increase motor evoked potential amplitudes. These 
trends will be similar in both cSCI and able-bodied participants. 
Hypothesis 1B: Secondary electrophysiological outcomes at the APB muscle will significantly change after 
active RIC plus isometric hand exercise compared to sham RIC plus isometric hand exercise. Short-interval 
and long-interval cortical inhibition will decrease; intracortical facilitation will increase. Active RIC alone will 
not significantly change these outcome measures. These trends will be similar in both cSCI and able-bodied 
participants. 
 
We hypothesize that RIC might synergize with motor task learning via increased corticospinal excitability at 
supraspinal level. In order to test our hypothesis, we select an isometric hand exercise as the motor training task 
in this pilot study. The reason is that several studies have demonstrated immediate and transient increased 
MEPs as a result of post-exercise facilitation in able-bodied participants after a short period of repetitive 
contraction exercise in thenar muscle44, wrist muscle45, forearm46 and leg47,48. Additionally, the various 
combinations of the intensity and the duration of pinch movements in our study, as well as the use of an intrinsic 
hand muscle, theoretically involves more cortical attention, which should magnify the likelihood of supraspinal 
neuroplasticity42,43,49. We will test MEPs at baseline, post-RIC, post-RICx-0 and post-RICx-15. We expect to 
observe further increased MEPs of the APB thenar muscle at post-RICx due to the synergistic effects of active 
RIC on isometric hand exercise compared to sham RIC. Likewise, we expect that intracortical inhibition and 
intracortical facilitation of the APB muscle will decrease and increase, respectively. We also anticipate similar 
responses of all electrophysiological outcomes in both participants with cSCI and able-bodied participants. 
Method: We will conduct electrophysiological measurements at four time points: baseline, post-RIC, post-
RICx-0 and post-RIC-15. The post-RIC measurement allows us to first observe whether RIC-alone acutely 
affects corticospinal excitability. In addition, the 15-minute follow-up measurements (post-RICx-15) will allow us 
to investigate if the exercise effects will last longer due to active versus sham RIC. In order to localize changes 
on the pathway from the motor cortex to muscle, the electrophysiological outcomes include changes of intra-
cortical facilitation/inhibition, peak-to-peak amplitude of MEPs at 120% resting motor threshold (RMT), and 
peripheral nerve profile including M/F waves. We have and already use all the major equipment necessary for 
outcome assessments, including a MagPro X100 TMS system (MagVenture), Digitimer peripheral nerve 
stimulators (Digitimer), surface EMG pre-amplifiers (Motion Lab Systems), and data acquisition boards (National 
Instruments).  

Peak-to-Peak Amplitude of Motor Evoked Potentials at 
120% intensity of Resting Motor Threshold (MEP120): 
The optimal scalp location for APB will be determine at the 
screening session and stored in our Brainsight TMS 
Navigation system (Rogue Resolutions) for later use in each 
experimental session. After navigating to the optimal 
stimulation spot, the RMT, used for calculating single- and 
paired-pulse stimulation of the APB will be determined by 
the lowest TMS intensity at which an MEP could be induced 
with at least 5 of the 10 stimuli with peak to peak amplitude 
of 50-100 uV at rest. The single-pulse TMS will be applied 
at 120% RMT to induce and record peak-to-peak amplitude 
of MEP120. 
Cortical inhibition and facilitation: Paired-pulse TMS will be used to measure short interval cortical inhibition 
(SICI), long interval cortical inhibition (LICI) and intra-cortical facilitation (ICF)50. Paired-pulse TMS includes a 
conditioning (CS) and test stimulus (TS) separated by a specified interstimulus intervals (ISI). The configuration 
for measuring SICI, LICI and ICF in this study are as follows51–54: 
• 
SICI: CS = 90% RMT, TS = 120% RMT, ISI = 3 ms 
• 
LICI: CS = 120% RMT, TS = 120% RMT, ISI = 100 ms 
• 
ICF: CS = 90% RMT, TS = 120% RMT, ISI = 12 ms 
Peripheral Nerve Profile: Supramaximal electrical stimulation will be delivered at median and ulnar nerves at 
wrist level. The peripheral nerve profile includes the latency and the peak-to-peak amplitude of the M/F waves. 
The peak-to-peak amplitude of the M waves will be used to normalize the MEP120 at each time point to ensure 
that changes of corticospinal excitability are not due to peripheral variation50. 
Data Analysis: 
Corticospinal Excitability: The primary outcome will be MEP120 on APB (primary outcome muscle) and FDI 
muscles. The MEP120 will be first normalized to peak-to-peak amplitude of M waves to take account of the 
peripheral variation. The changes of MEP120 at post-RIC, post-RICx-0 and post-RICx-15 will be expressed as 
percentage of the changes compared to baseline MEP120. The SICI, LICI and ICF will also be expressed as 
percentage of the changes compared to baseline in each value.  
Statistical Analysis:  Electrophysiological outcomes will be compared after RIC and after the isometric hand 
exercise relative to baseline values. Descriptive analysis will be computed first for all outcomes variables to test 
the distribution of the data and correlation tests will be performed to check the independence among the outcome 
variables. A three way 2 (cSCI, able-bodied) by 2 (RIC, sham) by 3 (post-RIC, post-RICx-0, post-RICx-15) mixed-
ANOVA will be used to analyze MEP120 and intra-cortical facilitation/inhibition. If the data is not normally 
distributed and the assumptions of the ANOVA are not met, Wilcoxon signed rank tests will be used instead. 
Post hoc pairwise comparisons will be performed using the Bonferroni adjustment, if there are any main or 
interaction effects within the three independent variables (group, active/sham RIC and time points). 
 
Potential Pitfalls/Alternative approaches/Future Directions: Applying RIC on motor task learning is 
relatively new area with little preliminary data – therefore, our primary hypothesis that RIC may promote motor 
task learning via increasing corticospinal excitability is highly speculative. Additionally, the effects of RIC and 
acute post-exercise facilitation have mostly been shown in able-bodied participants, and there are no published 
data in the SCI population that measured corticospinal excitability as a mechanism for acute post-exercise 
facilitation. Therefore, individuals with SCI might demonstrate uncertain responses toward RIC and the isometric 
hand exercise than that exhibited in able-bodied participants. The inconsistent injury level and the residual nerve 
circuits among participants with cSCI might result in the wide variability of the outcomes. Nevertheless, although 
our hypotheses are speculative, the proposed study is designed to provide clear answers via observing the 
responses in participants with cSCI and able-bodied participants. If this brief isometric hand exercise cannot lead 
to significantly increased MEPs in participants with cSCI, our next step might test RIC in combination with more 
advanced interventions such as non-invasive paired stimulation, a technique that our research team is actively 
studying in other protocols. Finally, if the pilot study shows a significant synergistic effect of RIC on the isometric 
hand exercise task, our future goal will be coupling RIC with more prolonged rehabilitation training to promote 
long-term effects. 
Figure 2. Illustration of electrophysiological outcomes used to 
localize changes of excitability from cortex to peripheral nerve. 

Aim 2: To investigate effects of active versus sham RIC on systemic inflammatory mediators in 
individuals with cSCI. 
Hypothesis 2A:  The gene expression of inflammatory mediators will significantly decrease after active RIC 
compared to the sham RIC in participants with cSCI. 
Hypothesis 2B: The trends of inflammatory mediator change will be similar in both participants with cSCI and 
able-bodied participants. 
 
Our collaborator Dr. Bloom and others have demonstrated elevated inflammatory mediators in persons with 
chronic SCI55–57. Our objective here is to profile systemic immune responses to determine if RIC has anti-
inflammatory effects in cSCI and able-bodied participants. Dr. Bloom (see letter of support) recently 
demonstrated broad changes in inflammatory gene expression in persons with chronic SCI, which was 
particularly evident in persons with higher level injuries57. Specifically, they found elevated members of the Toll-
like receptor 2/4 (TLR) signaling pathway, metalloproteinases (ADAM10), caspases (CASP1, 3, 8) and 
chemokine gene families.  Previously, it was shown in able-bodied adults that RIC (3x5 min) resulted in reduced 
levels of inflammatory mediators in the blood at 15min and 24h later58. Specifically, members of the same genes 
and gene families elevated in persons with chronic SCI57 were reduced by RIC in able bodied individuals: TLR 
signaling pathway, TNF receptor pathway, MAP kinases, apoptosis pathway (CASP8), chemokines, T cell 
signaling molecules, metalloproteinases and leukocyte adhesion moleculesref58 Here, we will test if RIC in the 
current experimental paradigm has a similar anti-inflammatory effect in persons with SCI as has been 
documented in the able-bodied population.  
 
Methods: Blood samples (3cc) will be collected before the active/sham RIC cycle and 15 minutes after the 
end of RIC at the post-RIC measurement. According to previous research, the alteration of inflammatory 
mediators should occur after 15 minutes58.  
Data analysis: Given the previous data from the Bloom Lab indicating that TLR signaling is elevated in 
persons with chronic SCI and the data from able bodied persons that RIC reduces TLR signaling, we will first 
profile expression of genes related to TLR signaling in the current participants using qPCR profiling. Briefly, RNA 
will be isolated from whole blood collected in PAXgene tubes (PreAnalytix, BD), using standard methods and 
the manufacturer’s protocol (Qiagen QIAcube, Venlo, The Netherlands). RNA quality and quantity will be 
determined using the Bioanalyzer (Agilent). As per standard Qiagen’s instructions, RNA will be converted to 
cDNA using the RT2 First Strand Kit will be used to prepare cDNA, which is then mixed with RT2 SYBR Green 
Mastermix. We will use the PCR Array for Human Toll-Like Receptor Signaling Pathway (Qiagen, USA) on the 
Roche Lightcycler 480 (384-well block). Relative gene expression will be determined using the delta delta Ct 
method.  
Statistical analysis: A three-way 2 by 2 by 2 mixed model ANOVA will be performed for 2 within group factors 
(baseline vs. post-RIC) (active vs. shame) and one between group factor (able-bodied vs. cSCI) to compare the 
gene expression intensity. If the data is not normally distributed and the assumptions of the ANOVA are not met, 
Wilcoxon signed rank tests will be used instead. Post hoc pairwise comparisons will be performed using the 
Bonferroni adjustment, if there are any main or interaction effects within the three independent variables (group, 
active/sham RIC and baseline vs. post-RIC). 
Potential Pitfalls/Alternative approaches/Future Directions: We propose to use standard gene 
expression profiling techniques and we do not anticipate technical difficulties with the approach. If we do not 
observe changes in gene expression of the TLR signaling pathway, we can use RNA from the samples for RNA-
seq to obtain a broader and unbiased gene expression profile.  Initial RNA-seq runs could be limited to 8 million 
reads/sample, 100bp single end, which would yield a general overview of relative changes in gene expression 
of the high to moderately expressed genes. If the initial pilot data look promising, then we would seek funding to 
perform a fuller RNA-Seq profiling. 
 
Aim 3: To determine changes in heart rate (HR), blood pressure (BP) and oxygen saturation (SaO2) 
during active versus sham RIC in individuals with incomplete cSCI and able-bodied subjects. 
Hypothesis 3A:  There will be no difference in HR, BP and SaO2 (pulse oximeter on the finger of the target 
arm) responses among baseline, inflation phase, deflation phase and post-RIC during active and sham RIC 
in persons with SCI and able-bodied controls. 
 

Although RIC has been shown to be safe in the healthy able-bodied population as well as in individuals with 
heart disease and critically ill patients with subarachnoid hemorrhage39,40,59, there are no data describing the 
safety of RIC in persons with SCI. The SCI population, particularly those with cSCI, have widespread sensory 
impairment, including a limited ability to feel pain/discomfort. In addition, damage to the ANS after cSCI 
contributes to cardiovascular dysregulation and may alter hemodynamic responses to RIC. Several studies60–63 
have reported stable HR and BP responses before and after RIC not just in healthy participants but also in 
participants with heart diseases or vascular  stenosis. The BP responses even remained unchanged during the 
whole course of RIC in able-bodied participants and in participants with stable angina pectoris60,62. However, the 
sympathetic hypoactivity after cSCI might result in altered or delayed hemodynamic responses, possibly leading 
to fluctuation of HR and BP. Therefore, we will real-time record HR, BP and SaO2 on the contralateral arm and 
document the pain scale and any adverse effects during RIC. 
 
Method: During the 50-minute active and sham RIC (5 cycles of 
5 min inflation plus 5 min deflation), beat-to-beat HR, RR and SaO2 
will be monitored in real-time and digital signals will be stored on a 
computer hard-drive for subsequent analysis. Electrocardiogram - 
A 3-lead ECG (UFI: model RESP 1, Morro Bay CA) will be used to 
measure beat-to-beat HR during testing.  Electrodes will be placed 
at the right and left clavicle and in the V-5 position; data will be 
recorded from V-5. Finger Arteriolar Blood Pressure - Beat-to-
beat BP will be continuously monitored from the left middle or ring 
finger 
using photoplethysmography 
(FMS: Finometer, Pro; 
Amsterdam, Netherlands).  HR and finger arteriolar BP will be 
viewed in real time on a computer screen and will be stored for 
offline analysis using customized programs written with LabView 
graphical software.  Brachial Blood Pressure and Oxygen 
Saturation (SaO2) - Brachial BP and SaO2 will measured by a trained technician using a standard adult BP cuff 
(GE Healthcare Information Technologies, Milwaukee, WI) with a finger pulse oximeter at 1 minute intervals 
during administration of the sham and RIC conditions. The peak HR, BP and the minimal SaO2 in baseline, 
inflation phase, deflation phase and post-RIC will be reported for statistical analysis.  
 
 
 
 
Statistical analysis: Changes from baseline in HR, BP and SaO2 will be compared following RIC and Sham 
conditions in the cSCI and Able-bodied groups separately using a 2 (RIC, Sham) by 4 (baseline, inflation, 
deflation and post-RIC) repeated measures ANOVA to measure the hemodynamic responses for the within 
subject variability, and to determine main and interaction effects with Tukey post-hoc analyses. If the data is not 
normally distributed and the assumptions of the ANOVA are not met, Wilcoxon signed rank tests will be used 
instead. Post hoc pairwise comparisons will be performed using the Bonferroni adjustment, if there are any main 
or interaction effects within the two independent variables. The pain scale will be also compare with the same 
ANOVA model. 
 
Project timeline 
 
The IRB protocol will be submitted within the first month of funding notification. We expect to obtain the full approval 
within two months. We estimate one participant with SCI and one able-bodied control every two months, so the 
total enrollment period would be completed in about 16 months. We will begin the data analysis after the first two 
or three participants and continue to examine subject responses and modify the protocol if and when necessary. 
During the final quarter of the funding period, we will prepare a manuscript to disseminate the findings. 
 
Figure 3. The equipment configuration of testing HR 
variability, respiratory rate and blood pressure 
changes during RIC/Sha conditioning.