Treatment With Romosozumab Versus Denosumab to Improve Bone Mineral Density and Architecture in Subacute SCI
Phase: PHASE4
Conditions: Osteoporosis, Spinal Cord Injuries
Sponsor: James J. Peters Veterans Affairs Medical Center

08/30/2022 Version 4 
STUDY PROTOCOL with STATISTICAL ANALYSIS PLAN 
TITLE OF STUDY: Treatment with Romosozumab versus Denosumab to Improve Bone 
Mineral Density and Architecture in Subacute SCI 
NCT# NCT05101018 
2/21/2025 
PI: Christopher Cardozo, MD 
Co-investigators: Michael LaFountaine, Ed.D; Ann M. Spungen, Ed.D; Christopher M. 
Cirnigliaro, Ph.D; Noam Y. Harel, MD, Ph.D; John Handrakis, PT, DPT, Ed.D 

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Study Title: Treatment with Romosozumab versus Denosumab to Improve Bone Mineral Density and 
Architecture in Subacute SCI                
 
PI: Christopher Cardozo, MD    
Co-Investigators: Ann M. Sungen, EdD; Micheal LaFountaine, EdD; Christopher Cirnigliaro, PhD; Noam Y. 
Harel, MD, PhD                                                                             
 
ABSTRACT:  
Background: Sublesional bone loss after acute spinal cord injury (SCI) is sudden, progressive, and 
dramatic. After depletion of bone mass and the loss of architectural integrity, it may be difficult, if even 
possible, to restore skeletal mass and strength. Romosozumab is a human monoclonal anti-sclerostin antibody 
bone anabolic agent that recently gained FDA approval to treat osteoporosis in postmenopausal women. This 
study will test the ability of romosozumab administered in FDA-approved therapeutic doses for 12 months to 
prevent loss of BMD to regions of interest of the lower extremities in persons with subacute SCI; attention will 
be focused to the knee region (distal femur), but the proximal tibia and hip regions will also be acquired and 
analyzed. The ability of denosumab to preserve the gains in BMD attained with romosozumab will be 
determined.The romosozumab + denosumab group will be compared to a group that receives 24 months of 
denosumab. Objective: In persons with acute/subacute motor-compete SCI (<6 months since SCI):The 
primary objectives in the intervention group are to maintain baseline values of sublesional distal femur aBMD 
at 12 months after single drug therapy (12 months of romosozumab) and at 24 months after sequential dual 
drug therapy (12 months of romosozumab followed by 12 months of denosumab). This dual drug intervention  
group will be compared to a group that receives denosumab for 24 months; each active drug group will be 
compared to a historical control (placebo) group. Setting: James J. Peters VA Medical Center (JJPVAMC) and 
Kessler Institute for Rehabilitation (KIR) (each facility will perform patient enrollment and study procedures). 
Design: A prospective, randomized clinical trial. Participants:  Fourty (40) subjects with subacute SCI (≤6 
months) motor complete and incomplete SCI who have been admitted to JJPVAMC or the KIR will be recruited 
for participation in the study.  The age of study participation will be males and females, between the ages of 18 
and 55 years old. Main Outcome Measures: Primary outcome measure will be areal bone mineral density 
(aBMD; by DXA) of the distal femur at 12 and 24 months. Funding Source: (New York State Department of 
Health (NYS DOH): Grant # DOH01-C34461GG-3450000)    
 
1. Hypothesis  
 
In persons with subacute motor complete and incomplete SCI who are injured less ≤6 months and have been 
randomized to receive either 12 months of romosozumab followed by 12 months of denosumab or 24 months of 
denosumab (comparitor group). Each of the active drug intervention study groups will each be compared to a 
historical control group that has been composed of participants from the identical study sites who were enrolled 
in the study with almost identical entrance criteria. The hypothesis is that areal bone mineral density (aBMD) will 
be maintained for all regions of interest (ROI) at the specified time points post baseline with active drug 
treatment—that is, romosozumab or denosumab, regardless of which agent is administered, as opposed to 
marked and progressive loss of BMD in the historical control group: 
a. Primary hypotheses: 
i. At 12 month, 80% of the intervention (active drug) groups and 7% of the historical control 
(placebo) group will maintain ≥90% of baseline distal femur aBMD. 
ii. At 24 months, 80% of the intervention groups (12 months of romosozumab + 12 months 
of denosumab or 24 months of denosumab) and 7% of the historical control (placebo) 
group will maintain ≥90% of baseline distal femur aBMD. 
b. Secondary hypotheses: 
At 12 and 24 months, ≥90% of baseline aBMD at the other ROIs (e.g., total hip, femoral 
neck, proximal tibia, and calcaneus) will be maintained in 80% of the intervention (active 
drug) and 7% at these ROI at 12 and 24 months in the historical control group. 
c. Exploratory hypotheses: 
i. Microarchitectural changes measured by peripheral quantitative computed tomography 
(pQCT) by will comparable to the aBMD changes at the distal femur and the other ROIs. 

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ii. Level of suppression of C-telopeptide (CTx) will correlate with preservation of aBMD, 
integral volumetric BMD (vBMD) and trabecular BMD (tBMD) at the ROIs at 12 and 24 
months. 
 
2. Study Objectives (primary, secondary, exploratory) 
 
In persons with acute/subacute motor complete and incomplete SCI (<6 months since SCI): 
 
The primary objectives in the active drug intervention groups are to maintain baseline values of sublesional 
distal femur aBMD at 12 months (12 months of romosozumab or 12 months of denosumab) and at 24 months 
after 12 months of romosozumab + 12 months of denosumab administration or 24 months of denosumab 
administration.  The rationale for 90% preservation of aBMD at 12 and 24 months, rather than 100% preservation, 
is that the dose of romosozumab and/or denosumab may not be sufficient to prevent complete bone resorption 
in all subjects.  
 
The secondary objectives in the active drug intervention groups are to maintain 90% of baseline aBMD values 
at the femoral neck, total hip, proximal tibia, and calcaneus at 12 and 24 months of drug therapy.  
 
The exploratory objectives are to demonstrate that microarchitectural, vBMD and tBMD changes are 
comparable to changes in aBMD in the ROIs in both groups.  Additional exploratory aims are to evaluate the 
magnitude of changes in bone biomarkers (P1NP & CTx) in relation to the ROI of the sublesional bone.  In the 
romosozumab group, it is hypothesized that the magnitude of increase in P1NP coupled with the suppression of 
CTx will correlate with the most favorable changes in the skeletal endpoints (aBMD, vBMD, and tBMD at 12 
months); those participants who have the greatest suppression in CTx from 12 months to 24 months will have 
the greatest preservation at the ROIs for aBMD, vBMD, and tBMD at 24 months. In the denosumab group, those 
participants who have the greatest suppression in CTx from baseline to 24 months will have the greatest 
preservation at the ROIs for aBMD, vBMD, and tBMD at 24 months. 
 
3. Study Endpoints (primary, secondary, exploratory) 
 
Primary Endpoints:  Distal femur aBMD values at 12 and 24 months. 
 
Secondary Endpoints:  Total hip, femoral neck, proximal tibia, and calcaneus aBMD at 12 and 24 months. 
 
Exploratory Endpoints:  ROIs for microarchitectural, vBMD, and tBMD changes at 12 and 24 months. Sum CTx 
values (summed up to and including 12 and 24 months) in relationship to aBMD, vBMD, tBMD at the ROI and 
microarchitectural changes at the distal femur. 
 
The ROIs to be studied are the hip, knee and calcaneus.  DXA will be used to measure aBMD at the hip and 
knee. pQCT will be used to measure knee and ankle vBMD, tBMD and microarchitecture at the distal tibia. 
 
BACKGROUND:   
There is no practical treatment to prevent the severe loss of sublesional bone in persons with 
acute/subacute spinal cord injury (SCI) until recently when our group demonstrated in a randomized, placebo 
controlled clinical trial that denosumab administration preserved BMD at ROI in the lower extremities. The 
objective of the proposed work is to determine whether administration for 12 months of romosozumab (the 
maximal length of treatment approved by the FDA), a recently FDA-approved bone anabolic drug, followed by 12 
months of denosumab (a potent anti-resorptive agent) will maintain bone mass at the knee in subjects with 
subacute SCI compared to 24 months of denosumab administration. It is possible, and even likely, that if 
romosozumab or denosumab does preserve bone mass that these gains in aBMD will be fairly rapidly lost once 
treatment is discontinued.  As such, any gains achieved in bone mass from active drug administration will be 
attempted to be preserved with treatment for an additional 12 months with denosumab. Preservation of bone 
below the level of injury would reduce morbidity associated with fractures and permit safer participation in upright 
rehabilitation activities.  

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Immobilization osteoporosis results from unloading of the skeleton, and the magnitude of bone loss is in 
proportion to time and degree to which the forces of ambulation are interrupted, and it leads to an increased 
risk of low-impact fractures, especially at the knee (e.g., distal femur and proximal tibia) in a wheelchair-
dependent population [1, 2]. The severity of bone loss may exclude individuals with SCI from being eligible to 
participate in rehabilitation programs designed to increased mobility and increase functional independence, 
which would be anticipated to result in further worsening of the disuse osteoporosis. In the VA Cooperative 
Study entitled “Exoskeletal-assisted Walking in Persons with SCI: Impact on Quality of Life,” 69 of 158 
(44%) of all screen failures from a total of 254 persons pre-screened for study participation were due to 
low bone mineral density (BMD) and/or prior fractures (interim analysis by PI).  
Thus, persons with chronic SCI represent a unique population that is permanently immobilized due to 
partial or complete paralysis of the lower extremities. To characterize the magnitude and specificity of post-SCI 
bone loss of the lower extremities over the initial years after paralysis, peripheral quantitative computed 
tomography (pQCT) was performed to monitor loss of trabecular and cortical bone compartments until steady 
state levels were once again established; investigators observed that the femoral and tibial epiphyses (e.g., 
predominantly trabecular bone) each declined by about half over the initial 2 to 3 years after SCI, whereas 
cortical bone in the femoral and tibia shafts decreased by about one-third over the initial 7 to 8 years after SCI 
[3]. Of note, low BMD of the epiphyseal trabecular region by pQCT has been associated with an increased risk 
of fracture [4]. In a study of persons with SCI, the risk of fracture at the femoral neck increased 2.2 and 2.8 
times for each 0.1 decrement in BMD or for each unit decrease in the standard deviation, respectively [5]. 
Thus, the vast majority of persons with SCI develop premature and extensive bone loss of the lower 
extremities, increasing the risk for low-impact fracture, especially in those with greater degrees of neurological 
impairment [6]. Moreover, these data support the use of BMD of the femoral epiphyseal region as a surrogate 
for predicting fracture risk. It should also be appreciated that those with SCI will continue to age and may be 
prescribed medications or make lifestyle modifications that will adversely affect vitamin D and calcium 
intake/metabolism and/or have endocrine dysfunction (e.g., depressed anabolic hormones: testosterone and 
growth hormone) [7, 8], which would serve to further aggravate bone loss of immobilization and further 
increase the risk of fracture [9]; albeit these effects would be anticipated to have a relatively minor impact upon 
skeletal deterioration than that of profound disuse.  
There are two broad classifications of agents that are currently FDA approved for the treatment of 
osteoporosis: bone anti-resorptive agents and bone anabolic agents. The anti-resorptive agents include 
bisphosphonates (e.g., alendronate, risedronate, ibandronate, tiludronate, pamidronate, and zoledronate) and 
an antagonist to receptor activator of nuclear factor kappa-B ligand (RANKL; denosumab). The anabolic 
agents that are currently FDA approved are 1-34 parathyroid hormone (e.g., 1-34 PTH; teriparatide), an analog 
of parathyroid hormone-related peptide (PTH-rp; abaloparatide), and a human monoclonal anti-sclerostin 
antibody (romosozumab). The bone biomarker studies that have been performed in persons who are in the 
chronic stage of SCI suggest that the skeletal regions are in a state of low bone turnover due to a permanent 
and marked reduction in the forces applied to the sublesional skeleton from upright posture and ambulation. As 
such, anti-resorptive agents alone may not prove to be effective in reversing bone loss in the~300,000 persons 
with chronic SCI in the United States [10]. Work to date has shown that rehabilitation strategies, such as 
locomotor training and electrical stimulation (ES), are labor-intensive to perform and marginally effective in 
preventing bone loss (e.g., bone mass will be regained only in the regions of the skeleton to which the forces 
have been applied, and only for the duration of the ES treatment) or reversing the bone loss that has occurred 
in persons with chronic SCI (e.g., the degree of improvement is relatively small and limited to the regions 
exposed to the forces of ES, and the benefit is lost once ES is discontinued). 
This study will test the ability of romosozumab for 12 months followed by administration of denosumab 
for 12 months to prevent loss of BMD to regions of interest of the lower extremities; the romosozumab group 
will be compared to the group that received 24 months of denosumab administration and a historical control 
(placebo) group. Attention will be focused to the knee region (distal femur), but the proximal tibia and hip 
regions will also be acquired and analyzed. In addition, the ability of denosumab to preserve the gains in BMD 
attained with romosozumab will be determined. 
 
Therapy with Bone Anti-Resorptive Agents: The mechanism responsible for the anti-resorptive action of 
bisphosphonates is inhibition of farnesyl pyrophosphate synthase, and later generation bisphosphonates 
interfere with isoprenylation of GTPases at the ruffled border of osteoclasts, preventing attachment of 
osteoclasts to the bone surface, halting resorption, and initiating cell death [11]. The efficacy of 

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bisphosphonates has been addressed in various clinical and preclinical models of immobilization [12-18].  
However, our experience, as well as work by others, has raised questions of the efficacy of bisphosphonates to 
prevent bone loss at the regions of interest in persons with neurologically more motor-complete forms of acute 
SCI [17-19]. It should be appreciated that other investigators have reported varying degrees of success with 
bisphosphonate administration in patients after acute SCI, but not at the knee in persons with motor-complete 
lesions, and there exist no reports of success in those with chronic SCI [15, 20-23]. 
Denosumab, a human monoclonal antibody of the IgG2 immunoglobulin isotype with a high affinity and 
specificity for binding RANKL to antagonize its action, represents a novel pharmacological approach to the 
treatment of osteoporosis. This agent has received FDA approval and is commercially available.  While being 
an anti-resorptive agent, the mechanism of action of denosumab, to inhibit the osteoclast is distinctly different 
from that of bisphosphonates. Denosumab has been demonstrated to be an effective agent in post-
menopausal osteoporosis in the Fracture Reduction Evaluation of Denosumab in Osteoporosis Every 6 Months 
(FREEDOM) Trial (36 months in duration), with reduction of fracture risk at several sites with associated 
increases in BMD and a marked and persistent reduction in markers of bone resorption [24]. In another report 
from the FREEDOM Trial, markers of bone resorption (serum C-telopeptide of type 1 collagen; CTx) were 
suppressed more rapidly (-80% to 90% at 6 months after each dose) and to a greater degree than those for 
bone formation, suggesting a tilt toward net bone formation [25]. Administration of denosumab every 6 months 
for 3 years has been demonstrated to increase BMD, decrease bone remodeling (a marker of bone resorption 
was suppressed in association with a reduction in a marker of bone formation, findings confirmed by bone 
histomorphometry), and reduce risk of fractures in postmenopausal women with osteoporosis [26]. 
Histomorphometic and biochemical bone marker findings suggest that the effects of denosumab on bone 
remodeling are more potent than those with bisphosphonates [26-29]. Trans-iliac crest bone biopsies 
performed after 5 years of denosumab therapy in the FREEDOM Trial Extension revealed normal mineralized 
lamellar bone—that is, normal bone quality; bone turnover was depressed by dynamic remodeling indices [30]. 
The most recent published follow-up of the FREEDOM Trial, which followed subjects for 10 years (in these 
subjects, administration of denosumab was begun at the start of the study and continued for the next 7 years) 
or 7 years [in these subjects, administration of denosumab began after the first 3 years of the study (when 
these participants received placebo) and then subjects received active agent for the next 7 years], 
demonstrated continued low bone turnover by circulating metabolic bone markers, a continuous and steady 
increase in BMD at skeletal sites measured, and low fracture rate for vertebral and non-vertebral fractures [31, 
32].  
Anti-resorptive agents have been used to preserve and extend the effect of anabolic agents on bone in 
postmenopausal osteoporosis [33-36]. Prescription of these agents after bone anabolic agents is rapidly 
becoming the standard of practice. The investigators will test this approach to preserve and, possibly, to 
extend, gains in BMD in regions of interest (ROI) in the proposed work. 
The only published work to date addressing the efficacy of the administration of denosumab in 
individuals with SCI was performed by Gifre et al. [37]. Fourteen persons were studied who had a mean 
duration of injury of 15 months (range: 8-21 months); thus, it may be assumed that the sublesional skeleton in 
this SCI cohort was still in a rapid state of bone resorption [37]. Treatment with denosumab (60 mg at baseline 
and at 6 months) was for 12 months. Compared to baseline values, a slight increase in BMD at the hip (total 
hip=2.4±3.6%; femoral neck=3±3.6%) was observed, which is a remarkable finding because a continued loss 
in BMD would have been anticipated without drug intervention. With treatment, there was a profound reduction 
in bone turnover, as determined by suppression of biochemical markers of bone resorption and formation. 
Thus, in individuals who averaged ~1.5 years after acute SCI, the predominant mechanism for the observed 
treatment benefit with denosumab administration may be assumed to be prevention of further bone 
deterioration at the hip rather than bone accrual. Our group has recently broken the randomization blind and 
found that denosumab has successfully prevented sublesional bone loss after acute SCI (treatment initiated  
within 3 months of acute SCI), which would also suggest that this agent would act to preserve bone gain in 
those with chronic injury. If the balance of resorption to formation could be tilted to net formation, bone loss in 
persons with chronic SCI may be favorably affected with an anti-resorptive medication but, because the 
skeleton below the level of lesion is in a low turnover state, it may take several years to observe an increase in 
BMD at ROI. Thus, an approach to increase bone formation with an anabolic agent for bone should be 
considered prior to the administration of an anti-resorptive agent. 
 

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Therapy with Bone Anabolic Agents: There are two classes of commercially available anabolic agents (e.g., 
the ability to stimulate osteoblast activity) indicated for the treatment of osteoporosis: PTH/PTH analogs or 
sclerostin antagonists. On April 9, 2019, romosozumab, a human monoclonal anti-sclerostin antibody was 
approved by the FDA to treat postmenopausal osteoporosis. 
The anabolic effects of teraparatide occur by two mechanisms, as determined by metabolic bone 
markers and histomorphometry [38]. One mechanism is the direct stimulation of bone formation that occurs in 
active remodeling sites and on the surfaces of bone previously inactive, or modeling-based bone formation. 
The second mechanism is an increase in new remodeling sites. It is appreciated that both these mechanisms 
are responsible for the increase in BMD observed. The efficacy of teriparatide to prevent bone loss at time of 
acute SCI, or to restore bone lost in those with chronic injury, has not been adequately addressed in clinical 
trials, although preliminary work followed by a more comprehensive study by one group of investigators has 
been reported. A pilot study was essentially negative with teriparatide administration and mechanical 
stimulation (e.g., robotically-assisted gait training) in 12 chronically injured non-ambulatory subjects [39]. An 
article by Edwards et al. randomized individuals with chronic SCI into 3 groups for a 1 year intervention clinical 
trial: teriparatide alone, teriparatide + vibration, or vibration alone, and then a 12 month open-label extension of 
the study; despite positive BMD changes of the spine, and modest changes to cortical bone at the knee, the 
authors concluded that the therapeutic effect was not of clinical significance for those with SCI [40]. When used 
to treat postmenopausal osteoporosis, abaloparatide appears to be more effective to increase BMD than 
teriparatide. The difference in action between these two drugs is especially evident for the appendicular 
skeleton [41]. Abaloparatide administration reduces vertebral fractures, similar to teriparatide, but treatment 
with abaloparatide also appeared to reduce nonvertebral fractures, a benefit which has not been observed with 
teriparatide therapy [42, 43]. 
Until April 2019, when the FDA approved romosozumab, an agent which represents a completely new 
class of medications to treat bone loss, teriparatide and abaloparatide were the only two pharmacological 
agents commercially available with the ability to stimulate osteoblast activity. Romosozumab was 
demonstrated to be more potent than teriparatide (i.e., teriparatide 20 µg/day vs. romosozumab 210 
mg/month) to increase BMD [44, 45]; treatment for one year with romosozumab significantly increased vBMD 
and bone mineral content (BMC) at the lumbar spine and total hip from baseline values compared with 
teriparatide [44]. After 12 months of romosozumab, strength of the proximal femur for a sideways fall 
significantly increased for romosozumab compared to teriparatide (3.6% versus -0.7%); compartmental 
analysis showed that that the increases in strength were associated with contributions from both cortical and 
trabecular bone compartments [45].There have been two Phase 3 clinical trials in postmenopausal women with 
osteoporosis that have tested the safety and efficacy of romosozumab [46, 47]. In the FRAME study, treatment 
with romosozumab reduced new vertebral fractures at 12 months compared to placebo. This reduction in risk 
of fracture was observed for two years in those who received romosozumab during the first year and then 
continued on denosumab during the second year compared to those who were on placebo the first year and 
denosumab the second year. At 12 months, romosozumab increased BMD at all sites tested (e.g., lumbar 
spine, total hip and femoral neck) compared to placebo; BMD progressively increased for two years in 
participants on active agents [46]. In the ARCH study, treatment with romosozumab for 12 months followed by 
12 months of alendronate reduced the incidence of new vertebral fracture at 24 months; at 12 and 24 months, 
BMD increased at the lumbar spine, total hip and femoral neck to a greater extent on romosozumab than those 
treated with alendronate [47]. The risk of clinical fracture, which was defined as a composite of symptomatic 
vertebral fracture and nonvertebral fracture, was also lower in the romosozumab group [47]. After initiating 
romosozumab administration, propeptide of type 1 procollagen (P1NP), a marker of bone formation, was 
increased early (50-100% increase compared to baseline values at 1 and 3 months) with a return to pre-
treatment values by 6 months; C-telopeptide (CTx), a marker of bone resorption, was suppressed early and 
remained low for the duration of drug treatment [48]. 
Our group performed preclinical studies of sclerostin antagonism or genetic ablation in acute and 
chronic rodent models of SCI [49-51]. In a rodent model, anti-sclerostin antibody (reagent provided by Amgen) 
was begun 7 days after spinal cord transaction (significant bone loss occurs as early as 7 days after SCI in the 
rat model) and the agent was then administered weekly over the next 7 weeks; sclerostin antagonism 
completely prevented and/or reversed the marked bone loss that occurred in the untreated SCI animals [49]. 
Of note, the osteocyte appeared far more viable in the romosozumab-treated animals than in the control 
animals, which suggests that long-term bone health may be improved by improving the Wnt signaling pathway, 
a result over and above that of preservation of aBMD alone. Sclerostin knockout (SOST-KO) mice (animals 

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were provided by Amgen) that underwent spinal cord transaction were protected from the severe sublesional 
bone loss that occurred in wild type mice with acute SCI [50]. To test whether sclerostin antagonism could 
reverse bone loss that occurred after chronic motor-complete SCI, rats were treated with anti-sclerostin 
antibody or vehicle for 8 weeks 12 weeks after complete spinal transection [51]. In SCI rodents that received 
normal saline injections, there was significant reduction in BMD, estimated bone strength, and deterioration of 
bone structure at the distal femoral metaphysis at 20 weeks whereas animals that received anti-sclerostin 
antibody had remarkably restored BMD, bone structure, and bone mechanical strength [51]. There have been 
no clinical trials on the effect of sclerostin antagonism in persons with acute or chronic SCI. 
 
Considerations Relevant to Study Design: Patients with SCI tend to more frequently fracture at the distal femur 
and proximal tibia than at the hip or other sublesional regions [1, 2]. As such, pharmacologic intervention 
studies that have noted preservation of BMD and bone strength at the hip, without regard to BMD changes at 
the knee, are of lesser relevance to clinicians caring for patients with long-standing SCI [17, 19, 20, 52]. In the 
work proposed, the primary endpoints are areal BMD (aBMD) at the distal femur after 12 months of 
romosozumab treatment and after 24 months of sequential dual drug treatment (12 months of romosozumab 
treatment followed by 12 months of denosumab treatment). Because of the observed efficacy of denosumab to 
prevent bone loss at the knee in persons with recent SCI (manuscript in preparation), the comparison group 
will be 12 and 24 months of denosumab administration; a historical control (placebo) group will also be used to 
compare the two active drug groups for efficacy to preserve aBMD at the knee. 
Subjects with subacute SCI are proposed to be studied with a 1:1 romosozumab to denosumab ratio in 
randomization to test the efficacy and safety of romosozumab to prevent SCI-related changes in aBMD at the 
distal femur; the proximal tibia, hip regions, and calcaneus will also be captured by DXA. Volumetric BMD 
(vBMD) and trabecular BMD (tBMD) of the distal femur and the proximal tibia will be acquired as exploratory 
endpoints, along with trabecular microarchitectural changes of the distal tibia (the only skeletal site that can 
acquire these skeletal parameters) by pQCT.  
BMD was chosen as a surrogate endpoint in the proposed work because BMD predicts fracture in 48 to 
89% of cases [53].  It has been reported by Lazo et al. that the risk of fracture at the femoral neck in men with 
SCI increased 2.2 and 2.8 times for each 0.1 decrement in BMD or for each unit decrease in the standard 
deviation, respectively [5];  as such, BMD may be considered as a surrogate marker for risk for fracture. Unlike 
clinical trials that are designed to test the efficacy of anti-osteoporotic agents in women with postmenopausal 
osteoporosis that have the statistical power to determine differences in fracture incidence as an endpoint, the 
use of BMD as a surrogate endpoint for fracture is necessary when investigating immobilization osteoporosis in 
those with chronic SCI due to the markedly smaller, less accessible subject population. Thus, to designate 
fracture as our primary study endpoint would require a sample size of at least several hundred SCI subjects 
who would be followed for at least 5-10 years, which is not a practical alternative to obtaining BMD 
measurements at the distal femur as our endpoint.  
Hypercalciuria, and infrequently, hypercalcemia are recognized complications of acute immobilization 
secondary to SCI. However, hypocalcemia is a recognized potential complication of treatment with 
romosozumab because calcium is being more rapidly and extensively deposited in the skeleton as new bone. 
As such, participants will be determined to have sufficient serum levels of vitamin D, and then monitored for 
serum vitamin D levels and calcium intake during the length of the study. 
Because of the regulatory limit of 12 months to treat with romosozumab, and the knowledge that gains 
in bone health have a likelihood of being lost when therapy is terminated, it is now routine clinical practice to 
place patients on an anti-resorptive therapy when the bone anabolic agent is discontinued. Several studies 
have demonstrated that treatment with denosumab after treatment with romosozumab results in positive 
increases in BMD at the lumbar spine and hip, as well as a continued reduction in risk of fracture [35, 36, 48]. 
A such, ther proposed prospective, randomized controlled trial will test whether romosozumab transitioned to 
denosumab can prevent sublesional bone loss in persons with chronic SCI who have lost substantial bone 
mass yet are deemed still to have sufficient bone mass to respond to anabolic-bone therapy.  
 
The work proposed in this application will attempt to identify a second agent (romosozumab) 
that will be available as an efficacious clinical option to prevent sublesional bone loss in individuals 
with subacute SCI.. Sequential addition of anti-resorptive therapy (e.g., with denosumab) will test as to 
whether lower extremity skeletal ROI will be maintained in those with subacute SCI. 
 
The PI and his collaborators have considerable experience in conducting clinical trials that have 
evaluated the efficacy of agents to prevent bone loss in patients with acute and chronic SCI [17, 18], 

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addressing the pathophysiological changes associated with disuse osteoporosis [54-56],  and performing bone 
imaging by employing DXA and pQCT methodologies in the acute and chronic SCI populations [57].  Previous 
work demonstrated the lack of efficacy of bisphosphonates to preserve BMD at the knee (e.g., BMD of the 
distal femur and proximal tibia) in persons after acute SCI; however, hip BMD was observed to be better 
preserved after zoledronic acid administration [17]. Biochemical markers of bone function have also been 
performed in several past and current investigations conducted by the PI [17, 18].  
 
Replacement and/or Maintenance of Adequate Vitamin D and Calcium Levels: To study the efficacy of an 
intervention on bone, and also because romosozumab may cause a fall in the serum calcium concentration in 
vitamin D deficient individuals or those on a calcium restricted diet, it is requisite that calcium intake be 
adequate and vitamin D levels be maintained within the normal range. By adequately replacing and/or 
maintaining sufficient intake, the possible confounding effects of calcium/vitamin D deficiency on the skeletal 
endpoints being tested after intervention will be removed from consideration. Thus, it is vital that vitamin D 
levels remain in the normal range (≥30 ng/ml) and calcium intake be adequate so as not to impede bone 
mineralization [58, 59]. Levels of vitamin D will be monitored at baseline, 12, and 24 months. 
  
 
PRELIMINARY STUDIES AND CURRENT STATUS OF THE FIELD 
 
 
Studies in our unit showed that sclerostin 
antagonism in rats or sclerostin knockout mice after 
acute spinal cord transection prevented the loss of 
BMD and several of the adverse microarchitectual 
changes [49, 50]. The work proposed in this 
application is to prevent the bone loss in persons 
with subacute SCI. To that aim, rats were studied 
that underwent complete spinal cord transection (or 
laminectomy) 12 weeks prior to the administration 
of anti-sclerostin antibody or placebo for 8 weeks 
[51]. The findings were dramatic to bone below the 
level of lesion. Animals that did not receive active 
treatment had a significant reduction of BMD, bone 
strength and deterioration of bone structure at the 
distal femoral metaphysis. The administration of 
anti-sclerostin antibody to SCI animals restored 
much of the BMD, bone structure, (Figures 1- 3), 
and bone mechanical strength. Furthermore, 
sclerostin antagonism markedly improved 
osteocyte number, cell spatial orientation, and 
number of dendritic projections, which strongly 
suggests an improvement in osteocyte viability, 
function, and health 
 
It is our hypothesis, strongly supported by recent literature, that romosozumab treatment in persons 
with subacute SCI will be the most potent approach to improve sublesional bone mass and mechanical 
strength. One may also speculate that in addition to the improved aBMD of the lower extremities with 
sclerostin antagonism after acute immobilization that long-term bone health will be favorably impacted 
because of the dramatic improvement in osteocyte viability. 
 
 
 
 
 
Figure 1. Sclerostin antibody reversed the loss in BMD 
after chronic SCI. Drug intervention was initiated in rats 12 
week post spinal cord transection. 

8 
8/30/2022 V.4 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 2. Effects of sclerostin antibody on trabecular bone architecture of 
the distal femur metaphysis. 
Figure 3. Effects of sclerostin antibody on cortical architecture 
of the midshaft of the femur. 

9 
8/30/2022 V.4 
 
 
RESEARCH DESIGN AND METHODS:   
A prospective, randomized, open label two drug clinical trial will be performed to test the efficacy and 
safety of romosozumab administration compared to denosumab for preservation of aBMD at ROI of the lower 
extremities; 12 months of denosumab will follow each of the initial administration of these agents for 
maintenance of aBMD. An IND will be obtained from the FDA for the use of these agents in the study protocol. 
 
Study Population: 
Forty (40) subjects with acute/subacute SCI are proposed to be studied with a 1:1 ratio of randomization of 
romosozumab or denosumab for the first 12 months; for the next 12 months, each group will receive 
denosumab. The anticipated dropout rate is 30%, with approximately 30 subjects completing the entire study 
protocol. The study will be performed at the National Center for the Medical Consequences of Spinal Cord 
Injury, JJP James J. Peters VA Medical Center, Bronx, NY, and Kessler Institute for Rehabilitation. A 
convenience sample of patients with subacute SCI who are affiliated with the SCI Service at the JJP VA 
Medical Center or the Kessler Institute for Rehabilitation will be potential participants for study enrollment. The 
initial ~32 months will be used to recruit, enroll, treat subjects with active agents (Post study plan: Assuming 
that denosumab successfully retains or increases BMD achieved by 12 months of romosozumab 
treatment, the subject’s primary care provider will be informed of the study outcome and provided the 
opportunity to consider continuing therapy with denosumab or another anti-resorptive medication after 
the subject has completed the study in an effort to preserve the gains in BMD achieved with the 
experimental dual drug intervention.). The remaining ~4 months of the study will be used to complete data 
collection and perform data analysis. The study will require four years to complete. 
 
RESEARCH DESIGN AND METHODS:   
A prospective, randomized, two drug clinical trial will be performed to test the efficacy of romosozumab 
administration for 12 months for preservation of BMD followed by 12 months of denosumab versus 24 months 
of denosumab administration. A historical control group will be compared to each active drug group. An IND 
will be obtained from the FDA for the use of these agents in the study protocol. 
 
Inclusion Criteria 
1. Traumatic motor-complete or incomplete SCI C4-L2 {International Standards for Neurological 
Classification of Spinal Cord Injury (ISNSCI) grade A-C (wheelchair dependent 100% of the time)};; 
2. ≤6 months; 
3. Males and females (e.g., premenopausal) between the ages of 18 and 55 years old; and 
 
Exclusion Criteria 
1. Active and/or history of coronary heart disease or stroke; 
2. Osteosarcoma (bone cancer);  
3. Long-bone fracture of the leg within the past year;  
4. History of prior bone disease (Paget’s hyperparathyroidism, osteoporosis, etc.);  
5. Postmenopausal women;  
6. Men with known hypogonadism (low functioning testes) prior to SCI;  
7. Anabolic therapy (drugs geared towards increasing BMD) longer than six months duration after SCI; 
8. Glucocorticoid administration longer than three months duration within the last year;   
9. Endocrinopathies (hyperthyroidism, Cushing’s disease or syndrome, etc.);  
10.  Severe underlying chronic disease (e.g., COPD, end-stage heart disease, chronic renal failure);  
11.  Heterotopic ossification (HO) of the distal femur (the knee end of the thigh bone). HO is a condition 
where bone tissue forms outside of the skeleton. If HO is found in any other area than the distal femur it 
will not prevent study participation. 
12.  History of chronic alcohol abuse;  
13.  Diagnosis of hypercalcemia (high levels of calciuuum in the blood);  
14.  Pregnancy;  
15.  Prescribed a bisphosphonate for heterotopic ossification (HO), or prescribed any other agent to treat 
osteoporosis other than calcium and vitamin D;  

10 
8/30/2022 V.4 
16.  Current diagnosis of cancer or history of cancer;  
17.  Prescribed moderate or high dose corticosteroids (>40 mg/d prednisone or an equivalent dose of other 
corticosteroid medication) for longer than one week, not including drug administered to preserve 
neurological function at the time of acute SCI; and 
18.  Life expectancy less than 5 years.  
 
 
Methods and Procedures   
Subjects will be informed verbally and in writing of the purpose of this study. Informed consent will be 
obtained from all subjects who agree to participate. If the subject is not able to provide written informed 
consent because of paralysis of the upper extremities, despite full mental capacity to provide verbal informed 
consent, written informed consent will be obtained from their legal surrogate. Subjects will be free to withdraw 
their consent at any time. Subject travel costs and a stipend for participation will be provided by the study. 
Standard rehabilitation care that is appropriate may be prescribed for patients with motor complete and 
incomplete neurological classifications, and may include range of motion exercises, mat activities, transfer 
training, activities of daily living, strengthening maneuvers, and use of a standing frame. Records will be kept 
confidential by linking subject data identifier numbers; the numeric identifier will be linked to the subject’s 
names using a separate key accessible only to the study coordinator and PI. A study investigator or research 
coordinator will enroll subjects, schedule patient travel, coordinate densitometry and blood/urine laboratory 
studies, collect data, and coordinate the responsibilities of all study subjects. Subjects will be contacted by 
phone or email at least every 2 weeks to assure compliance with drug treatment, confirm the level of upright 
activity, and as a method to maximize study retention. Because subjects will have motor complete and 
incomplete (ISNSCI grade A-C) SCI, they will not have the ability to walk without benefit of sophisticated 
upright rehabilitation modalities that, if engaged in prior to the study, may be continued during the duration of 
the study. In the absence of electrical stimulation of muscle groups, which is an exclusion criterion, there is no 
credible evidence that an upright ambulatory activity alone increases BMD of regions of the lower extremity. 
However, all individuals who are engaged in walking” activities will be recorded and analyzed for a possible 
effect that may be observed in combination with drug administration post hoc. At each visit, subjects will be 
interviewed by the research coordinator, and the use of alcohol or cigarettes will be recorded, and this 

11 
8/30/2022 V.4 
information will be analyzed post hoc for potential confounding effects; it is speculated that alcohol and/or 
cigarettes will have a negligible effect on the study endpoints when compared to the relatively large effect 
exerted by SCI and immobilization.  
 
The serum 25 hydroxyvitamin D level will be measured at baseline, 12, and 24 months to exclude a 
vitamin D deficiency/insufficiency. A deficiency/insufficiency of vitamin D will not disqualify a patient from study 
participation. If an absolute vitamin D deficiency/insufficiency is identified (<30 ng/ml), supplemental vitamin D 
4000 IU/d for 4 weeks will be administered (in those who have a vitamin D deficiency, it is anticipated that 
serum values will be raised  on average ~1 ng/ml for each 100 IU/day of vitamin D administered, or ~40 ng/ml 
for 4000 IU/d [60]; serial testing will be performed monthly until the serum 25 hydroxyvitamin D level is within 
the normal range, before reducing the dose to 2000 IU/day. If not vitamin D deficient, subjects will receive 2000 
IU vitamin D/day. All subjects will be instructed by nutritional evaluation and counseling to consume a normal 
calcium diet of 700-1,000 mg/day to assure sufficient calcium is available not to impede bone formation. 
 
Study Timeline: 
 
 
 
Romosozumab 210 mg SQ will administered at baseline and then each month subcutaneously (SQ) for 
12 months followed by denosumab for 12 months; in the comparator group, denosumab 60 mg SQ will 
be administered at baseline and 6, 12, and 18 months. Bone Biomarkers: serum C-telopeptide, serum 
osteocalcin, bone alkaline phosphatase, and carboxyterminal propeptide of type 1 procollagen. Calcium 
Metabolism: serum total and ionized calcium concentrations, 24-hour urine calcium, 25 OH-vitamin D 
(performed monthly during supplementation therapy), 1,25 (OH)2-vitamin D, and intact PTH. Endocrine 
Labs: serum thyroid function tests (T3, T4, & TSH), cortisol, total testosterone, calculated free 
testosterone, estradiol, growth hormone, insulin-like growth factor-1. 
 
Romosozumab or denosumab will be administered to enrolled subjects by a designated administrator. 
Subjects will be asked to visit the JJPVAMC or KIR once a month for 12 months to receive the monthly 
injection of romosozumab or biannual injection of denosumab. Romosozumab and denosumab will each be 
administered at the currently recommended dose by the FDA for the treatment of osteoporosis and is 
anticipated to be well tolerated, with the most frequently reported adverse events being injection-site erythema; 
arthralgias and headache have been reported to occur at rates ≥5% over that of placebo. Hypocalcemia has 
occurred, particularly in patients with severe chronic renal disease; during the treatment intervention, vitamin D 
levels will be checked at baseline, and 12 months with supplementation provided, if indicated, and subjects will 
be monitored throughout the study for adequate calcium intake. Safety laboratory values (calcium metabolism 
and general lab studies) will be drawn at 3 and 6 months and then at 6 month intervals for the duration of the 
study. At 12 months, measurements will be performed for calcium and bone metabolism, tBMD, vBMD, 
microarchitecture by pQCT at the distal tibia, and aBMD by DXA at the knee and hip ROI. Regardless of group 
assignment, all subjects will receive denosumab 60 mg SQ at months 12 and 18. The complete battery of 
imaging studies and blood work will be performed at 24 months. 
 
Participants will be allowed to enroll in other ambulatory rehabilitation clinical trials after the last administration 
of denosumab at the 18 month time point and pror to the final follow-up visit 24 months after randomization to 
treatment allocation. 
Month 
Baseline (0) 
1 
3 
6 
12 
18 
24 
Studies/Tests 
 
 
 
 
 
 
 
DXA  
X 
 
 
X 
X 
X 
X 
pQCT 
X 
 
 
X 
X 
X 
X 
Bioelectrical Impedance 
Spectroscopy (BIS): 
X 
 
 
X 
X 
X 
X 
Markers of Bone  
Formation/Resorption 
X 
X 
X 
X 
X 
X 
X 
Calcium Metabolism 
X 
X 
X 
X 
X 
X 
X 
General Laboratories 
X 
X 
X 
X 
X 
X 
X 
Endocrine Laboratories 
X 
 
 
 
X 
 
X 

12 
8/30/2022 V.4 
Pitfalls/Limitations 
The PI is an authority on bone disease in persons with SCI and highly experienced in performing the 
work proposed in this application. As such, no technical obstacles are anticipated. All the equipment and 
resources are, or will shortly be, in place to perform the study (the investigator has recently purchased a 
Stratec XCT 3000 pQCT scanner which will be delivered in December 2019). The most common hurdle to 
overcome in any clinical investigation is to meet the subject recruitment target. If there are not sufficient 
Veterans who satisfy the entrance criteria for recruitment at our VA facility, there are large numbers of potential 
subjects at the Kessler Institute for Rehabilitation, a premire rehabilitation facility to which the VA has an active 
Collaborative Research Agreement and maintains a staffed VA research unit. Although romosozumab has 
been well tolerated in the nondisabled population, it is conceivable that this medication may be less well 
tolerated in the SCI population. Every effort will be made to retain subjects in the protocol, but a high dropout 
rate may occur due to medication side effects or intercurrent illness over the length of the 2-year clinical trial, 
which commonly occurs in clinical trials with subjects with subacute SCI. If termination of study medication 
should occur, the subject’s data will be analyzed with that of their group assignment for the length of time that 
the participant was compliant with and adhered to drug therapy. An amendment for recruitment of additional 
subjects for study participation will be considered if a greater subject attrition rate occurs than expected. If no 
significant net difference between the drug groups is demonstrated, a negative result will suggest that either 
medication may be used to prevent bone loss after acute SCI, and that further research of each of these 
medications should be pursued in the chronic SCI population. The possibility that the knee does not respond to 
drug with preservation of aBMD but the hip exhibits a significant response, this too would be useful information, 
and stimulate further study with other classes of anti-osteoporotic agents to improve BMD at the knee. A 
noninferiority analysis will certainly be underpowered with 30 subjects randomized 1:1 to each drug group and 
an expected efficacy of each agent to preserve aBMD at the distal femur. Realizing this highly likely possibility, 
the analysis may still provide useful feasibility and proof-of-principle finding for future studies with a larger 
subject population sample.  
The absence of preliminary data in persons with SCI to support the efficacy of romosozumab to prevent 
bone loss in persons with acute SCI and the anticipated magnitude of the drug effect are the main limitations of 
the work proposed. Although data regarding the ability of romosozumab to prevent bone loss is not available in 
persons with SCI, this agent has been investigated extensively in the nondisabled population [46, 47]. In 
human trials, the efficacy of romosozumab (a bone anabolic agent) appears to exceed that of PTH (another 
bone anabolic agent, or its analog) at the lumbar spine in its potency to increase BMD and reduce fracture 
occurrence [44, 45, 61]. In addition, romosozumab has a beneficial effect on the appendicular skeleton, 
increasing BMD and reducing risk of long-bone fracture, unlike that reported for teriparatide, making 
romosozumab the preferred agent to test in the SCI population. As previously discussed, the femoral epiphysis 
and metaphysis have a relatively large component of trabecular bone, which one may anticipate would 
respond to romosozumab treatment in a similar manner as that of the lumbar spine, a skeletal region in post-
menopausal women that had a gain on average of ~10% BMD after treatment for 12 months [31, 35]. If 
romosozumab does prove to prevent bone loss, postponing this work will invariably result in further bone 
deterioration in persons with SCI, possibly rendering romosozumab therapy ineffective if initiated at a future 
date (e.g., it is the belief of the investigator that there must be sufficient bone mass/structure to permit 
meaningful improvement in bone because bone re-models appositionally). Because progressive lower 
extremity bone loss in the chronic SCI population will invariably limit weight-bearing rehabilitation options and 
place persons at increased risk of fracture even while performing activities of daily living, strong preclinical and 
clinical evidence exists that the approach proposed in this application has merit. Thus, the argument to obtain 
preliminary clinical data prior to funding this clinical trial is a not reasonable request because of the high cost of 
the medication and the length of time required to adequately test the dual drug intervention. 
 
Measurements: 
Dual Energy X-ray Absorptiometry (iDXA, GE Lunar): aBMD of ROI in the lower extremity (distal femur 
and proximal tibial; total hip & its subregions; calcaneus) are the study outcome measures. BMD will be 
performed at baseline, 6, 12, 18, and 24 months (the final scan will be performed after completing denosumab 
administration). The same GE Lunar iDXA bone densitometers with the same software packages are available 
at all three study sites (VA, Mount Sinai & Kessler). Cross calibration has been performed and demonstrated 
that the two devices are essentially identical. Dedicated ISCD certified technicians with more than 15 years of 
experience will acquire DXA images. Imaging will be performed with the subjects lying on a padded tabletop to 

13 
8/30/2022 V.4 
acquire regional BMD of the knee (e.g., distal femoral and proximal 
tibial epiphyses using the orthopedic knee software commercially 
available from GE Lunar) and hip (total dual hip and subregions). The 
hip has been investigated by prior groups and is a region routinely 
acquired; the hip also has accepted values for T-score and Z-scores, 
which have not yet been reported for the knee. The starting point to 
acquire the knee is set on the tibia approximately 10 cm distal from the 
edge of the patella, with the scan field extending to the epiphysis and 
metaphysis of the distal femur. This software acquisition and analysis 
method has established reliability and validity in persons with SCI [62] 
and has been used previously by our group to successfully monitor 
changes in BMD at the knee [17] (Figure 5). In accordance with ISCD 
guidelines, serial DXA scans for precision error were performed and 
expressed as the least significant change (LSC–CV%) at the 95% level 
of confidence to assess and quantify for changes attributed to random 
machine error and technician variability [63, 64]. The LSC for the 
femoral neck, total hip, distal femur epiphysis, and proximal tibia 
epiphysis was obtained by performing two scans on 30 SCI subjects 
with SCI using an on-and-off-the-table method, yielded a LSC–CV % as 
follows: femoral neck = 4%; total hip = 3%; femoral epiphysis = 4%; and 
tibial epiphysis = 5% [17]. DXA requires a very low dose of radiation. It 
is estimated that all of the DXA measurements combined will be 
approximately 30-45 μSv of radiation exposure per visit (for 
comparison, a routine chest x-ray is an approximately 60μSv).  
 
Peripheral Quantitative Computed Tomography 
(pQCT): Imaging will be performed at baseline and 
then at 6 month intervals for the duration of the 
study protocol. Imaging in the proposed study will 
be performed at either the JJP VA Medical Center 
and/or Kessler Institute for Rehabilitation; both 
sites will have the identical device with identical 
software packages (Stratec XCT 3000 scanner; 
STIM designs, Carmel, CA). A scout view will be 
obtained for locating the desired scan 
positions.  Measurements of bone geometry and 
vBMD will be made at the epiphyseal region at the 
4% femoral length proximal to the knee joint; three 
additional tibial sites will be obtained by imaging 
proximal (e.g., superior ankle joint) to distal: 4%, 
38%, (for cortical BMD), 66% and 96% of tibial 
length. Slice thickness of 2.4 mm and default voxel 
size of 0.5 mm will be acquired, as previously 
described [65, 66]. The root mean square-
coefficient of variation (RMS-CV%) for pQCT are 1 
to 2.3% for vBMD, tBMD and geometric measures at the distal femur [67]. The following parameters will be 
obtained: total BMC, total vBMD (mg/cm3), trabecular BMC (mg), trabecular BMD (mg/cm3), total area (mm2), 
cortical BMC (mg), cortical volumetric BMD (mg/cm3), cortical area (mm2), cortical thickness (mm), polar moment 
of inertia (mm4), and stress-strain index (mm3). Radiation exposure from pQCT is <1.0 µSv. In addition to acquire 
these parameters, the higher resolution mode of the Stratec pQCT enables the calculation of the trabecular 
microarchitecture at the distal tibia region using a custom software program. Through the use of a custom software 
package (pQCT OsteoQ, Inglis Software Solutions Inc., Hamilton, ON) combined threshold-based and region-
growing algorithms will be used to measure trabecular microarchitecture [trabecular separation (Tb.Sp), bone 
volume fraction (BV/TV), trabecular number (Tb.N), and trabecular thickness (Tb.Th)]. Short term validity of bone 
microstructure measurements have demonstrated a precision error of less than 5% [68].   
Table 2.  Outcome Measurements for Bone Mineral 
Density Regions of Interest for DXA and pQCT 
Regions of 
Interest 
DXA 
pCT 
aBMD vBMD tBMD 
Micro- 
architectural 
Hip 
  
  
  
  
Femoral neck 
x 
  
  
  
Total hip 
x 
  
  
  
Knee 
  
  
  
  
Distal femur 
x 
x 
x 
  
Proximal tibia 
x 
x 
x 
  
Ankle 
  
  
  
  
Distal tibia 
  
  
  
x 
Calcaneus 
 
 
 
 
 
x 
 
 
 
Table 2 Legend.  DXA = dual photon x-ray absorptiometry; 
pQCT = peripheral quantitative computed tomography. 
Figure 5. Image of the knee 
using the manufacturer 
Orthopedic Knee software and 
the validated method to capture 
aBMD of the (1) distal femoral 
epiphysis, (2) distal femoral 
metaphysis, and the (3) 
proximal tibia epiphysis.    

14 
8/30/2022 V.4 
 
Bioelectrical Impedance Spectroscopy (BIS): Bioelectrical-Impedance Spectroscopy (BIS) is another method of 
measuring body composition. The BIS measures fat mass, fat free mass, intra and extracellular fluids via a small, 
insensible (cannot be felt), electrical current that is sent through the hands and feet. The electrical current sends a 
frequency between 4 and 1000 kHz, which will collect approximately 256 data points. The BIS also allows us to 
take segmental records that include the right arm, left arm, right leg or left leg and determine the hydration in each 
of these segments. The device has a tetra polar set of leads, which are attached to self-adhesive skin electrodes 
on the hands and feet by means of alligator clips. The subject will have this measurement performed while lying on 
the DXA table for ten minutes prior to the start of this test. The duration of this procedure is less than 5 minutes. 
 
Biochemical Bone Markers: The levels of the circulating biochemical markers of bone resorption and formation 
before (baseline) and after initiating romosozumab therapy (1, 3, 6, and 12 months), and then after 6 and 12 
months of denosumab administration. These biochemical bone markers will be determined employing methods 
that have been used previously, as described by our investigators [17, 18]. Levels of serum C-telopeptide 
(CTx) (ABclonal. 86 Cummings Park, Woburn, MA) will be measured as the biomarker of bone resorption. 
Serum osteocalcin (Alpco Diagnostics, Salem, NH), bone alkaline phosphatase (MyBiosource, Inc., San Diego, 
CA) and propeptide of type 1 procollagen (P1NP) (MyBiosource, Inc., San Diego, CA) will be measured as 
biomarkers of bone formation [17, 18]. Romosozumab should increase biomarkers of bone formation, 
representing an increase in activity and number of osteoblasts, and suppress the biomarker of bone resorption. 
 
Calcium Metabolism Studies: Serum total and ionized calcium concentration, 24-hour urine calcium, 25 OH-
vitamin D level (DiaSorin Inc. Stillwater, MN), 1,25 (OH)2-vitamin D level (Quest Diagnostics), and intact PTH 
level (ALPCO Diagnostics, Salem, NH) will be measured employing methods used previously by our 
investigators [17, 18]. The serum 25 OH-vitamin D level will be measured at baseline and 12 and 24 months; 
more frequent measurement will be performed, if indicated, as previously described. Serum total and ionized 
calcium concentrations will be measured at baseline, 1, 3 months, and at 6-month intervals until month 24. 
 
General Endocrine Studies: Serum thyroid function (T3, T4, & TSH; DiaSorin Inc. Stillwater, MN) will be 
determined by kit assay. Cortisol, total testosterone (T), free testosterone (calculated from total T, albumin and 
SHBG)[69], estradiol (E2), growth hormone (GH) will be determined by kit assays (MP Biomedicals, 
Orangeburg, NY); insulin-like growth factor-1 (IGF-I) will be measured by kit assay (ALPCO Diagnostics, 
Salem, NH). Sex-hormones (T & E2) play a significant role in promoting bone health, with low levels causing 
increased bone resorption. Hypogonadal states generally result in bone loss, which may confound 
interpretation of study endpoints. GH and IGF-1 have anabolic effects on bone; stress may reduce levels of 
GH/IGF-1, which may blunt the effect of any therapeutic intervention. As such, it is important to confirm that 
these hormones (T3, T4, TSH, cortisol, T, and GH/IGF-1) are within the normal range and not significantly 
different between the experimental and control groups. General endocrine studies will be performed at 
baseline, 12 and 24 months. 
 
General Laboratory Studies: To ensure that the general health of the subject is acceptable for study, CBC and 
comprehensive chemistry panels will be obtained at each study visit.  
 
Data, Safety and Monitoring Plans:  
A member of the study team will be present at all times with the subject. Subjects will be monitored 
continuously throughout the study visits. All subjects enrolled will be under the direct care and supervision of 
the principal investigator, the study coordinator, and the study physician. Subjects will be interviewed at each 
study visit and medication administration visit to determine any side effects they may have experienced. These 
symptoms will be recorded, and the study investigators will meet on a monthly basis to review the data and 
adverse events for any identifiable trends. Results of blood tests will also be reviewed by the study team after 
every study visit to ensure the subject is in good health. A minimum number of tests will be performed while 
still ensuring that study outcomes are met. All AEs and SAE’s will be reported without exception to the local 
IRB. Serious adverse events will be reported immediately. If any significant trend is detected, subject 
recruitment and testing will be discontinued for project evaluation and modified as necessary.  
To ensure confidentiality, data and the VA subjects’ records will be stored on a VA server located at the 
JJP VAMC behind a VA firewall and not on any individual computer hard drive. Access to this computer 

15 
8/30/2022 V.4 
storage system is password protected with access to shared project data files limited to individually-authorized 
project staff members. Further, remote access is, and will continue to be, limited to authorized users of the VA 
Virtual Private Network (VPN) controlled by the NSOC and authenticated by the JJP VAMC Bronx Information 
Security Officer in compliance with VA policy (VA Directive and Handbook 6500). The database for 
computation and analysis will be stored on this VA server so that these raw data files will remain unchanged if 
there are computational errors or computer problems. Once this study has been completed, the de-identified 
research records will be retained in accordance with the record control schedule. Access to specific data files 
will be protected by strong passwords (numbers, special symbols, upper and lower case letters), provided only 
to project staff members authorized to access to the data. For research subjects at Kessler Institute of 
Rehabilitation signing a VA consent form, PHI information and consent forms will be temporarily stored in a 
locked cabinet at the Kessler Institute of Rehabilitation Room L-050. VA consent forms will be hand delivered 
to the VA in a locked briefcase at approximately monthly intervals, and are stored behind locked doors in a 
locked file cabinet at the VA Room 7A-13. Case report forms and data collected will be kept in a separate 
locked cabinet at the Kessler Institute of Rehabilitation before being transferred to the VA for permanent 
storage.In addition, incremental back-ups of data on servers will be performed weekly with full back ups 
completed on a monthly basis. Back up media will be removed and stored in a physically secure location within 
the Center of Excellence (JJP VAMC). External access to systems via an enterprise gateway already is and 
will continue to be strictly controlled and monitored by the VA Network Security Operations Center (NSOC). 
Hard copies of subjects intake and raw data will be stored in locked files in the investigator’s VAMC Office in 
room 7A-13. 
 
Statistical Considerations and Analyses: 
 
Sample size 
A sample size of 14 per group is needed to complete the study. Due to the 24-month length of the study, 20 per 
group (total enrollment = 40 subjects) will be enrolled to account for as much as 30% attrition (Table 3). 
 
Sample size justification 
Assuming the proportion in the historical control group achieving a clinically meaningful aBMD retention (≥90%)  
at the distal femur to be 7% (0.07; n=1) for both the 12- and 24-month distal femur aBMD outcome measures, 
the needed sample sizes range from 11 (80% power) per group to 14 (90% power) per group.  [Estimating a 
20% attrition and rounding up, 15 (80% power) per group and 18 (90% power) per group will be required.] Being 
more conservative (estimating a 30% attrition and also rounding up), 16 (80% power) per group and 20 (90% 
power) per group will be required.  The targeted enrollment will be 20 per group (Table 3). 
 
Sample Size 
Calculations 
There 
are 
two 
primary 
outcome 
measures in this 
study:  the first is 
the 
12-month 
value for the distal 
femur aBMD and 
the second is the 
24-month value for 
the distal femur 
aBMD for each of 
the active study 
drugs. The primary 
study hypotheses 
are: 
1) 
at 
12 
months, 80% of 
the 
intervention 
group and 7% of 

16 
8/30/2022 V.4 
the control group will maintain ≥90% of baseline distal femur aBMD and 2) at 24 months, 80% of the intervention 
group and 7% of the historical control group will maintain ≥90% of baseline distal femur aBMD. For each of the 
outcomes, the proportion of participants successful at achieving a clinically significant improvement will be 
compared between the two groups (intervention vs. historical control) using a chi-square analysis.   
 
Primary Analyses 
There will be two primary analyses. To test the hypotheses for the primary outcome measures, each randomized 
participant will be deemed a success or failure at attaining:  maintenance of ≥90% of baseline distal femur aBMD 
at 12 months. The second primary analyses will test the hypotheses for the primary outcome measures for each 
randomized participant who completes the 24-month study for success or failure at attaining:  maintenance of 
≥90% of baseline distal femur aBMD at 24 months. Because of the expected 20 to 30% dropout rate, most of 
which may occur during the first year due to heterotopic ossification, an intent-to-treat model will not be 
employed. Drop outs will be included up to the last time point or removed fully from the data analyses. 
 
To test the hypotheses for the secondary outcome measures, each randomized participant who has completed 
up to the 12- and 24-month timepoints will be deemed a success or failure at attaining: 1) maintenance of ≥90% 
of baseline distal femur aBMD at 24 months; 2) maintenance of ≥90% of the other ROIs of total hip, femoral neck 
and proximal tibia aBMD at 12 and 24 months.  For the control group, two separate analysis using a Wilcoxon 
Signed Rank test will be performed to test the hypothesis that compared with baseline, at 24 months, ≥90% of 
12-month distal femur aBMD will be achieved. 
 
For each of the outcomes, the proportion of participants successful at achieving a clinically significant retention 
of ≥90% distal femur aBMD at 12 and 24 months will be compared between the two groups (intervention vs. 
historical control) using a chi-square analysis.  These two time points will constitute the primary efficacy analyses. 
 
Noninferiority Analysis 
The efficacy of treatment with romosozumab will be compared to treatment with denosumab. Because both 
agents are anticipated to successfully retain aBMD at the distal femur, it is hypothesized that no significant 
difference will be found between the administration of each of these agents for retention of aBMD at the distal 
femur. If a small, nonsignificant difference between these agents is observed, a far larger sample size will be 
required to confirm a significant difference in efficacy between the two drug treatments. 
 
Secondary Analyses  
Several secondary analyses will be performed that include only those participants who complete the study 
(excluding drop-outs). Chi-square analyses of the primary and major secondary outcome measures (proportion 
of successes) will be repeated for only those participants who complete the 24-month intervention phase.  
Analyses of all the ROI aBMD and other secondary outcome measures will include comparisons of the mean 
difference scores (change from baseline to the 12- and 24-month intervention phase) of these outcome variables 
using t-tests. 
 
Other Statistical Considerations   
 An analysis to determine the characterization of the drop-outs will be performed by using descriptive and 
correlation statistics.  The reasons for study termination and the number of time points completed will be 
described.  A correlation analysis will be performed with the reasons for study termination and the demographic 
variables and other potential variables to identify characteristics of persons who dropped out of the study.  
Knowledge of the reasons for termination will be important for clinical administration of the sequential dual drug 
administration if this approach is found efficacious at preventing bone loss in persons with motor complete and 
incomplete SCI. 
 
Statistical Analysis Plan 
Baseline comparability between the treatment groups will be evaluated with respect to such variables as 
demographics (e.g., age, gender, race, and level of SCI) and baseline values of outcome measures (ROIs 
aBMD).  Chi-square and analysis of variance techniques, as appropriate, will be used to determine any 
differences in distribution of the variables across the treatment groups.  Any variable that appears to be different 
between the groups (p<0.10) will be considered as a potential covariate in statistical analyses.   

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All statistical tests will be 2-sided.  The two primary outcome measures will be tested at a 0.01 level of 
significance.  Because of the large number of secondary outcomes to be analyzed, all other secondary outcomes 
will also be tested at a significance level of 0.01 to maintain control over Type I error.  A variety of analytic 
methods will be used for the primary endpoints, secondary endpoints and other analyses.   
For each of the outcomes, the proportion of participants successful at achieving a clinically significant 
improvement will be compared between the two groups (Intervention vs. historical controls) using a chi-square 
analysis.  These will constitute the primary and secondary efficacy analyses. Participants who drop out will be 
treated as failures.  As such, by design, there will be no missing data: participants either meet the outcome 
criteria (successes), do not meet these criteria (failures) or they drop out (also failures).      
 
 

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BIBLIOGRAPHY: 
 
1. 
Morse, L.R., R.A. Battaglino, K.L. Stolzmann, et al., Osteoporotic fractures and hospitalization risk in chronic 
spinal cord injury. Osteoporos Int, 2009. 20(3): p. 385-92. 
2. 
Akhigbe, T., A.S. Chin, J.N. Svircev, et al., A retrospective review of lower extremity fracture care in patients with 
spinal cord injury. J Spinal Cord Med, 2015. 38(1): p. 2-9. 
3. 
Eser, P., A. Frotzler, Y. Zehnder, et al., Relationship between the duration of paralysis and bone structure: a 
pQCT study of spinal cord injured individuals. Bone, 2004. 34(5): p. 869-80. 
4. 
Eser, P., A. Frotzler, Y. Zehnder, et al., Fracture threshold in the femur and tibia of people with spinal cord injury 
as determined by peripheral quantitative computed tomography. Arch Phys Med Rehabil, 2005. 86(3): p. 498-504. 
5. 
Lazo, M.G., P. Shirazi, M. Sam, et al., Osteoporosis and risk of fracture in men with spinal cord injury. Spinal 
Cord, 2001. 39(4): p. 208-14. 
6. 
Garland, D.E., Z. Maric, R.H. Adkins, et al., Bone mineral denisty about the knee in spinal cord injured patients 
with pathologic fractures. Contemp Orthop, 1993. 26: p. 375-379. 
7. 
Bauman, W.A., C.M. Cirnigliaro, M.F. La Fountaine, et al., A small-scale clinical trial to determine the safety and 
efficacy of testosterone replacement therapy in hypogonadal men with spinal cord injury. Horm Metab Res, 2011. 
43(8): p. 574-9. 
8. 
Bauman, W.A., M.F. La Fountaine and A.M. Spungen, Age-related prevalence of low testosterone in men with 
spinal cord injury. J Spinal Cord Med, 2014. 37(1): p. 32-9. 
9. 
Jiang, S.D., L.Y. Dai and L.S. Jiang, Osteoporosis after spinal cord injury. Osteoporos Int, 2006. 17(2): p. 180-92. 
10. 
Spinal Cord Injury (SCI) 2016 Facts and Figures at a Glance. J Spinal Cord Med, 2016. 39(4): p. 493-4. 
11. 
Fisher, J.E., M.J. Rogers, J.M. Halasy, et al., Alendronate mechanism of action: geranylgeraniol, an intermediate 
in the mevalonate pathway, prevents inhibition of osteoclast formation, bone resorption, and kinase activation in 
vitro. Proc Natl Acad Sci U S A, 1999. 96(1): p. 133-8. 
12. 
Kurokouchi, K., T. Ito, S. Ohmori, et al., Changes in the markers of bone metabolism following skeletal unloading. 
Environ Med, 1995. 39(1): p. 21-4. 
13. 
Kurokouchi, K., T. Ito, S. Ohmori, et al., Effects of bisphosphonate on bone metabolism in tail-suspended rats. 
Environ Med, 1996. 40(1): p. 39-42. 
14. 
Williams, C.J., R.A. Smith, R.J. Ball, et al., Hypercalcaemia in osteogenesis imperfecta treated with pamidronate. 
Arch Dis Child, 1997. 76(2): p. 169-70. 
15. 
Gilchrist, N.L., C.M. Frampton, R.H. Acland, et al., Alendronate prevents bone loss in patients with acute spinal 
cord injury: a randomized, double-blind, placebo-controlled study. J Clin Endocrinol Metab, 2007. 92(4): p. 1385-
90. 
16. 
Poole, K.E., N. Loveridge, C.M. Rose, et al., A single infusion of zoledronate prevents bone loss after stroke. 
Stroke, 2007. 38(5): p. 1519-25. 
17. 
Bauman, W.A., C.M. Cirnigliaro, M.F. La Fountaine, et al., Zoledronic acid administration failed to prevent bone 
loss at the knee in persons with acute spinal cord injury: an observational cohort study. J Bone Miner Metab, 
2015. 33(4): p. 410-21. 
18. 
Bauman, W.A., J.M. Wecht, S. Kirshblum, et al., Effect of pamidronate administration on bone in patients with 
acute spinal cord injury. J Rehabil Res Dev, 2005. 42(3): p. 305-13. 
19. 
Shapiro, J., B. Smith, T. Beck, et al., Treatment with zoledronic acid ameliorates negative geometric changes in 
the proximal femur following acute spinal cord injury. Calcif Tissue Int, 2007. 80(5): p. 316-22. 
20. 
Bubbear, J.S., A. Gall, F.R. Middleton, et al., Early treatment with zoledronic acid prevents bone loss at the hip 
following acute spinal cord injury. Osteoporos Int, 2011. 22(1): p. 271-9. 
21. 
Pearson, E.G., P.W. Nance, W.D. Leslie, et al., Cyclical etidronate: its effect on bone density in patients with 
acute spinal cord injury. Arch Phys Med Rehabil, 1997. 78(3): p. 269-72. 
22. 
Nance, P.W., O. Schryvers, W. Leslie, et al., Intravenous pamidronate attenuates bone density loss after acute 
spinal cord injury. Arch Phys Med Rehabil, 1999. 80(3): p. 243-51. 
23. 
Bryson, J.E. and M.L. Gourlay, Bisphosphonate use in acute and chronic spinal cord injury: a systematic review. J 
Spinal Cord Med, 2009. 32(3): p. 215-25. 
24. 
Cummings, S.R., J. San Martin, M.R. McClung, et al., Denosumab for prevention of fractures in postmenopausal 
women with osteoporosis. N Engl J Med, 2009. 361(8): p. 756-65. 
25. 
Eastell, R., C. Christiansen, A. Grauer, et al., Effects of denosumab on bone turnover markers in postmenopausal 
osteoporosis. J Bone Miner Res, 2011. 26(3): p. 530-7. 
26. 
Reid, I.R., P.D. Miller, J.P. Brown, et al., Effects of denosumab on bone histomorphometry: the FREEDOM and 
STAND studies. J Bone Miner Res, 2010. 25(10): p. 2256-65. 
27. 
Kendler, D.L., C. Roux, C.L. Benhamou, et al., Effects of denosumab on bone mineral density and bone turnover 
in postmenopausal women transitioning from alendronate therapy. J Bone Miner Res, 2010. 25(1): p. 72-81. 

19 
8/30/2022 V.4 
28. 
Brown, J.P., R.L. Prince, C. Deal, et al., Comparison of the effect of denosumab and alendronate on BMD and 
biochemical markers of bone turnover in postmenopausal women with low bone mass: a randomized, blinded, 
phase 3 trial. J Bone Miner Res, 2009. 24(1): p. 153-61. 
29. 
McClung, M.R., E.M. Lewiecki, S.B. Cohen, et al., Denosumab in postmenopausal women with low bone mineral 
density. N Engl J Med, 2006. 354(8): p. 821-31. 
30. 
Brown, J.P., I.R. Reid, R.B. Wagman, et al., Effects of up to 5 years of denosumab treatment on bone histology 
and histomorphometry: the FREEDOM study extension. J Bone Miner Res, 2014. 29(9): p. 2051-6. 
31. 
Papapoulos, S., K. Lippuner, C. Roux, et al., The effect of 8 or 5 years of denosumab treatment in 
postmenopausal women with osteoporosis: results from the FREEDOM Extension study. Osteoporos Int, 2015. 
26(12): p. 2773-83. 
32. 
Bone, H.G., R.B. Wagman, M.L. Brandi, et al., 10 years of denosumab treatment in postmenopausal women with 
osteoporosis: results from the phase 3 randomised FREEDOM trial and open-label extension. Lancet Diabetes 
Endocrinol, 2017. 5(7): p. 513-523. 
33. 
Leder, B.Z., J.N. Tsai, A.V. Uihlein, et al., Denosumab and teriparatide transitions in postmenopausal 
osteoporosis (the DATA-Switch study): extension of a randomised controlled trial. Lancet, 2015. 386(9999): p. 
1147-55. 
34. 
Ebina, K., J. Hashimoto, M. Kashii, et al., The effects of switching daily teriparatide to oral bisphosphonates or 
denosumab in patients with primary osteoporosis. J Bone Miner Metab, 2017. 35(1): p. 91-98. 
35. 
Cosman, F., D.B. Crittenden, S. Ferrari, et al., FRAME Study: The Foundation Effect of Building Bone With 1 Year 
of Romosozumab Leads to Continued Lower Fracture Risk After Transition to Denosumab. J Bone Miner Res, 
2018. 33(7): p. 1219-1226. 
36. 
Lewiecki, E.M., R.V. Dinavahi, M. Lazaretti-Castro, et al., One Year of Romosozumab Followed by Two Years of 
Denosumab Maintains Fracture Risk Reductions: Results of the FRAME Extension Study. J Bone Miner Res, 
2019. 34(3): p. 419-428. 
37. 
Gifre, L., J. Vidal, J.L. Carrasco, et al., Denosumab increases sublesional bone mass in osteoporotic individuals 
with recent spinal cord injury. Osteoporos Int, 2016. 27(1): p. 405-10. 
38. 
Lindsay, R., J.H. Krege, F. Marin, et al., Teriparatide for osteoporosis: importance of the full course. Osteoporos 
Int, 2016. 27(8): p. 2395-410. 
39. 
Gordon, K.E., M.J. Wald and T.J. Schnitzer, Effect of parathyroid hormone combined with gait training on bone 
density and bone architecture in people with chronic spinal cord injury. Pm r, 2013. 5(8): p. 663-71. 
40. 
Edwards, W.B., N. Simonian, I.T. Haider, et al., Effects of Teriparatide and Vibration on Bone Mass and Bone 
Strength in People with Bone Loss and Spinal Cord Injury: A Randomized, Controlled Trial. J Bone Miner Res, 
2018. 33(10): p. 1729-1740. 
41. 
Leder, B.Z., L.S. O'Dea, J.R. Zanchetta, et al., Effects of abaloparatide, a human parathyroid hormone-related 
peptide analog, on bone mineral density in postmenopausal women with osteoporosis. J Clin Endocrinol Metab, 
2015. 100(2): p. 697-706. 
42. 
Cosman, F., G. Hattersley, M.Y. Hu, et al., Effects of Abaloparatide-SC on Fractures and Bone Mineral Density in 
Subgroups of Postmenopausal Women With Osteoporosis and Varying Baseline Risk Factors. J Bone Miner Res, 
2017. 32(1): p. 17-23. 
43. 
Miller, P.D., G. Hattersley, B.J. Riis, et al., Effect of Abaloparatide vs Placebo on New Vertebral Fractures in 
Postmenopausal Women With Osteoporosis: A Randomized Clinical Trial. Jama, 2016. 316(7): p. 722-33. 
44. 
Genant, H.K., K. Engelke, M.A. Bolognese, et al., Effects of Romosozumab Compared With Teriparatide on Bone 
Density and Mass at the Spine and Hip in Postmenopausal Women With Low Bone Mass. J Bone Miner Res, 
2017. 32(1): p. 181-187. 
45. 
Keaveny, T.M., D.B. Crittenden, M.A. Bolognese, et al., Greater Gains in Spine and Hip Strength for 
Romosozumab Compared With Teriparatide in Postmenopausal Women With Low Bone Mass. J Bone Miner 
Res, 2017. 32(9): p. 1956-1962. 
46. 
Cosman, F., D.B. Crittenden, J.D. Adachi, et al., Romosozumab Treatment in Postmenopausal Women with 
Osteoporosis. N Engl J Med, 2016. 375(16): p. 1532-1543. 
47. 
Saag, K.G., J. Petersen, M.L. Brandi, et al., Romosozumab or Alendronate for Fracture Prevention in Women with 
Osteoporosis. N Engl J Med, 2017. 377(15): p. 1417-1427. 
48. 
McClung, M.R., J.P. Brown, A. Diez-Perez, et al., Effects of 24 Months of Treatment With Romosozumab 
Followed by 12 Months of Denosumab or Placebo in Postmenopausal Women With Low Bone Mineral Density: A 
Randomized, Double-Blind, Phase 2, Parallel Group Study. J Bone Miner Res, 2018. 33(8): p. 1397-1406. 
49. 
Qin, W., X. Li, Y. Peng, et al., Sclerostin antibody preserves the morphology and structure of osteocytes and 
blocks the severe skeletal deterioration after motor-complete spinal cord injury in rats. J Bone Miner Res, 2015. 
30(11): p. 1994-2004. 
50. 
Qin, W., W. Zhao, X. Li, et al., Mice with sclerostin gene deletion are resistant to the severe sublesional bone loss 
induced by spinal cord injury. Osteoporos Int, 2016. 27(12): p. 3627-3636. 

20 
8/30/2022 V.4 
51. 
Zhao, W., X. Li, Y. Peng, et al., Sclerostin Antibody Reverses the Severe Sublesional Bone Loss in Rats After 
Chronic Spinal Cord Injury. Calcif Tissue Int, 2018. 
52. 
Schnitzer, T.J., K. Kim, J. Marks, et al., Zoledronic Acid Treatment After Acute Spinal Cord Injury: Results of a 
Randomized, Placebo-Controlled Pilot Trial. PM R, 2016. 8(9): p. 833-43. 
53. 
Nelson, H.D., E.M. Haney, T. Dana, et al., Screening for osteoporosis: an update for the U.S. Preventive Services 
Task Force. Ann Intern Med, 2010. 153(2): p. 99-111. 
54. 
Bauman, W.A. and C.P. Cardozo, Osteoporosis in individuals with spinal cord injury. Pm r, 2015. 7(2): p. 188-201; 
quiz 201. 
55. 
Cardozo CP, B.W., Spinal Cord Injury: Pathophysiology and Clinical Issues. Primer on the Metabolic Bone 
Diseases and Disorders of Mineral Metabolism 8th Edition. American Society of Bone and Mineral Research. 
John Wiley & Sons, 2012. 
56. 
Bauman, W.A., F. Biering-Sorensen and A. Krassioukov, The international spinal cord injury endocrine and 
metabolic function basic data set. Spinal Cord, 2011. 49(10): p. 1068-72. 
57. 
Cirnigliaro, C.M., M.J. Myslinski, M.F. La Fountaine, et al., Bone loss at the distal femur and proximal tibia in 
persons with spinal cord injury: imaging approaches, risk of fracture, and potential treatment options. 
Osteoporosis International, 2016: p. 1-19. 
58. 
Dawson-Hughes, B., R.P. Heaney, M.F. Holick, et al., Estimates of optimal vitamin D status. Osteoporos Int, 
2005. 16(7): p. 713-6. 
59. 
Holick, M.F., N.C. Binkley, H.A. Bischoff-Ferrari, et al., Evaluation, treatment, and prevention of vitamin D 
deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab, 2011. 96(7): p. 1911-30. 
60. 
Institute of Medicine, F.a.N.B., Dietary Reference Intakes for Calcium and Vitamin D. 2010, National Academy 
Press: Washington, DC. 
61. 
Langdahl, B.L., C. Libanati, D.B. Crittenden, et al., Romosozumab (sclerostin monoclonal antibody) versus 
teriparatide in postmenopausal women with osteoporosis transitioning from oral bisphosphonate therapy: a 
randomised, open-label, phase 3 trial. Lancet, 2017. 390(10102): p. 1585-1594. 
62. 
McPherson, J.G., W.B. Edwards, A. Prasad, et al., Dual energy X-ray absorptiometry of the knee in spinal cord 
injury: methodology and correlation with quantitative computed tomography. Spinal Cord, 2014. 52(11): p. 821-5. 
63. 
Baim, S., C.R. Wilson, E.M. Lewiecki, et al., Precision assessment and radiation safety for dual-energy X-ray 
absorptiometry: position paper of the International Society for Clinical Densitometry. J Clin Densitom, 2005. 8(4): 
p. 371-8. 
64. 
Morse, L.R., A.A. Lazzari, R. Battaglino, et al., Dual energy x-ray absorptiometry of the distal femur may be more 
reliable than the proximal tibia in spinal cord injury. Arch Phys Med Rehabil, 2009. 90(5): p. 827-31. 
65. 
Pop, L.C., D. Sukumar, K. Tomaino, et al., Moderate weight loss in obese and overweight men preserves bone 
quality. Am J Clin Nutr, 2015. 101(3): p. 659-67. 
66. 
Pop, L.C., D. Sukumar, S.H. Schneider, et al., Three doses of vitamin D, bone mineral density, and geometry in 
older women during modest weight control in a 1-year randomized controlled trial. Osteoporos Int, 2017. 28(1): p. 
377-388. 
67. 
Cervinka, T., L. Giangregorio, H. Sievanen, et al., Peripheral Quantitative Computed Tomography: Review of 
Evidence and Recommendations for Image Acquisition, Analysis, and Reporting, Among Individuals With 
Neurological Impairment. J Clin Densitom, 2018. 21(4): p. 563-582. 
68. 
Wong, A.K., K.A. Beattie, K.K. Min, et al., A Trimodality Comparison of Volumetric Bone Imaging Technologies. 
Part II: 1-Yr Change, Long-Term Precision, and Least Significant Change. J Clin Densitom, 2015. 18(2): p. 260-9. 
69. 
Vermeulen, A., L. Verdonck and J.M. Kaufman, A critical evaluation of simple methods for the estimation of free 
testosterone in serum. J Clin Endocrinol Metab, 1999. 84(10): p. 3666-72.