Effect of Vibration Exercise on Upper Limb Strength, Function, and Pain
Phase: NA
Conditions: Spinal Cord Injuries
Sponsor: Alicia Koontz

Title: Effect of Vibration Exercise on Upper Limb Strength, Function and Pain 
Clinical Trials.gov ID:  NCT02998021 
Protocol Date:  5/24/2019 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Background 
Strong upper limb musculature is essential for people who have paraplegia with spinal cord injury (SCI) 
to operate manual wheeled mobility devices in order to live independently and perform activities of daily 
living such as wheelchair propulsion, wheelchair transfer activities, and weight relieving maneuvers. 
These activities, however, place high demands on the upper extremities and practicing them over time 
negatively impacts upper extremity health. The shoulders, elbows and wrists are all highly susceptible to 
degeneration, overuse injuries, and pain. The shoulder is the most common site of upper extremity pain 
in manual wheelchair users, with reported pain ranging from 32% to 78%. A range of pathological 
conditions at the shoulder have also been documented including impingement syndrome, adhesive 
capsulitis, recurrent dislocations, rotator cuff tears, and tendinitis. Shoulder pain has been most closely 
associated with transfers, weight relieving activities, and ramp propulsion indicating that these activities 
may be the most demanding ones performed.  
The benefits of upper limb resistance training for wheelchair users with paraplegia have been well 
documented and include moderate to large gains in muscle strength, endurance, and performance of 
activities of daily living. Studies among various populations ranging from children to older adults, 
untrained to elite athletes, and persons with and without disabilities have shown that when resistance 
training is paired with high-frequency whole body vibration there is greater potential to increase and 
coordinate muscle recruitment and build muscle strength and power more quickly. More recently vibrating 
dumbbells have been developed so that training can be localized to the upper extremities. This form of 
training could greatly benefit persons with paraplegia who need an effective and efficient solution to 
building muscle work capacity for weight bearing tasks and for protecting the joints from overuse and 
aging effects.  
Numerous studies have examined the effects of varying forms of structured resistance and endurance 
training among individuals with SCI. These studies have demonstrated that engaging in structured fitness 
training, including resistance training 2-3 times/week, of the upper limbs following SCI leads to 
improvements in muscle strength, increased performance during activities of daily living and improved 
quality of life. While a combination of endurance and resistance training is recommended for overall 
increased fitness, resistance training targets and leads to greater gains in upper extremity work capacity, 
muscle strength, and power over endurance training. Resistance training is also recommended for 
combating muscle imbalances associated with overuse and for treating shoulder pain. In one study 
wheelchair users with SCI who concentrated on strengthening the muscles of the posterior shoulder and 
upper back while stretching the muscles of the anterior shoulder and chest reported greater pain relief 
and an easier time performing propulsion and weight relief activities when compared to an attention 
control group who received video instruction on pain relief. The amount of strength gain achieved through 
resistance training reportedly varies from study to study (10-60%) with larger gains found in studies that 
involve weight lifting universal systems or equipment and frequent, progressive increases in training 
loads. Most of the studies evaluating effects of training report outcomes of muscle strength, anerobic 
power, endurance, pain, and general improvement in the performance of daily tasks (e.g. Functional 
Independence Measure). Few studies have examined the effects of resistance training on propulsion 
performance and skills. We are not aware of any studies that have assessed the impact of resistance 
training on transfer ability specifically. Therefore the present study will determine the effectiveness of 
the proposed resistance training programs (vibration and non-vibration) in improving forces generated 
during wheelchair mobility tasks and the ability to transfer to higher and lower surfaces. 
Vibration exercise has gained recent popularity and adoption among recreational to elite athletes. This is 
because vibration training has been shown in numerous studies to increase muscle strength, power and 
performance when integrated into a resistance training program or when used as a supplement to 
alternative modes of training. Vibration exercise is mostly practiced in the form of whole body vibration 

(WBV), where one stands or sits on an oscillating platform. Vibrating dumbbells have also been developed 
more recently for upper-body exercise. Despite controversy surrounding possible training effects with 
vibration, multiple studies have shown that both WBV and vibrating dumbbell use elicits greater muscle 
activation not only in the muscles targeted but also in the surrounding and supporting muscle groups 
(e.g. antagonists). Using vibration above a certain threshold frequency (12 Hz for plates, and 16 Hz for 
dumbbells) elicits a stretch reflex (contraction) in the muscle. The number of contractions is equivalent 
to the vibration frequency (e.g. 20 Hz = 20 contractions per second). When frequencies exceed 20 Hz 
for plates (28 Hz for dumbbells), the muscle fibers activated do not have enough time to complete a full 
contraction and relaxation cycle and are therefore in constant co-contraction which results in increased 
muscle force and power post-vibration. Moreover, muscle electromyographic patterns observed with 
upper limb vibration at high frequencies (44 Hz) have indicated a more efficient and effective recruitment 
of high threshold motor units during fatiguing contractions. The effects of vibration on the body have 
been extensively studied and guidelines have been developed to regulate exposure to such stimuli. The 
frequency, amplitudes and exposures used in previous vibration studies and the proposed study are 
considered acceptable and safe. Results from all of these studies combined suggest that vibration may 
be an effective and safe tool for enhancing resistance training among wheelchair users with SCI. 
Objective 
The primary purpose of this study is to explore the benefits of vibration dumbbell resistance improving 
upper limb strength, function and pain among manual wheelchair users with paraplegia. 
Specific Aim 1) Explore the effects of vibration dumbbell training on improving strength, function and 
pain 
 
Hypothesis 
1): 
Subjects 
will 
demonstrate 
the 
following 
changes 
overtime: 
Primary outcomes: Increased peak isokinetic muscle torque output as measured using a Biodex machine 
of the shoulder internal rotators, external rotators, shoulder abductor/adductors, and shoulder 
flexion/extension, elbow flexion/extension, forearm pronation/supination, wrist flexion/extension, and 
hand grip measured using a handheld dynomometer at 6 weeks (mid-way into training) and 12 weeks 
(end of training) when compared to baseline.  
Secondary outcomes:  
o Propulsion testing: Increased maximum speed and acceleration attained, peak force, and mechanical 
effective force measured using the SmartWheel during start-up propulsion over level and inclined 
surfaces at 12 weeks when compared to baseline 
o Transfer testing: Higher maximum and minimum attainable transfer heights to a height-adjustable 
transfer station at 12 weeks when compared to baseline;  
o Reduced upper limb pain across all joints (as recorded on the Numerical Rating Scale (NRS) and 
shoulder pain reported during activities (Wheelchair Users Shoulder Pain Index (WUSPI)) at 6 weeks 
and 12 weeks when compared to baseline; 
o Increased self-perceived aspects of health and function as measured using the Short Form SF-36 
Walk Wheel scale at 6 weeks and 12 weeks and when compared to baseline. 
o Increased peak power and average power output at 12 weeks compared to baseline. 
Specific Aim 2) Assess subjects’ perceptions of the effectiveness of the vibration dumbbell training 
program 
 
Hypothesis 2) Subjects will report a high level of satisfaction with the training on factors of efficiency, 
tolerance, perceived strength and functional benefits. 
 

Study Design and Methods 
Each subject will be asked to come to HERL three times over a 12-week study period. During these visits 
the following activities will take place a) Pain and Health Surveys (Baseline and Weeks 6, and 12), b) 
Muscle Strength Testing (Baseline and Weeks 6 and 12), c) Functional Testing (Baseline and Week 12), 
and Pre-Training Assessment and Instructions (Baseline). The 12-week Training Phase will start after 
Visit 1  
Data will be collected electronically using redcap, or on paper as needed.  
Visit 1 (Initial Visit) 
After signing informed consent, all subjects will complete a basic information questionnaire. The 
questionnaire will survey the frequency of wheelchair usage, transfers, percentage of non-level transfers, 
basic demographics (age, gender, years since SCI, etc.), work history, history of medical problems, 
current medications, and alcohol and smoking usage.  
Pain and Health Measures 
Numerical rating scale (NRS): Subjects will complete this scale once for each upper limb joint (wrist, 
elbow, and shoulder). The subjects will be asked to rate their average, most severe, and least severe 
wrist, elbow or shoulder pain during the past 24 hours using an 11-point scale (i.e. 0-10) anchored at 
the ends by “no pain” and “worst pain ever experienced.” An 11-point NRS measure of pain intensity 
allows for comparison across clinical trials of pain treatment and is recommended as a core outcome 
measure for chronic pain clinical trials. NRS pain measures are widely used and have been shown to be 
valid and reliable assessments of pain.  
WUSPI – Wheelchair User’s Shoulder Pain Index: The WUSPI is a 15-item, self-report instrument that 
measures shoulder pain intensity, within the last week, in wheelchair users during various functional 
activities of daily living, such as transfers, loading a wheelchair into a car, wheelchair mobility, dressing, 
bathing, overhead lifting, driving, performing household chores, and sleeping. The WUSPI is a valid and 
reliable measure of shoulder pain. This survey asses the previous tasks over the time span of the week 
leading up when the survey was being answered. Test-retest reliability of the total index score was 0.99 
and Cronbach’s alpha (internal consistency) was 0.98. 
Carpal Tunnel Syndrome Self-Report Questionnaire: This self-report instrument includes two scales: a 
Symptom Severity Scale consisting of 11 questions and a Functional Status Scale evaluating 8 different 
activities. This instrument is reproducible, internally consistent, and responsive to clinical changes in 
symptoms. 
Vibration Tolerance: Participants will be screened for their tolerance to the feeling of the vibration prior 
to collecting the biomechanics outcome measures. Participants will hold the dumbbell at 25Hz for 30 
seconds with their arm at a forty-five-degree angle away from their bodies (position similar to a bicep 
curl). If they are unable to complete the assessment they will not be permitted to continue the study.  
If subjects successfully complete the vibration screening they will continue with the following 
assessments during Visit 1: 
General Health and Function: The 36-Item Short Form Health Survey Walk Wheel (SF-36 WW) is a slightly 
modified version of the original SF-36 that has been validated for persons with SCI. The SF-36 is a brief, 
multi-dimensional, self-report health questionnaire that measures eight concepts - Physical Functioning, 

Role limitation due to Physical problems, Bodily Pain, General Perception of Health, Vitality, Social 
Function, Role limitation due to Emotional problems, and Mental Health. The domain scales ranges from 
0 (worst possible health state measured by the questionnaire) to 100 (best possible health state).  
Power output: the Lode Arm Ergometer will be used to measure the maximum power output for each 
participant. This test will be done with the participant seated in their wheelchair. The arm ergometer 
height will be adjusted such that participants are able to comfortably reach and crank both pedals. 
Additionally, we will want subjects to be in a stable participation. If they are able to, participants should 
brace their feet on their foot plate. If a participant does not feel enough stability in their wheelchair we 
will have a stable chair for them to transfer to in order to perform the evaluation. Participants will start 
out by cycling on the arm ergometer at a comfortable pace as a warm up. Once the participant feels as 
though they are sufficiently warmed up the test will begin. Participants will begin cycling against 
maximum resistance. Once that happens participants will be instructed to cycle as hard and as fast as 
they can for as long as they are able to. Once they are no longer able to crank against the resistance the 
test will stop and the maximum resistance will be recorded. We will complete this process three separate 
times, with a minimum of 30 seconds of rest in between. After the test is completed, the resistance will 
return to zero and the participants will cycle at a comfortable pace to cool down. They will cycle as long 
as they need to in both the warm up and cool down phases.  
Muscle Strength Testing 
Isokinetic strength measurements will be recorded at a torque arm speed of 60 deg/sec using an 
instrumented dynamometer (Biodex Medical System, New York, USA). The torque measurements will be 
recorded in a randomized fashion for both arms for the following test maneuvers: shoulder 
flexion/extension in the sagittal plane (-30 to 50 degrees), shoulder abduction/adduction in the frontal 
plane (10 to 70 degrees), shoulder internal/external rotation in the transverse plane (0 to 45 degrees), 
elbow flexion/extension (0 to 90 degrees), forearm supination/pronation (-80 to 80 degrees) and wrist 
flexion/extension (-45 to 45 degrees) and grip strength. One trial of 5 practice repetitions for each 
movement tested will be completed prior to data collection. In order to ensure the maximal force 
production of the tested upper extremity subjects will be secured into the chair with three padded belts: 
two diagonally across their chest and one across their lap. After the practice trial, one trial of five 
repetitions will be recorded for each muscle group. In between the practice trial and data collection trial, 
participants will rest a minimum of 60 seconds and in between each muscle groups participants will rest 
a minimum of 2 minutes. Participants may request additional time as needed. After completing all the 
strength testing subjects may rest before performing the functional tests.  
Functional Testing 
Wheelchair Propulsion Assessment: If a subject’s wheelchair is equipped with quick release wheels, it 
will be fit with a SmartWheel (Three Rivers Holdings, Mesa, AZ), an instrumented wheel that measures 
forces and moments applied to the pushrim on the non-dominant side of the subject’s wheelchair. A 
dummy wheel with matching inertial properties to the SmartWheel will be placed on the dominant side. 
Subjects will propel down a level hallway that is 5 feet wide by 250 feet long. Subjects will be asked to 
start from a dead stop with their front castors at the beginning of the runway and propel their wheelchairs 
up to a maximum velocity until they reach the end of the runway. Subjects will also propel up three 
different ramp grades (3, 5 and 8 degrees) at a comfortable pace. The ramps are 4 feet wide by 10 feet 
long with a 4 by 4 foot landing platform at the top. Three propulsion trials on the level surface and for 
each ramp slope will be collected. Subjects may rest in between trials as needed. Each trial will be timed 
using a stop watch and their level of exertion recorded for each trial. If a person does not have quick 
release wheels or uses manual power assist wheels, they will complete the propulsion trials with their 

standard wheels instead of the Smartwheel. All propulsion trials will still be timed and the exertion 
recorded. 
Transfer Assessment: Subjects will be asked to transfer to a custom height adjustable transfer station. 
The platform on the station contains a 24 inch wide by 16 inch deep cushioned seat and has an adjustable 
height range from 10 inches to 43 inches above the floor in 1 inch increments. The subject will first 
transfer to and from the platform set at level height with their wheelchair seat using their habitual 
methods. Afterwards the platform will be raised to a level that the subject feels would be the maximum 
height that they could transfer and then the subject will perform a transfer to and from the elevated 
platform. Subjects will be spotted by study personnel throughout the process. If a subject has difficulty 
making the transfer or requires any help from the spotters, the platform will be lowered and the subject 
will be offered a second attempt. If they feel they can go higher, the platform will be raised and they will 
be given another attempt. Subjects will be instructed to only perform transfers in this protocol that they 
feel comfortable and safe in performing. The subject will repeat the attempts until their maximum transfer 
height has been found with success (e.g. defined by requiring no spotting assistance and by landing 
safely and securely on the target surface). The same procedure will be used to determine how low the 
subject can transfer. The maximum transfer heights high/low that were attainable will be recorded. In 
addition to recording the height attained, participants will be asked about their perceived exertion using 
the Borg scale. Participants will be shown a visual analog scale ranging from 6 to 20, where 6 is no 
exertion and 20 is maximum exertion. From the scale, participants will select their level of exertion after 
each transfer. In addition to the perceived level of exertion, measurements about the wheelchairs location 
next to the transfer station will be recorded. Participants will initially set up in front of the station as they 
would normally transfer. To insure they transfer in the same place at the follow up visit, their position 
will be recorded. This protocol has been used successfully in our previous work to measure transfer ability 
and generally involves performing fewer than 10 transfers.  
All subjects’ one rep maximum (1RM) for each of the exercises to be performed in the training phase will 
be determined at their baseline visit with a non-vibrating dumbbell in accordance with standard 
procedures. The following exercises will be tested for a one rep max as well as will be performed during 
the study: butterflies, serratus punches, side flies, straight arm rows, bicep curls, internal and external 
rotation, front raises, triceps extension, and bent over rows. Pictures of each exercise can be found in 
other attachments. Dumbbell weight will be increased accordingly until the subject reaches their 1 RM. 
If a subject is not able to perform a 1RM with the dumbbell for a given exercise, they will start their 
training protocol using a lower weight dumbbell for that exercise until they can hold the vibrating 
dumbbell for 30 seconds.  
After the standard 1RM test, subjects will receive education and instructions on the use of the vibrating 
dumbbell. They will start with holding the dumbbell at a moderate frequency (25 Hz) and experience 
how the effects of the vibration on the arm and body can change with differing arm positions and grips. 
They will be instructed to grip the dumbbell as hard/tightly as possible throughout the course of training 
in order to concentrate the vibrations to the arm muscles and surrounding structures. Subjects will receive 
a pair of gloves to aid in maintaining a strong, firm grip during the exercises. These gloves will be for the 
personal use of each participant during the testing and will be theirs to keep at the conclusion of the 
study. Starting with the biceps curl exercise to demonstrate what higher vibrations feel like, subjects will 
hold the bicep curl in the static training posture (90 degrees of elbow flexion, 60% 1 RM) while the 
frequency is progressively increased to 40 Hz. They will be asked to hold the position for as long as they 
can until they reach a pain-free level of muscle exhaustion. This same process will be repeated for all 
the exercises to ensure they can tolerate each position at 40 Hz. If they can hold the position for an 
exercise for longer than 60 seconds at 40 Hz, weight will be added to the dumbbell (see below Training 
Intensity Assessment and Adjustments). If a subject is unable to tolerate 40 Hz for any one of the 
exercises, they will start that exercise in their first training session at 30 Hz, the minimum frequency for 

training upper limb muscle force and power. For any subject who begins training at 30 Hz, the frequency 
will be reassessed at each training session to progressively increase him/her (in increments of 5 Hz) to 
40 Hz.  
The vibrating dumbbell, without added weights, weighs 6 pounds. It is possible that early in the exercise 
program a subject in the vibration intervention group may not be able to properly perform a specific 
exercise with that weight. In this case the subject will perform the exercise with a lighter weight standard 
dumbbell until they increase sufficiently in strength.  
Visit 1 will take up to 5 hours to complete. 
Optimally, each subject will be scheduled for three training sessions per week in their home for 12 
consecutive weeks. Although the home was chosen for the training setting to make it easier on subjects 
to comply with the protocol, training can take place in another location based on subject convenience. 
The training equipment is portable and can be easily setup and broken down after each session. All the 
training for both the control and vibration groups will be supervised by a trainer with appropriate 
knowledge of proper exercise form and safety. The trainer will travel to the agreed upon location and 
guide the subject through each training session. The training sessions will be monitored by a physical 
therapist (PT). Both the trainer and PT will be masked to subjects' performance on outcome 
measurements.  
Prior to beginning each exercise session, female subjects will be reminded that they should not participate 
in vibration exercise activities if they are pregnant and should notify the study team if they think they 
could be. Female subjects will be asked weekly if they are or could be pregnant and this will be 
documented. If pregnancy is a possibility, the subject will be offered an over the counter pregnancy test. 
Subjects will be given the test to perform themselves, unless they are physically unable to because of 
disability related functional limitations. In these circumstances, a female staff member will assist as 
needed. Any subject reporting or testing positive for pregnancy will be withdrawn from the study. 
Sessions will ideally be scheduled on a Monday, Wednesday and Friday to allow time for muscles to rest 
and rebuild in between training sessions. Prior to starting the weight training, subjects will go through a 
warm-up phase (approximately 5-10 minutes) and stretching phase (approximately 5 minutes). The 
warm-up phase will consist of non-resisted arm movements that parallel motions of the resistance 
exercises and forward and backward arms circles. The stretching phase will consist of stretching exercises 
for the arms, chest and upper back. 
Subjects will perform nine training exercises. For each exercise, subjects will perform one repetition of 
each exercise at 60% of their 1 RM holding the high-frequency (40 Hz) vibrating dumbbell in a static arm 
posture. This posture will be at the point where the force generating output of the targeted muscle group 
is maximized. This point is at the 'End' range of motion (ROM) for each of the dynamic upper limb 
exercises with the exception of the biceps curl which occurs when the elbow is flexed at 90 degrees. 
Subjects will be asked to hold the 40 Hz vibrating dumbbell in the position for as long as they can until 
they reach a pain-free level of muscle exhaustion. The amount of time subjects hold on to the dumbbell 
will be recorded for each exercise and ideally will be 30-45 seconds, a standard isometric training goal 
for increasing muscle hypertrophy. Falling below or above this time will result in changes in the amount 
of dumbbell weight added or removed for the next session.  
Two sets of each exercise will be performed alternating between the left and right sides. The resisted 
exercise phase is estimated to take about 40-50 minutes with total session time of 60-65 minutes. For 
the two exercises that require a supine position, the subject will transfer to a weight bench provided to 
them for the duration of the study and returned to HERL after the study ends. Subjects may choose to 

use another surface in their home for these exercises if it is determined to be safe and appropriate by 
the trainer or other member of the study team. For the rest of the exercises, subjects will exercise while 
in their wheelchair. A lap belt will be provided to subjects who do not have one and will be used to secure 
their pelvis in the wheelchair and to provide a more stable base of support while exercising. Emphasis 
will be placed on maintaining a neutral thoracic and cervical posture and avoiding scapular elevation 
during seated exercises. Depending on the amount of trunk control present, subjects may use their 
opposite limb to brace their trunk (either forearm pressed against their thighs or placed on an adjacent 
table) for exercises involving forward trunk flexion (e.g. bent over rows, triceps extensions and side flies). 
Verbal cuing and spotting from the trainer will be provided during the sessions to monitor positioning 
and safety with the exercises.  
The trainer will only facilitate and supervise the exercise training. The trainer who will be conducting the 
training sessions will guide the subjects through each exercise set and ensure that the correct weights, 
timing, vibration frequency, arm postures and technique are being used to maximize subject safety. 
He/she will also perform survey-based data collection and research procedures. Training procedures will 
be stopped immediately by the trainer if a subject complains of pain or extreme discomfort during the 
exercises. The subject will be instructed to check in with his/her physician before resuming training. 
The trainer will reassess the intensity of the training parameters at the end of each session and adapt as 
necessary. He/she will keep a training log for each subject and session that documents the training 
parameters (e.g. hold times completed each session), total session duration time, and changes made to 
increase/decrease efforts for the next session. Health parameters, such as heart rate and blood pressure 
will be collected. An automatic blood pressure monitor will be placed on the upper arm of the subject to 
measure their blood pressure. An automatic pulse ox monitor will be placed on the finger of the subject 
to measure their heart rate. The trainer will also take general notes on the sessions and the exercises, 
as well as the plan for the next exercise session. 
Each training session is expected to take up to 1.5 hours. 
Training Intensity Assessment and Adjustments 
Training intensity will be adjusted progressively with add-on dumbbell weights that will be added to the 
vibrating dumbbell. Subjects will be asked to hold onto the vibrating dumbbell tightly for as long as they 
can for each exercise. If they are unable to hold on tightly for at least 15 seconds, the weight for the 
next session will be decreased, whereas if they are able to hold onto the dumbbell for greater than 60 
seconds, the trainer will stop the exercise and the dumbbell weight will be increased for the next session. 
The amount of weight increased and decreased will be determined by the trainer and will be reviewed 
and verified by a member of the senior study personnel.  
The trainer will meet with the senior study personnel (PT and PI) at minimum once a week to review 
subjects' training progress, performance, any complications, concerns or complaints that the subject 
expresses, and any changes in the health status of the subjects who had been seen over the course of 
the week. Senior personnel will re-assess and modify the training procedures as appropriate.  
During the last week of training (week 12), the trainer will give subjects a survey to assess satisfaction 
with the training program to collect their feedback on factors such as tolerance, perceived strength, 
performance and health benefits, efficiency of training, choice to continue training, and if they would 
recommend this form of exercise to others. 
The follow-up outcome assessment visit, which take place at our laboratory, will be conducted by the 
PhD student and overseen by the PI.  

Visit 2 (midway visit) 
Participants will come back to the lab 6-8 weeks from the beginning of the intervention. The follow-up 
visit intake form will be completed to identify any changes in the participants health or medical status, 
lifestyle or any other changes that could impact the participants ability to complete the exercise program. 
At this visit we will test their strength in the same way that it was tested on initial visit. Additionally, they 
will fill out the pain measure forms, the health and satisfaction form and the carpal tunnel questionnaire 
that were filled out at the first visit.  
This visit is expected to take no more than 2 hours to complete.  
Visit 3 (end of the exercise program) 
At the end of the 12-week intervention period, subjects will come back to the lab for the final visit. This 
visit will be scheduled 12-14 weeks after the start of the intervention. However, even if a participant is 
unable to come back at 12 weeks exactly, the exercise program will still end at 12 weeks.  
The follow-up visit intake form will be completed to identify any changes in the participants health or 
medical status, lifestyle or any other changes that could impact the participants ability to complete the 
exercise program. At this visit subjects will complete all the measures that were completed during the 
first visit. This includes the pain measures, measure of health and function, carpal tunnel questionnaire, 
strength, power output and functional measures. These tasks are expected to take up to 5 hours to 
complete.  
As stated above, three exercise sessions will be scheduled each week. We expect that this schedule will 
be modified due to scheduling conflicts, illness, etc. and it is possible that subjects may sometimes 
complete less than three visits per week. All visits that are changed or missed will be documented in the 
research record but will not be considered protocol deviations so long as they are completing a minimal 
number of sessions (10) per six-week period. If a subject completes less than 10 exercise sessions in a 
6-week period they will be removed from the study.  
As stated above, testing sessions at the HERL lab will be scheduled at 6 and 12 weeks from the baseline 
visit. We expect that this schedule will be modified due to scheduling conflicts, illness, etc. For this reason, 
subjects will be given a 2-week window (6-8, 12-14 weeks) in which to complete these visits. Testing 
sessions within this window will not be considered protocol deviations. 
Eligibility Criteria 
Inclusion Criteria: 
(1) have a neurological impairment secondary to a SCI or disease at T2 or lower  
(2) greater than 6 months post injury 
(3) use a manual wheelchair as primary means of mobility (at least 30 hrs. per week) 
(4) 18 to 65 years of age 
(5) provide signed medical release by primary care physician to engage in a high-intensity resistance 
training exercise program 
(6) live within 60 minutes driving time (1 hour) from the research center 
(7) able to perform a transfer independently to and from a wheelchair  
(8) have normal range of motion in the upper limbs.  
Exclusion Criteria: 

(1) history of fractures or dislocations in the shoulder, elbow and wrist from which the subject has not 
fully recovered or joint replacement of any of the joints in the upper extremities  
(2) upper limb pain that interferes with the ability to propel or transfer  
(3) recent hospitalization for any reason (within the past three months) 
(4) pregnant women  
(5) history of coronary artery disease, coronary bypass surgery or other cardiorespiratory events 
Statistical Plan 
Distributions of all data will be examined. Should outliers or distributions that are nonlinear in nature be 
present, appropriate transformations will be performed. Means and standard deviations, or medians and 
ranges, as appropriate, will be calculated for all variables. A repeated measures ANCOVA will be used to 
examine primary (strength) and secondary outcome measures (pain, quality of life, power, transfer 
ability, propulsion characteristic) for the three time points. For significant models, post-hoc analyses with 
Bonferroni corrections will be used. Total number of training sessions completed will be entered as a 
covariate if necessary. The training progress (e.g. hold times) and training adaptations made and 
documented by the trainer during each session will be analyzed using graphical methods to further assess 
training effects that occur overtime.