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Effects of Electrical Stimulation and Vitamin D Supplementation on Bone Health Following Spinal Cord Injury.

Primary Purpose

Spinal Cord Injury

Status
Recruiting
Phase
Phase 2
Locations
United States
Study Type
Interventional
Intervention
NMES
Vitamin D
Passive movement
Sponsored by
VA Office of Research and Development
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Spinal Cord Injury focused on measuring Vitamin D, Electrical Stimulation, Bone Density, Cancellous Bone, Spinal Cord Injury, Rehabilitation, Rowing Exercise

Eligibility Criteria

18 Years - 65 Years (Adult, Older Adult)All SexesAccepts Healthy Volunteers

Inclusion Criteria:

To be included, participants will have to:

  • Be 18-65 years of age
  • Have history of traumatic SCI ( 1-year) with NLI of C8-T10 and AIS A or B (confirmed by AIS examination performed by PI or a qualified Provider
  • Have a caregiver who is available and willing to be trained to apply intervention protocol in the home (placing weights and positioning the Veteran) throughout study duration
  • Be a wheelchair user for primary mode of mobility
  • Have Knee extensors that must respond to standard surface electrical stimulation procedures (stimulation frequency procedures, 30 Hz; pulse duration:1 ms and amplitude of the current of less than200 mA)
  • Be able to receive written clearance from their medical Providers to ensure safety of participants
  • Be a Veteran (male or female), however, the Department of Veteran Affairs has limited number of female Veterans, especially those with motor complete injury at level C8-T10 (currently, there are only 3 female Veterans with the target NLI in our SCI registry). Hence, inclusion of women Veterans may be challenging due to this disparity in the SCI population. If we fail to recruit 20 Veterans, we may seek an IRB approval to recruit non-Veterans to meet our target sample size
  • Have normal ECG
  • Commit to undergo 9 months of trial; 4.5 months of open-kinematic chain resistance training followed by 4.5 months of closed-kinematic chain using simple rowing approach + Vit. D supplementation (Experimental group) or 9 months of passive movement +Vit D supplementation (control group)

Exclusion Criteria:

Potential participants will be excluded if they exhibit any of the following:

  • Neurological injury other than SCI
  • Older than 65 years of age as they may likely have considerable amount of bone loss at that age
  • Have severe osteoporosis because loading porous/fragile bone by electrical stimulation may result in bone fracture
  • Those classified as AIS C & D, as they may already be engaging in weight bearing activities that may confound the results of this trial
  • Unhealed or unstable fractures in either lower or upper extremities
  • Severe scoliosis, deformities in the hip, knee, or ankles OR impaired range-of-motion, as these could be a barrier to safe positioning on the rowing machine, and on MRI or DXA tables
  • No caregiver or family member/significant other, willing to help with placing weights and positioning participants' lower extremities on the rowing machine
  • Untreated or uncontrolled hypertension (systolic blood pressure (BP) > 140 mmHg; diastolic BP > 90 mmHg), and/or sudden hypotension upon transferring from bed to wheelchair, characterized by a drop in BP by 20 mmHg (especially in persons with tetraplegia) or heart rate > 100 beats per minute
  • Anti-coagulation or anti-platelet therapy (including aspirin)
  • Implanted pacemakers, implanted defibrillator devices or any metallic implants including knee or hip implants
  • Presence of bullets in vertebral column or shrapnel anywhere in the body that may interfere with MRI procedure
  • Other medical conditions including cardiovascular disease, uncontrolled type II DM, active deep vein thrombosis (DVT), uncontrolled autonomic dysreflexia, use of insulin for DM management, pressures injuries of stage 3 or higher, or active urinary tract infection
  • Severe hypercalcemia (serum calcium > 16mg/dl), stage III-V kidney disease, post-menopausal or estrogen dependent female, and men undergoing anti-androgen therapy or are post orchiectomy
  • DXA total body T-score less than -2.5. Total hip BMD T-scores < -3.5 and knee BMD scores of less than 0.6 g/cm2
  • Untreatable severe spasticity bearing on potential participants' activities of daily living, such as transfers from bed to wheelchair or maintaining position in wheelchair
  • Any psychiatric illness confounding judgment or cognitive impairment in participant or caregiver who is expected to help participant in the trial
  • Those with prosthetic lower limbs
  • Any condition that, in the judgment of the PI or other medical Providers, preclude safe participation in the study and/or has the potential to expose/increase participant's risk of infection
  • Unable to tolerate increasing either electrical stimulation current or weights to the lower legs for any reason

Sites / Locations

  • Hunter Holmes McGuire VA Medical Center, Richmond, VARecruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Experimental

Arm Label

NMES Plus Vitamin D

Passive movement plus vitamin D

Arm Description

Subjects will undergo 4.5 months of open kinematic chain resistance training followed by 4.5 months of closed kinematic chain using simple rowing approach and 2000IU oral vitamin D supplementation daily for 9 months.

Subjects will undergo 9 months of simple passive movement exercise at home and 2000IU oral vitamin D supplementation daily for 9 months.

Outcomes

Primary Outcome Measures

Changes in Trabecular microarchitecture
Magnetic resonance imaging will be used in persons with SCI to measure trabecular bone parameters.

Secondary Outcome Measures

Changes in Bone mineral density
Dual energy x-ray absorptiometry will be used to measure knee bone mineral density in persons with SCI
Changes in Muscle area
Magnetic resonance imaging will be used in persons with SCI to measure muscle cross-sectional area.
Changes in Bone biomarkers
Blood samples from persons with SCI will be used to measure bone biomarkers.
Changes in Quality of life (QOL)
WHO-QOL survey instrument will be used to measure QOL in persons with SCI. The scale is composed of 5 items that ranged from very poor or dissatisfied to very good or very satisfied.

Full Information

First Posted
August 6, 2021
Last Updated
October 6, 2023
Sponsor
VA Office of Research and Development
Collaborators
Virginia Commonwealth University, NYU Langone Health
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1. Study Identification

Unique Protocol Identification Number
NCT05008484
Brief Title
Effects of Electrical Stimulation and Vitamin D Supplementation on Bone Health Following Spinal Cord Injury.
Official Title
Effects of Electrical Stimulation and Vitamin D Supplementation on Bone Health Following Spinal Cord Injury.
Study Type
Interventional

2. Study Status

Record Verification Date
October 2023
Overall Recruitment Status
Recruiting
Study Start Date
October 1, 2021 (Actual)
Primary Completion Date
March 31, 2024 (Anticipated)
Study Completion Date
March 31, 2024 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
VA Office of Research and Development
Collaborators
Virginia Commonwealth University, NYU Langone Health

4. Oversight

Studies a U.S. FDA-regulated Drug Product
Yes
Studies a U.S. FDA-regulated Device Product
Yes
Product Manufactured in and Exported from the U.S.
Yes
Data Monitoring Committee
No

5. Study Description

Brief Summary
Neurogenic osteoporosis is a common complication of spinal cord injury (SCI) that is associated with low impact bone fractures. It is concerning that more than 46,000 Veterans affected with SCI and are at risk of osteoporosis and possible low impact fractures. About fifty percent of all individuals with SCI will develop low impact fracture in their life time. The management of osteoporosis-related fractures can impose substantial economic burden on the health care system, the individual and the families. Previous studies did not succeed in reversing the process of bone loss after SCI. In the present pilot study, we will evaluate the effect of Neuromuscular Electrical Stimulation Resistance Training in combination with oral Vitamin D supplementation, on bone quality in Veterans with chronic SCI, using a randomized experimental design.
Detailed Description
Neurogenic osteoporosis is a devastating problem that is likely to impact 46,000 Veterans with chronic spinal cord injury (SCI). It is typically associated with low impact fractures of long bones and other medical comorbidities. It is estimated that approximately fifty percent of all individuals with SCI will develop low impact fracture during their lifetime. The management of osteoporosis related fractures can impose substantial economic burden on the health care system, individuals with SCI and their families. Advancement in medical research clearly indicated that neurogenic osteoporosis is linked to reduced loading and Vitamin D (Vit D) deficiency. Our pilot work indicated that a simple rehabilitation paradigm targeting towards evoking skeletal muscle hypertrophy may attenuate deterioration in trabecular bone parameters after SCI. Evoked resistance training (RT) using surface neuromuscular electrical stimulation (NMES) has been shown as a successful and feasible home-based approach to load skeletal muscles after SCI. Our earlier results may imply long-term compliance and adherence if successfully applied in conjunction with a telehealth approach. In the present study, we propose a simple home-based approach of using NMES RT in conjunction with oral Vit D supplementation on trabecular bone quality in 20 Veterans with chronic SCI. Data will include measurements of trabecular bone quality as determined by magnetic resonance imaging (MRI) and bone biomarkers associated with the process of bone remodeling. Twenty participants with chronic (> 1-year post-injury) motor complete (AIS A and B) SCI (18 to 65 years of age) will be randomly assigned into either NMES RT plus 2000IU of Vit D (10 participants) or passive movement plus 2000IU Vit D (10 participants) to participate in a repeated measure design trial for 9 months. The NMES RT plus Vit D will undergo 4.5 months of open kinematic chain resistance training followed by 4.5 months of closed kinematic chain using simple rowing approach. This pilot work will have two main specific aims. Aim 1. To determine the impact of home-based NMES RT protocol plus oral Vit D supplementation compared to passive movement plus oral Vit D on bone microarchitectural properties. Aim 2. To determine the impact of home-based NMES RT protocol plus oral Vit D compared to passive movement and Vit D supplementation on biomarkers of bone formation and bone resorption.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Spinal Cord Injury
Keywords
Vitamin D, Electrical Stimulation, Bone Density, Cancellous Bone, Spinal Cord Injury, Rehabilitation, Rowing Exercise

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 2, Phase 3
Interventional Study Model
Parallel Assignment
Model Description
There are two groups
Masking
None (Open Label)
Allocation
Randomized
Enrollment
20 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
NMES Plus Vitamin D
Arm Type
Experimental
Arm Description
Subjects will undergo 4.5 months of open kinematic chain resistance training followed by 4.5 months of closed kinematic chain using simple rowing approach and 2000IU oral vitamin D supplementation daily for 9 months.
Arm Title
Passive movement plus vitamin D
Arm Type
Experimental
Arm Description
Subjects will undergo 9 months of simple passive movement exercise at home and 2000IU oral vitamin D supplementation daily for 9 months.
Intervention Type
Device
Intervention Name(s)
NMES
Intervention Description
Subjects will undergo 4.5 months of open kinematic chain resistance training followed by 4.5 months of closed kinematic chain using simple rowing approach
Intervention Type
Drug
Intervention Name(s)
Vitamin D
Intervention Description
2000IU oral vitamin D supplementation daily for 9 months
Intervention Type
Procedure
Intervention Name(s)
Passive movement
Intervention Description
Subjects will perform simple passive movement exercise for their legs while sitting in their wheelchairs at their home. The frequency of the training will be twice weekly. .
Primary Outcome Measure Information:
Title
Changes in Trabecular microarchitecture
Description
Magnetic resonance imaging will be used in persons with SCI to measure trabecular bone parameters.
Time Frame
0. 4.5 months and 9 months
Secondary Outcome Measure Information:
Title
Changes in Bone mineral density
Description
Dual energy x-ray absorptiometry will be used to measure knee bone mineral density in persons with SCI
Time Frame
0. 4.5 months and 9 months
Title
Changes in Muscle area
Description
Magnetic resonance imaging will be used in persons with SCI to measure muscle cross-sectional area.
Time Frame
0. 4.5 months and 9 months
Title
Changes in Bone biomarkers
Description
Blood samples from persons with SCI will be used to measure bone biomarkers.
Time Frame
0. 4.5 months and 9 months
Title
Changes in Quality of life (QOL)
Description
WHO-QOL survey instrument will be used to measure QOL in persons with SCI. The scale is composed of 5 items that ranged from very poor or dissatisfied to very good or very satisfied.
Time Frame
0 and 9 months

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Maximum Age & Unit of Time
65 Years
Accepts Healthy Volunteers
Accepts Healthy Volunteers
Eligibility Criteria
Inclusion Criteria: To be included, participants will have to: Be 18-65 years of age Have history of traumatic SCI ( 1-year) with NLI of C8-T10 and AIS A or B (confirmed by AIS examination performed by PI or a qualified Provider Have a caregiver who is available and willing to be trained to apply intervention protocol in the home (placing weights and positioning the Veteran) throughout study duration Be a wheelchair user for primary mode of mobility Have Knee extensors that must respond to standard surface electrical stimulation procedures (stimulation frequency procedures, 30 Hz; pulse duration:1 ms and amplitude of the current of less than200 mA) Be able to receive written clearance from their medical Providers to ensure safety of participants Be a Veteran (male or female), however, the Department of Veteran Affairs has limited number of female Veterans, especially those with motor complete injury at level C8-T10 (currently, there are only 3 female Veterans with the target NLI in our SCI registry). Hence, inclusion of women Veterans may be challenging due to this disparity in the SCI population. If we fail to recruit 20 Veterans, we may seek an IRB approval to recruit non-Veterans to meet our target sample size Have normal ECG Commit to undergo 9 months of trial; 4.5 months of open-kinematic chain resistance training followed by 4.5 months of closed-kinematic chain using simple rowing approach + Vit. D supplementation (Experimental group) or 9 months of passive movement +Vit D supplementation (control group) Exclusion Criteria: Potential participants will be excluded if they exhibit any of the following: Neurological injury other than SCI Older than 65 years of age as they may likely have considerable amount of bone loss at that age Have severe osteoporosis because loading porous/fragile bone by electrical stimulation may result in bone fracture Those classified as AIS C & D, as they may already be engaging in weight bearing activities that may confound the results of this trial Unhealed or unstable fractures in either lower or upper extremities Severe scoliosis, deformities in the hip, knee, or ankles OR impaired range-of-motion, as these could be a barrier to safe positioning on the rowing machine, and on MRI or DXA tables No caregiver or family member/significant other, willing to help with placing weights and positioning participants' lower extremities on the rowing machine Untreated or uncontrolled hypertension (systolic blood pressure (BP) > 140 mmHg; diastolic BP > 90 mmHg), and/or sudden hypotension upon transferring from bed to wheelchair, characterized by a drop in BP by 20 mmHg (especially in persons with tetraplegia) or heart rate > 100 beats per minute Anti-coagulation or anti-platelet therapy (including aspirin) Implanted pacemakers, implanted defibrillator devices or any metallic implants including knee or hip implants Presence of bullets in vertebral column or shrapnel anywhere in the body that may interfere with MRI procedure Other medical conditions including cardiovascular disease, uncontrolled type II DM, active deep vein thrombosis (DVT), uncontrolled autonomic dysreflexia, use of insulin for DM management, pressures injuries of stage 3 or higher, or active urinary tract infection Severe hypercalcemia (serum calcium > 16mg/dl), stage III-V kidney disease, post-menopausal or estrogen dependent female, and men undergoing anti-androgen therapy or are post orchiectomy DXA total body T-score less than -2.5. Total hip BMD T-scores < -3.5 and knee BMD scores of less than 0.6 g/cm2 Untreatable severe spasticity bearing on potential participants' activities of daily living, such as transfers from bed to wheelchair or maintaining position in wheelchair Any psychiatric illness confounding judgment or cognitive impairment in participant or caregiver who is expected to help participant in the trial Those with prosthetic lower limbs Any condition that, in the judgment of the PI or other medical Providers, preclude safe participation in the study and/or has the potential to expose/increase participant's risk of infection Unable to tolerate increasing either electrical stimulation current or weights to the lower legs for any reason
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Dora E Ifon, PhD
Phone
(804) 547-4723
Email
Dora.Ifon@va.gov
First Name & Middle Initial & Last Name or Official Title & Degree
Ashraf Gorgey, PhD PT
Phone
(804) 675-5000
Ext
3386
Email
ashraf.gorgey@va.gov
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Dora E Ifon, PhD
Organizational Affiliation
Hunter Holmes McGuire VA Medical Center, Richmond, VA
Official's Role
Principal Investigator
Facility Information:
Facility Name
Hunter Holmes McGuire VA Medical Center, Richmond, VA
City
Richmond
State/Province
Virginia
ZIP/Postal Code
23249-0001
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Dora E Ifon, PhD
Phone
804-547-4723
Email
Dora.Ifon@va.gov
First Name & Middle Initial & Last Name & Degree
Ashraf Gorgey, PhD PT
Phone
(804) 675-5000
Ext
3386
Email
ashraf.gorgey@va.gov
First Name & Middle Initial & Last Name & Degree
Dora E Ifon, PhD

12. IPD Sharing Statement

Plan to Share IPD
No
Citations:
PubMed Identifier
33443609
Citation
Holman ME, Chang G, Ghatas MP, Saha PK, Zhang X, Khan MR, Sima AP, Adler RA, Gorgey AS. Bone and non-contractile soft tissue changes following open kinetic chain resistance training and testosterone treatment in spinal cord injury: an exploratory study. Osteoporos Int. 2021 Jul;32(7):1321-1332. doi: 10.1007/s00198-020-05778-2. Epub 2021 Jan 14.
Results Reference
background
PubMed Identifier
33134108
Citation
Ifon DE, Ghatas MP, Davis JC, Khalil RE, Adler RA, Gorgey AS. Long-term effect of intrathecal baclofen treatment on bone health and body composition after spinal cord injury: A case matched report. World J Orthop. 2020 Oct 18;11(10):453-464. doi: 10.5312/wjo.v11.i10.453. eCollection 2020 Oct 18.
Results Reference
background

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Effects of Electrical Stimulation and Vitamin D Supplementation on Bone Health Following Spinal Cord Injury.

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