Standing (n=4 studies)

Kunkel et al. 1993; USA
Downs & Black =12
Pre-post
N=6

Population: 6 men, ages 36-65, injuries were complete and incomplete from C5-T12. Study had no controls.
Treatment: Passive standing frame. Increased gradually until able to "stand" 30 mins 3x/day. Progressed to 45 mins 2x/day then participants completed 45 mins of standing 2x/day for 5 months.
Outcome measures: BMD and fracture risk by DPA.

1. There was no significant change in fracture risk as measured with BMD for femoral neck or lumbar spine with "standing".

Needham-Shropshire et al. 1997; USA
Downs & Black =10
Pre-post
N=16

Population: 16 men and women, mean age=29, complete injuries from T4-T11, no controls.
Treatment: Standing and ambulation. 32 sessions then participants continued ambulation for 8 more weeks.
Outcome measures:BMD by DPA.

1. There were no significant changes in BMD in the femoral neck, Ward's triangle, or the trochanter.

Kaplan et al. 1981; USA
Downs & Black =10
Pre-post
N=10

Population: 10 men and women, ages 19-56, with incomplete tetraplegia, no controls.
Treatment: Tilt-table weight-bearing and strengthening exercises. Each tilt table session lasted at least 20mins 1x/day, and the tilt table angle attained was ≥450. Two groups: 1) early (within 6 mos of SCI) and 2) late group (12-18 mos post SCI).
Outcome Measures: urinary calcium excretion.

1. Significant improvement (p<0.01) in calcium excretion, urinary calcium, and calcium balance for the early group.
2. The late group had a significant improvement for urinary calcium, and calcium balance.

Goktepe et al. 2008
Turkey
Downs & Black =14
Observational
N = 92

Population: 71 consecutive adults (18-46 years) and at least 1 year post injury.
Treatment: Participants were divided into 3 groups: Group A had standing ≥1hr daily, Group B stood <1hr/day, and Group C did not stand at all.
Outcome Measures: BMD by DXA of bilateral hips (Ward’s triangle and femoral neck) and spine (L2 to L4).

1. There was no statistically significant difference between the 3 groups in the BMD of any of the regions measured.
2. Group A had a tendency to have higher t-scores, although the differences were not significant

Walking (n=4 studies)

Carvalho et al. 2006; Brazil
Downs & Black =16
Prospective controlled trial
N=21

Population: 21 men with mean age 31.95 ± 8.01 yrs; Level of injury was C4-C8; TSI: mean 66.42±48.23 months, range 25-180 months. Two groups: In the treatment group, all individuals had a complete lesion; in the control group individuals had an incomplete lesion (AIS B).
Treatment:  Treadmill gait training provided by neuromuscular electrical stimulation (NMES). Quadriceps and tibialis anterior stimulated for <5 months before beginning gait training (2x/week) in order to walk for 20 min and support <50% of body weight  (pre-gait training)
Either 1) NMES for 6 months, 20 min/session,2x/wk (n=11).; or
2) No training (n=10)
Outcome measures: BMD by DXA, bone markers.

1. Increase in bone formation markers after gait training occurred in 81.8% (9/11) of the participants, with 66.7% (8/11) had a decrease in bone resorption markers.
2. In the control group, no changes were observed in three people; two people had an increase in bone formation markers; while three people had a decrease in bone resorption markers.

Giangregorio et al. 2006;
Canada
Downs & Black =20
Pre-post
N=14

Population: 14 men and women aged 22-53 yrs with incomplete injuries from C4-T12; AIS B,C; reference control group
Treatment: Body-weight-supported treadmill training, 12 months.
Completed protocol 3x/wk for 144 sessions; intensity increased as tolerated
Outcome Measures: BMD by DXA, bone markers.

1. There were no significant changes in bone density or bone geometry at axial or peripheral sites with the exception of a small but significant decrease in whole body BMD.
2. No significant difference in bone markers.

Ogilvie et al. 1993;
England
Downs & Black =8
Pre-post
N=4

Population: Bone assessment with 2 men and 2 women, ages 16-42. Both subjects had paraplegia. No controls.
Treatment: Reciprocal gait orthosis. No protocol provided. Quantitative computed tomography repeated every 6 months from the 1st referral, orthotic fitting and training, to independent and regulator ambulation (mean=5 months). The RGO was used daily on average for 3 hrs.
Outcome measures: BMD by QCT

1. Three of 4 participants increased or maintained femoral neck BMD but no change in lumbar spine.

Thoumie et al. 1995; France
Downs & Black =8
Pre-post
N=7

Population: For bone assessment there were 6 men and 1 woman, ages 26-33, with injuries between T2-T10. No controls.
Treatment: RGO-II hybrid orthosis. Completed the protocol within 3-14 months (2-hr sessions 2x/wk).
Outcome measures:BMD by DPA.

1. At baseline, participants (compared with age-matched Z-score) had no significant change in L-spine BMD but a decrease in femoral neck BMD.
2. After the training program (16 mos), no consistent changes at the femoral neck BMD among participants (4 participants decreased BMD, 1 participant increased BMD and no change in 2 participants).