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Subsequently, we asked participants questions regarding the severity of onset of secondary complications
commonly seen in SCI including spasms, joint stiffness, constipation, urinary tract infection, pain, etc.,
[34]
using the following scale previously developed in this population : (1) “I don’t have this problem”; (2)
“Problem is not at all bothersome”; (3) “Problem is slightly bothersome”; (4) “Problem is moderately
bothersome”; and (5) “Problem is greatly bothersome”.

[35]
Lastly, the Center for Epidemiological Studies Depression scale was completed. Participants were asked
to rank on a 0 (rarely or none of the time) to 3 (most or all of the time) scale how they felt about each of 20
items during the last week. The overall score was the sum of all 20 items for a total possible score equal to
[36]
60. This survey is reliable and valid in persons with SCI .
Assessment of body composition
Participants arrived at the laboratory after an overnight fast (> 10 h) wearing exercise attire without metal.
Initially, the participant was placed on the dual-energy X-ray absorptiometer (DXA software version 13.5,
Lunar Prodigy Advance, GE Healthcare, Madison, WI, USA) for a few minutes to minimize muscle spasm.
They were instructed to remain motionless and not talk during the scan, which was used to estimate
whole-body and regional (arm, trunk, and legs) FM and FFM. Body weight (in kg) was calculated from
the summation of FM, FFM, and bone mineral content. Body composition changes during the study
were expressed in absolute units (kg). Analyses were performed by the same technician who followed
standard quality control procedures developed by the manufacturer. Intraclass correlation coefficients
and coefficients of variation for whole-body and regional determinations of FM and FFM obtained in
five individuals with SCI measured three months apart were equal to 0.98 and 0.99 and 0.7% and 0.8%,
respectively. In addition, waist circumference was obtained in duplicate in the supine position according to
standardized procedures .
[37]

Assessment of dietary intake
Participants completed a four-day food log (including two weekend days) at baseline and at three and six
months. They were encouraged to actively report all food and drink ingested (including supplements)
each day with specific instructions to describe method of preparation, portion sizes, and brands where
applicable. This information was reviewed during each visit and used to determine total caloric intake as
well as fat, carbohydrate (CHO), and protein intake (in g) using a commercially-available website (http://
ndb.nal.usda.gov/ndb/foods/list). They were asked to maintain their dietary practices during the study.

Intervention
Participants performed 2-3 h sessions of supervised ABT targeting the lower extremities (80% for those with
tetraplegia and 100% for paraplegia) a minimum of two days/week to a maximum of five days/week. Activity-
[38]
based therapy was shown to enhance motor gains in persons with chronic SCI . This regimen elicits energy
expenditure between 5 and 8 mL/kg/min , which is similar to circuit training and FES leg cycling [40,41] yet lower
[39]
[42]
[40]
than arm ergometry, wheelchair ambulation , or exoskeleton-assisted walking . ABT as performed in the
current study consisted of these modalities as previously described [38,43] : 1.5-2.0 h/week of active assistive
exercise, 1.5 h/week of upper/lower body and core resistance training, 1 h/week of load bearing, 30 min/
week of arm/cycle ergometry, 1.0-2.0 h/week of gait training including assisted and unassisted walking
as well as body weight-supported mechanized elliptical training, 10-30 min/week of vibration training,
and 30 min/week of FES of the quadriceps, gluteals, and hamstrings. Training was individualized for each
client based on their baseline function, and progression was instituted daily based on participant tolerance
to training and level of adaptation. During the study, time performing active assistive exercises and
passive gait training generally decreased while time performing resistance training and active gait training
increased. Training volume differed across participants as rehabilitation costs were paid out-of-pocket.