Intervention on Bone Health in Wheelchair Users

Inclusion Criteria:

• BMD Z-score of the spine ≤ 0 SD

• primary aid for mobility being a manual wheelchair, i.e. ≥50% of the time

• 18-60 Y

• congenital (i.e., CP, spina bifida, dysmelia, hip dysplasia) and acquireddisabilities (i.e., SCI, amputation)

• non-progressive impairment, and in the case of SCI; ≥ 2 years since time of injury

• ability to perform key exercises (e.g., overhead press)

Exclusion Criteria:

• injury acquired <2 Y ago

• change in health and/or medication within the last 3 months

• fractures affecting measured sites or contraindicating strength testing/training

• menopausal, pregnancy or planned pregnancy during the study period

• language or cognitive barriers affecting the ability to understand all aspects ofthe study

• • patients with progressive neurological disease, serious or uncontrollableepilepsy, endocrine diseases (including diabetes mellitus type 1 or 2, thyroiddisorders, calcium homeostasis disorders and metabolic bone disease, pituitary glanddisorder, sex hormone disorders), cancer, serious mental disorder, or comorbidmedical conditions affecting either a) nutritional function: i.e., malabsorptionproblems due to previous surgery in the gastrointestinal tract, inflammatory boweldisease, coeliac disease, eating disorders, chronic pancreatitis, liver or kidneydisease (those that cannot convert vitamin D to its active form in the body), otherconditions affecting vitamin D or calcium absorption; b) musculoskeletal system:i.e., congenital systemic skeletal dysplasia affecting bone density, inflammatoryarthritis conditions (such as rheumatoid arthritis, psoriatic arthritis, ankylosingspondylitis, and lupus), ongoing tendinitis or muscle injuries not compatible withthe exercise intervention; c) cardiovascular system: i.e. congenital heart failure,congenital connective tissue disorders affecting the aorta and/or arteries, othercardiovascular conditions not compatible with the exercise intervention;

• the use of certain medications: bisphosphonates, PTH (teriparatide), Denosumab,Raloksiphen, Prednisolone/steroids/androgenic steroids, high dose oestrogen (including medroxyprogesterone acetate contraceptives) immunosuppressivemedications/ chemotherapies, vitamin K, anti-epileptic medication (Lamotrigine,Phenytoin, Phenobarbital, Carbamazepine, Primidone), proton pump inhibitors (PPIs),selective serotonin receptor inhibitors (SSRIs), thiazolidinediones (TZDs),anticonvulsants, hormone deprivation therapy, calcineurin inhibitors, andisotretinoin.

• other therapies that aim to increase bone mineral density, e.g., vibration therapy,functional electrical stimulation (FES)

• alternative medicine that interfere with vitamin D or calcium metabolism or affectbone mineral density

• known other contraindication of resistance exercise.