Among the long-term consequences of spinal cord injury (SCI) is severe osteoporosis due to immobility and subsequent mechanical unloading of the paralyzed limbs. In fact, all individuals with motor complete SCI develop osteoporosis below the level of the injury. Unfortunately, physical therapy does not appear to have proven efficacy and there is no conclusive evidence supporting effective pharmacologic intervention for prevention and treatment. Recent advances in the application of functional electrical stimulation (FES) for rowing exercise provide a new and exciting opportunity to improve bone metabolism and to provide mechanical strain to the paralyzed lower limbs. Specifically, FES-row exercises use electrical stimulation of the paralyzed quads and hamstrings to actively engage both the arms and the legs in a full rowing cycle. However, while FES rowing exercise appears to be sufficient to stimulate new bone formation acutely, there are no longitudinal assessment of its long-term osteogenic effect. PURPOSE: To provide a case study of the longterm osteogenic effects of FES-Rowing after SCI resulting in bilateral lower extremity paralysis. METHODS: We obtained volumetric CT scans of proximal tibia and distal femur of an adult male (36 years old, normal BMI, T4 AIS A complete SCI, 13 years post-injury) who uses a wheelchair as primary mode of mobility and enrolled in an FES rowing program, at baseline and after 6 and 66 months of rowing exercise (12 days/month, 30 minutes/day at 150 bpm HR in the first 6 months, and 9 days/month, 25 minutes/day at 132 bpm in months 6–66). Subsequently, we estimated compressive bone strength via finite element analysis (9% margin of error). RESULTS: Compared to baseline, both femur and tibia were stronger (respectively, 37%/37% [Left/Right] and 55%/38%) after 6-months of FES-row exercise. Remarkably, this improvement was not only preserved, but also continued throughout the five years of exercise (46%/87% and 67%/54%, compared to baseline). CONCLUSION: These results suggest that FES rowing exercise is a sufficiently robust osteogenic stimulus for long-term prevention and reversal of osteoporotic changes after lower extremity paralysis, and warrant further long-term cohort studies. Supported by the Ellen R. and Melvin J. Gordon Center for the Cure and Treatment of Paralysis