Parker Indego

Steve Holbert, USMC veteran, was paralyzed after a motorcycle accident 10 years ago. Despite that and the new wheelchair, he took the challenge to establish a new normalcy in life. Thus, the Indego Exoskeleton came into play in March of 2019; and not only can Steve now stand up from his wheelchair, but he can also walk.

Steve and another paralyzed veteran were the first two to receive Indego Exoskeletons from the Houston VA Medical Center. With them being the first at the VA, it took about a year for them to get screened, trained, and complete a home trial period, before being issued their own devices. Since then, they have been working with the Houston VA to help others get an Indego as well. Thanks to them, the process is now quicker and smoother.

Many health benefits started to get noticed with the use of Indego, other than being able to stand and walk. This included Steve’s bones, intestines, bladder, bowel program, and his entire cardiovascular system. “The increased trunk control and strength I have gained, along with added good old physical exercise, has made me feel better too.”

Steve also notes the psychological benefits. “You just feel better about yourself, and I truly feel like I can just stand up and go for a walk now.”

Steve describes how he can also no longer speak to people at “butt-level,” constantly craning his neck to look up at others, or have them lean down to him. “It’s a huge mental boost to be able to stand at the height you were before you were paralyzed. Too many people take that for granted.”

The Indego exoskeleton goes around the waist, lower back, and legs. The pieces are all connected as one unit that the user can also have synced on a phone. “When you turn it on and stand up, it’s sort of like a pendulum to activate it. You lean forward to go, and lean back to stop.” The Indego does require an assistant, however with practice, Steve is at the point where he can go on hour-long walks by making laps in his driveway.

Steve uses the Indego Exoskeleton to walk up to five times a week around his home, and that has helped him hit his goal of walking 200,000 steps by Christmas of 2019.

Since then, Steve has been active in his local PVA chapter to help fellow veterans and has also been part of the Indego Veteran Peer Support Group. Then one day, Indego contacted him to offer an opportunity for him to participate in seeing the President of the United States at an event with SoldierStrong. With four other paralyzed veterans that are also Indego users, they would stand for the national anthem as the singer went on stage and prepared to sing. They would stand at the front of the stand to be seen by all and on TV.

“But he walked up and started singing immediately, before we even had a chance to stand.” Steve had rushed to stand up, but nothing happened, as the exoskeleton was not fully activated.  He and his wife took a few moments to reset it, and then Steve was up and moving. “I pulled off my hat, put my hand over my heart, and looked to see the President staring at me. I was thinking “holy crap, I had one simple job to do, and I flubbed it up!”

When the national anthem ended, Steve and the other military veterans used their exoskeletons to walk to the barrier in front of the stage. He brought some challenge coins from his Texas PVA Chapter, and held one up to the President, but a Secret Service agent shook his head at him. “Then the Vice President walked up, took the coin and shook my hand. I was so flabbergasted by that, that I have no idea what he even said to me.”

Upon returning home in Texas, Steve wrote thank you notes to SoldierStrong and Indego. “I don’t think I’ve ever felt the desire to stand up and walk more fiercely than right then, in front of the President of the United States of America during the national anthem, and with four other Indego users. I guess I feel like it was my duty to stand up, to hopefully show other paralyzed veterans that you can stand up and be proud of yourself and your country.

I am also thankful I got to attend the event and was able to share my experience of using my robot legs with other users, and hope other paralyzed veterans got to see us and were inspired to inquire about the Indego exoskeleton device.”

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Many individuals with spinal cord injury (SCI) require full or partial external support of their legs to be able to walk (i.e. using external bracing or neuroprosthetics, or manual facilitation). Exoskeletons may provide an alternative approach to traditional neurorehabilitation techniques. The Indego exoskeleton is able to provide full (100%) robotic assistance throughout the gait cycle for those who need it, and less assistance for those who do not. 

As a physical therapist working with individuals with SCI, Indego’s Variable Assist feature gives me the ability to modulate the level of powered assistance given to my patients. Variable Assist allows me to increase or decrease the level of assistance given by 10% increments at the left and right, hip and knee joints all independently of one another. This customization means that while Indego can replace lost mobility for some, it may also help restore or improve impaired mobility for others. 

Many patients present with preserved lower extremity function after a spinal cord injury. An estimated 67% of all those with SCI present with some level of incompleteness (sensory or motor function below the level of injury) (National Spinal Cord Injury Statistical Center 2020). For those with motor incomplete injuries (ASIA Impairment Scale C or D) at admission, 71% - 100% can be expected to regain community ambulation, with or without use of lower extremity orthotics, at 1 year post-injury (Scivoletto 2014). Locomotor training, including use of Indego, could potentially help these individuals regain walking function more quickly and efficiently, and with improved gait patterns. 

Additionally, many individuals with complete injuries, like those with low thoracic or high lumbar levels of paraplegia, may also have preserved proximal lower extremity musculature (i.e. hip flexor and/or quadriceps function). Depending on the location of the injury and extent of muscle preservation, locomotor training using Indego may help them to regain some walking function, or could simply help improve their functional mobility (i.e. transfers). 

1. Challenge the patient, and encourage him or her to use more of their available musculature (trunk or leg) in order to walk. With 100% Indego assistance, patients do not have to contribute their own muscle function in order to walk. While 100% assistance may be beneficial when initially learning how to use Indego, decreasing the amount of assistance at a particular joint can facilitate strength and functional gains outside of Indego.
2. Provide a cardiovascular workout. Decreasing the level of assistance from the Indego requires the patient to work harder, which increases the cardiovascular and muscular demands to maintain the quality and/or speed of the gait pattern. 
3. Decrease the “robotic feel.” Many individuals with SCI who have preserved lower extremity function may feel too restricted by the device at 100% Variable Assist. Decreasing the level of robotic assistance may make walking in Indego feel more “normal” and less automated as the patient takes over volitional control and contributes more to the gait pattern. 
4. Allow the patient to make errors in a safe and controlled manner. Error detection and correction has been shown to facilitate improved motor learning and carryover (Chisholm 2015; Lam 2006; Marchal-Crespo 2013). 

Individuals with paraplegia who purchase Indego for home use may also benefit from the Variable Assist feature. 

As a non-spinal cord injured individual, it takes very little effort for me to walk in my home or community. Likewise, Indego Users with preserved lower extremity muscle function may keep the Variable Assist level higher to avoid fatigue during casual walking around their home or community.

However, when I go to the gym, I want to challenge myself and get a good cardiovascular workout. Similarly, Indego Users may lower the Variable Assist to achieve a cardiovascular workout when the goal is exercise, rather than casual mobility. Decreasing the level of robotic assistance provides Users with greater challenges, and as such, is usually tolerated for much shorter durations. 

While Indego’s Variable Assist feature can be extremely beneficial for many, it must be used wisely and with discretion. Since decreasing levels of Variable Assist affects both flexion and extension moments surrounding each joint, some individuals may not tolerate changes in assist levels over extended amounts of time due to muscle fatigue. 

For example, a patient who presented to our facility with weak hip flexor preservation (2/5 MMT) and no hip extensor preservation (0/5 MMT) could tolerate walking short bouts at 20% Variable Assist at bilateral hips. However, when he attempted walking for longer durations he noticed an increase in abdominal fatigue and low back pain due to the decreased hip extension stability in stance provided at 20% Variable Assist. If this patient sought purchase of Indego, I would recommend that he maintain a much higher level of variable assistance at his hips for general walking, with the freedom to decrease Variable Assist for short durations of exercise. 

Indego’s Variable Assist feature provides clinicians, patients, and home Indego users with multiple options for adjusting levels of robotic assist to meet his or her individual goals. Using this feature within the clinical plan of care may help facilitate return to walking function for those with lower extremity preservation after spinal cord injury. Additionally, this feature will likely present unique opportunities in the future when used with other neurological diagnoses affecting the lower extremities, like stroke, traumatic brain injuries, multiple sclerosis, and others. 

Casey Kandilakis, PT, DPT, NCS is a clinical research scientist at Shepherd Center in Atlanta, Georgia.  Casey received her Bachelor of Science in Exercise Science from the University of Tennessee in 2007, and her Doctorate of Physical Therapy from East Tennessee State University in 2010.  Since that time, Casey has worked in the field of neurological rehabilitation and research, and has lectured at numerous national and international conferences on the use of advanced technologies in rehabilitation and the translation of research into feasible clinical practice.  She became a certified neurologic clinical specialist (NCS) in 2014.  Her current research focuses on the use of advanced technologies and exoskeletons with individuals who have lower extremity deficits due to neurological injury or disease.  Additionally, Casey is a Certified Indego Instructor, and has taught and lectured about Indego to clinicians around the world.

1. Lam T, Anderschitz M, Dietz V. Contribution of feedback and feedforward strategies to locomotor adaptations. J Neurophysiol. 2006;95:766–773. 
2. Marchal-Crespo L, Schneider J, Jaeger L, Riener R. Learning a locomotor task: with or without errors? Journal of Neuroengineering and Rehabilitation. 2014;11(25):1-10. 
3. National Spinal Cord Injury Statistical Center, Facts and Figures at a Glance. Birmingham, AL: University of Alabama at Birmingham, 2020. 
4. Scivoletto G, Tamburella F, Laurenza L, Torre M, Molinari M. Who is going to walk? A Review of the factors influencing walking recovery after spinal cord injury. Frontiers in Human Neuroscience. March 2014;141(8):1- 11. 

Laura Cowen, a US Navy veteran and proud mom of two, describes her rehabilitation following a spinal cord injury, raising two children, and dealing with the quarantine blues.

COVID-19, commonly called the coronavirus, has affected people across the globe in both drastic and subtle ways. Laura Cowen is no exception. A United States Navy veteran living in upstate New York, Laura shares she was born in Pennsylvania but traveled with the military from Florida to California. In 2002, four years after joining the Navy, Laura was in a motorcycle accident that left her without the use of her legs. She began rehabilitation and admits she was willing to try anything that might help her walk again.

Laura went through rehabilitation at the VA for three months, stating “it was better because in civilian life, you only get one month.” Laura felt the extra time helped her to learn how to “live life independently” again. Throughout her rehab, Laura’s main goal was to walk again. She tried traditional therapy, an alternative medicine gym, acupuncture, horseback riding and eventually found herself in a study at UCLA that introduced her to advanced technology. She states this was exciting because it was backed by science, and “I got to stand on my own.”

Soon after, her life got busy and she took a break from intensive therapy. “We got married, moved, built a house, had kids, and my husband went to college all in 6 years.” She laughs, saying “being a mom was quite the adventure, everything from carrying until now.” When the children were little somebody asked her once how she picks them up. “I was like they [the children] figure it out. When they started to crawl, they would come up to my chair and I would pick them up. I would slide them up my leg.” Laura adapted to motherhood, using a body sling to carry her children while she pushed her chair around and swept the floors. Laura explains “things don’t get better or worse, they just get different. Everything has stages and phases.”

Eventually, Laura restarted therapy at VA Syracuse, where she tried walking in the ReWalk exoskeleton. She states “I just had a child and felt completely out of shape.” After being passed up for trialing the Ekso exoskeleton due to a skin issue, Laura got a call about two years ago from her physical therapist, who asked her to try the Indego exoskeleton. Her first impression was that the exoskeleton looked much better, and it didn’t look as heavy. She also liked that she could use a walker for support instead of forearm crutches. Laura explains getting up in the Indego for the first time “I said ‘wow this is cool, this is going to work!’”

The Indego made an impact on Laura. “I did the training with it and now I have it at home. Oh my gosh I love having it at home, if I didn’t have it I’d be so bored. I use it predominantly inside the home. We have hard winters here, so it gives me something to stay active.” For over two months, Laura has been stuck at home like millions of others around the world due to COVID-19. She states “as far as having the Indego, I think that occupies my time, as well as exercise. I put it on myself now and that’s awesome. I get in it in about 10 minutes. I usually walk 20-30 minute sessions for 500-600 steps. My husband helps me on his lunch breaks. It’s part of our routine.”

Prior to the pandemic, Laura had been participating in training for Indego’s Advanced Gait feature which allows users to achieve faster walking speeds. “I love it the way its fluid, I can go so much further. I miss it. I need it.” Laura states she will continue her Advanced Gait training once the COVID-19 restrictions are lifted.

Here at Indego, we are committed to providing the highest quality technology and excellent customer service to support our device users, rehabilitation teams, and those in pursuit of the highest level of function after injury. Please contact us at support.indego@parker.com for any questions!

Dr. Michelle Martin, PT, DPT, is a Neuro-IFRAH certified physical therapist for the Janz Corporation, a Service Disabled Veteran Owned Small Business. Michelle graduated Summa *** Laude with a Bachelor’s Degree in Psychology from The University of Tennessee at Chattanooga where she continued her education to become a Doctor of Physical Therapy. Michelle has worked with patients with neurological, orthopedic, cardiopulmonary, and geriatric related impairments. She enjoys helping patients progress and find creative ways to overcome their barriers to mobility. Michelle hiked 2,190 miles of the Appalachian Trail from Georgia to Maine and cherishes her role as an Indego Instructor in-training where she is able to help individuals with mobility impairments enjoy the freedom of walking.

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Henry Hasson was injured in a car accident in 1994 that left him paralyzed at injury level T7. Although recovery from his injury was strenuous, Henry didn’t let it slow him down, as he went on to graduate medical school in 2001, followed by completing his neurology residency and fellowship in 2006. Dr. Hasson has now been practicing neurology for 12 years, with special qualifications in child neurology.

Dr. Hasson read an article in the Wall Street Journal about a clinical research study at NYU for the Indego exoskeleton which would give paraplegics the ability to walk again. After learning more, he decided to see if he would be a candidate for the device. His T7 injury level fell within the FDA approval range, making him eligible for training. He began his rehabilitation with the device in October 2016. Physical Therapist Clare Hartigan of the Shepherd Center conducted the training with Dr. Hasson at his home in Brooklyn, of which he said learning how to walk again was “easy and fun”. After first walking with Indego, Henry said he felt excited that the device may help with his core muscle strength and balance and that the weight bearing would be beneficial for his bones.

Henry had tried other exoskeletons, but chose Indego based on a variety of key features. The modular design of the device that allows it to be broken down into small parts for easy transport was one such differentiator. Other key attributes included how smoothly the device walks, the variable assist feature (which allows the user to customize the level of support given by the device), how easy it is to put the device on, and the fact that there is no backpack or exposed wires.

Although Indego has not replaced Dr. Hasson’s wheelchair, it acts as a complementary tool that has enabled him to do things he hasn’t done in years, such as exercising in an upright position. Henry uses Indego for his daily exercise, regular walks outside, and would hope to one day use it on stairs. He says that being upright has improved his quality of life and assisted with his breathing, circulation, and weight bearing.

Dr. Henry Hasson is one of the first users to own Indego for personal use. He has already found the device to have a positive influence on his day-to-day life and hopes it continues to improve his overall quality of life.

In November 2017, Dr. Hasson completed the 1 Mile Spinal Cord Damage Research Center Fundraiser Race using Indego. Below is a video documenting this tremendous accomplishment.

When thinking about an exoskeleton, walking often comes to mind. For rehabilitation therapists, however, exoskeletons are used for gait training along with additional therapeutic treatments. Today we are going to discuss additional therapy opportunities using the Indego exoskeleton’s software suites, including Pre-gait, Motion+, and Therapy+, and how you can optimize billing with these different treatments. Please contact your patient’s insurance provider prior to treatment, as some providers may require specific codes for reimbursement with the Indego exoskeleton.

• Pre-gait: Reaching for cones or items of variable size, weight, and height in standing
• Standing on firm levels and foam surfaces with therapist guarding
• Throwing and catching a ball
• Ball toss, light or weighted, to helper
• Increase challenge with a staggered stance
• Dynamic reaching activities with Dynavision light board or similar balance technology
• Therapy+: Weaving around cones or various objects to simulate sharp turns for object navigation at home or in community

• Pre-gait: Static standing tolerance for time
• Transfer training from various height surfaces including a mat, bed, wheelchair, car
• Standing at table playing card game or board game with helper
• Putting away groceries in therapy kitchen
• Preparing a meal in therapy kitchen
• Folding laundry while standing
• Playing hand eye coordination games on Wii Fit using remote control
• Playing shuffleboard, foosball, Jenga, horseshoes, cornhole while standing
• Therapy+: Simulate searching for a grocery shopping list with appropriate AD to incorporate cognitive skills
• Search around clinic for items with increasing difficulty in size or hiding spot; may hide puzzle pieces and incorporate a cognitive challenge by assembling puzzle, or matching shape task for appropriate patients
• Bowling using therapy equipment (cones or lightweight pins), or community outing to bowling alley. Could use several software suites to complete outing.
• Community outings to restaurant ordering food, navigating dining room, counting money, walking into and out of business, car transfers. Many software suites could apply to this outing.

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• Pre-gait: Performing mini squats with UE support on parallel bars, FWW, or crutches
• Standing front kicks
• Toe taps
• Stepping on/off various platform heights
• Single leg stepping forward and backward
• Weight shifting side to side with single leg lifts
• Upper extremity active range of motion
• UE static and dynamic resistance training using bands or dumbbells (totals less than 250-pound limit of patient plus weights)
• core stability with reaching and UE strengthening in standing position
• Boxing

• Therapy+ or Motion+: Gait training over level surfaces with FWW or crutches as appropriate
• Gait training over unlevel or outside surfaces with AD
• Navigation up and down ramps and curb cut outs with AD
• Increasing gait distance, gait speed, or improving gait mechanics
• Gait training within narrower rooms to simulate home, office, and community scenarios
• Gait training around park to simulate regular at home exercise routine

1. Pre-gait: Standing at a sink to brush teeth, comb hair, wash face, shave, apply makeup
2. Dressing while sitting, including donning shoes with Indego AFO, donning/doffing jacket while standing
3. Assisting males in performing standing urination per PLOF
4. Household chores such as folding laundry, cleaning counters, dusting, and loading/unloading a dishwasher
5. Making calls on telephone while standing
6. Medication management while standing at a raised table
7. Management of finances for a cognitive challenge while standing in Indego
8. Therapy+ or Motion+: Simulated grocery shopping, with option for patient to create a list for a meal to be prepared in a later session
9. Performing meal preparation in kitchen

Community Reintegration (97537)

• Therapy+ or Motion+: Community outing to the restaurant including navigating doors, dining room seating, ordering from a menu, and money management
• Car transfers in patient’s vehicle
• Going shopping at a local mall or shopping center
• Navigating various surfaces in parking lots, including curb cutouts, graded slopes, grass, and unlevel surfaces
• Creative and meaningful community outings based on individual’s interest (manicure at the salon, a haircut at the barber, shopping at the patient’s preferred grocery store, bowling, etc.)

Other codes may also be appropriate, including Education and Training for Patient Self-Management, PT Evaluation, and PT Reevaluation. Some overlap that exists between activities and clinical judgment is required to correlate specific patient goals with appropriate CPT codes. Please contact the Indego clinical staff for any questions or guidance on implementing the Indego in your therapy sessions!

Dr. Michelle Martin, PT, DPT, is a Neuro-IFRAH certified physical therapist for the Janz Corporation, a Service Disabled Veteran Owned Small Business. Michelle graduated Summa *** Laude with a Bachelor’s Degree in Psychology from The University of Tennessee at Chattanooga where she continued her education to become a Doctor of Physical Therapy. Michelle has worked with patients with neurological, orthopedic, cardiopulmonary, and geriatric related impairments. She enjoys helping patients progress and find creative ways to overcome their barriers to mobility. Michelle hiked 2,190 miles of the Appalachian Trail from Georgia to Maine and cherishes her role as an Indego Instructor in-training where she is able to help individuals with mobility impairments enjoy the freedom of walking.

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