Parker Indego

As a physical therapist and Indego instructor, I’m frequently asked, “Will the Indego really benefit me?” and “What improvements can I expect?” My best response involves referencing clinical research data on the subject, steering the conversation to an evidence-based discussion of what improvements users have experienced. In short, when making your decision, don’t overlook research data.

I have summarized the findings of a review titled Systematic review on wearable lower-limb exoskeletons for gait training in neuromuscular impairments, by Rodriguez-Fernandez, et al. published in February 2021. The systematic review covers the Indego exoskeleton and its competitors. My objective is to explain the benefits and limitations of exoskeletons, based on the evidence to date.

The systematic review analyzed 87 studies conducted between 2009 and 2019 and focused on wearable lower-limb exoskeletons for over-ground gait training.

Inclusion criteria:

• Use a wearable, powered, lower-limb exoskeleton

• Report over-ground outcome measures

• Include users with a neuromuscular disorder

Exclusion criteria:

• Soft exoskeletons or exo suits

• Body-weight support systems or treadmill training

• They remain bulky and heavy, require supervision, can be difficult to don and doff, and require use of walking aids which can hinder mobility and independence.

• Joint misalignments and improper fit can increase the metabolic costs, create discomfort and generate skin abrasions or risk of fractures.

• The cost for personal devices must be reduced. The vast majority of potential users are unable to afford them.

• Validation studies are currently in their early stages. Evidence is limited to short intervention trials with few participants.

• Protocol design variability combined with outcome measure variability hinders benchmarking.

• There is a great need for experimental studies using control groups to obtain stronger evidence on clinical effectiveness.

• The majority of outcome measures are focused on ambulation assessments rather than on physiological and psychological changes.

• Future studies in spinal cord injury should focus on assessing the impact of exoskeleton therapy on outcomes related to secondary health conditions.

• They promote health benefits including improved blood circulation, reflex activity, and bowel and bladder function.

• Exoskeletons activate mechanisms of neuroplasticity and re-connectivity which promote motor function recovery in individuals following spinal cord injury and stroke.

• They provide opportunities to stand and socialize at eye level.

• People with spinal cord injuries are the main users.

• People following stroke present the most reliable and promising results in terms of rehabilitation outcomes compared with traditional gait therapy.

• Randomized control trials are needed to demonstrate effectiveness as a rehabilitation device and their impact on psychological and physiological secondary health conditions.

• Twenty-one studies compared outcome measures before and after exoskeleton training. Nineteen of these reported that functional mobility improved.

• No randomized control trials comparing lower limb exoskeletons vs. traditional gait training have been performed. This is a significant limitation in the body of evidence to date.

• Sixteen studies compared gait performance before and after exoskeleton training. Twelve reported improvements, one reported a negative change, and three reported no change in gait performance. Three out of nine studies showed improvements to Fugl-Meyer following exoskeleton training.

• Five randomized control trials including 183 patients were identified. Four out of five studies report significant improvements in measures like gait speed, step length, spatial symmetry, Functional Ambulation Categories (FAC scores), corticospinal excitability, and muscle activation following rehabilitation using an exoskeleton. In addition, FAC scores were maintained at two and three months follow up assessments in two different studies.

• Four out of seven studies showed an improvement in gait speed.

The systematic review concludes that exoskeletons are safe and effective tools for gait training following neuromuscular impairment. However, effort should be invested in creating exoskeletons that are:

• Lightweight and easy to use

• Validated through well-defined protocols to provide the best rehabilitation possible and the opportunity for benchmarking

Systematic review on wearable lower-limb exoskeletons for gait training in neuromuscular impairments. Antonio Rodriguez-Fernandez, et al. J NeuroEngineering Rehabilitation (2021) 18:22 is available here: https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-021-00815-5.

Pro Tip: Stay up to date on new clinical research by signing up for free email notifications at https://www.ncbi.nlm.nih.gov/.

About the Author:

Robert McCloskey is a physical therapist, Indego Instructor, and the co-founder and Chief Care Officer at Next Level Rehab in Asheville, North Carolina. Robert earned his Bachelor of Science degree in Biology from Georgia Southern University, and his Doctor of Physical Therapy degree from the University of Kansas Medical Center. Robert has a background in treating individuals with neuromuscular disorders and traumatic brain injuries.  Next Level Rehab offers Indego-centered rehabilitation and wellness services, special event services, and Indego personal screening and training services. To learn more, visit www.NextLevelRehabAsheville.com.

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It was a chilly morning over three years when Paul Austin and Brandi Koltermann were enjoying their landscaping work together. Taking down a large tree was the next major task. Paul, formerly a rescue swimmer for the U.S. Navy, owns a landscaping business. One last limb had to be cut before the trunk. Paul climbed the tree while Brandi waited on the ground, ready to clear away the brush. Paul started up the saw but then grabbed the back of his leg. Falling from the tree ten feet, he broke his back and severed his spinal cord, a T11 complete injury.

Although life has changed, Paul and Brandi have maintained their business. They’re still receiving requests for work, but their roles are different. Paul cuts lawns and Brandi does the weeding. Paul is grateful he can still do the landscaping work he loves, even though tree removal is no longer an offering.

Brandi recalled her vivid memory of the accident. She held Paul’s head and talked to him to calmly while he received treatment. When told he was paralyzed, Paul looked dead in the eyes. He was devastated. He lost everything he worked so hard for. Paul worried that relationships would change.

Paul believed walking again was not an option. When he started rehab in Richmond, VA, he noticed the use of exoskeletons in physical therapy. He asked about “those Robo Cop legs.” As a Navy veteran, he went through the Hunter Holmes McGuire VA Medical Center. He submitted his name to the research department, expressing interest in the exoskeleton. Six months later, he was called to take part in a nine-month program involving therapy twice a week. “The VA definitely helped with this process. They’ve been so supportive,” said Paul.

Seeing the exoskeleton in use in rehab, provided a glimmer of hope. When he tried the Indego exoskeleton, there was a smile on Paul’s face and hope in his heart. When he stood up, Brandi was overwhelmed with emotion. “You lost the use of your legs, and now this gives that back to you,” she said.

When Paul first stood up, Brandi was able to hug him face-to-face for the first time since the accident, and she cried. Paul loved the feeling of being able to look someone in the eyes again. “It’s an indescribable feeling. It was such a good feeling, because in your head you’re thinking you’re never going to walk again, and I can’t do this or that,” he said.

When Paul saw the Indego exoskeleton at the 2018 National Veterans Wheelchair Games in Orlando, he knew he had to try it. The device wasn’t as bulky and had fewer components than the one he was using. With the Indego, mobility seemed almost graceful, very different than with his current exoskeleton. After a one-hour trial, they were convinced. The Indego provided a smoother more natural gait.

Plus, the Indego weighs significantly less. The couple did not travel with their first exoskeleton, but with the Indego, they knew that it was possible to be on the go. With the other brand, Paul felt like a machine because of its weight, feel, and rigid components. With the Indego, walking felt more natural.

The Indego exoskeleton was very easy to learn to use. He leaves the device charged and assembled in a chair. Then, with Brandi’s help, he simply transfers in and out as needed. “It does all of the work for you after that!” He did have to get used to walking around at home and on hills and ramps, but after practice, it didn’t take long to get accustomed to the Indego. Paul now walks three times a week, on average.

With the help of the VA and Indego, the process of acquiring the exoskeleton was streamlined. “As simple as it could be, and the communication was great,” said Paul.

Paul’s daughter is planning to get married, and he fully intends to walk her down the aisle. When he found out he was paralyzed, Paul gave up this dream, but Indego has made his dream possible. As a father, walking his daughter down the aisle is a major life milestone. “It’s a big deal,” he said.

A short time after using the Indego, Paul saw extreme improvement in his health, both physically and mentally. His upper body strength and bone and joint health has improved. And his mental outlook is better. “Thanks to the exoskeleton, there is hope for walking. It’s a great feeling. Everything feels a bit lighter. It’s made a true difference,” said Paul.

Paul is considered young for wheelchair use, but the couple has a positive outlook on life despite all that’s happened. They are always looking forward to new possibilities and opportunities. For example, Paul was able to start electrotherapy after using the Indego exoskeleton.

What’s next for the couple? This year’s 9/11 Memorial & Museum 5K Run/Walk in New York City. They set goals and the Indego helps achieve them. To prepare for the walk, Paul practices distance walking at home. Their quarter-mile long driveway is the perfect track. The first goal is to be able to walk a mile, with a pine tree or mailbox as the end marker. Recently, Paul has begun walking three quarters of a mile regularly. He’s excited to reach the one-mile mark. Brandi looks forward to the moment she can say, “You know what Paul, we did this.”

Brandi keeps an engraving near Paul’s National Wheelchair Games medals that states: An “I can’t” became “I can.” Later, Brandi updated the saying: An “I can’t” became an “I did.” Over the past few years, Paul progressed from believing he would never walk again and listing impossibilities to setting the goal of walking a mile.

Brandi keeps a list of things that Paul thinks he can’t do because he is in a wheelchair.  They cross things off as they accomplish them together.  Crossed off the list are: riding a four-wheeler, scuba diving, using a zero-turn lawn mower, going up in a hot air balloon, and walking!

The couple’s mission is now to encourage others. “We are in a place with technology where the question is, ‘Why not?’ At times, things can seem tough, but just never give up hope and always strive to be better,” they advised.

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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