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  • U.S. Marine Veteran Achieves 500,000 Steps - Steve Holbert - U.S. Marine Corps Veteran - IndegoSteve Holbert, a U.S. Marine Corps Veteran, was paralyzed in a 2010 motorcycle accident. Since then, his goal is to walk again and establish a new way of life. In March 2019, he received his Indego Personal exoskeleton and took 200,000 steps within the year. By July 2021, Steve had completed 500,000 steps or nearly 250 miles. What’s his secret? Harnessing the ambition and perseverance that made him a U.S. Marine. 

     

    What is your motivation to use your Indego exoskeleton? 

    The first motivation is to walk. Hopefully, the robot can help activate nerve pathways between my brain and legs. And if it doesn’t, there are the psychological and physical benefits.  

     

    What was the timeframe for achieving 500,000 steps? 

    It was March of 2019 that I got my personal Indego. I’ve pretty much averaged 200,000 steps per year, so about two and a half years to reach 500,000 steps.  

     

    Has your health improved? 

    My trunk control and posture have definitely improved. My bowel program always works better when I’m using the Indego regularly.  

     

    What is your general exercise routine? 

    I do a 40- to 45-minute session each time. Usually just non-stop walking, unless I stop to let the motors cool down a bit. In the heat of summer, I have to be careful with the temperatures.  

     

    How do you stay motivated? 

    I don’t know a good answer for that other than—I like it. Since I’ve used it for so long, I don’t really think about it being a robot as I’m walking. I don’t concentrate on making the robot function better; I try to make myself walk better, more efficiently. Standing for the national anthem along with all the other veterans in front of the president and vice president of our country is still one of the proudest moments of my life. (Read the Parker Indego blog post: Indego and the Commander in Chief: Steve Holbert's Story.) 

     

    Do you have any tips or tricks for using the Indego exoskeleton? 

    Since I’m a high-level injury, I have found that the tighter I strap on the unit, the better my body moves. My arm and shoulder movements can translate down into the robot to make it shift in the direction I intend to move. Also, when it’s tighter I can better feel where the robot is going. 

     

    How does the Indego exoskeleton benefit you? 

    I can break it down into two categories. Physical and mental. On the physical side, the first thing I noticed within just a few days of using it—my bowel program was better. I suppose it’s from standing up, walking and jostling around my insides; things just flow through my intestines much better, which makes my bowel program easier and more efficient. 

    Another physical aspect is putting weight on my leg bones. Hopefully it helps reduce the atrophy and even strengthens my bones. I don’t know if it affects my leg muscles, but I do know it strengthens my core and shoulder muscles. When I sit down in my wheelchair I am sort of hunched over in the sitting position, not activating my back muscles. The robot forces me to use my back muscles to keep me in a more upright, erect position. The straighter I stand up, the easier it is to make the robot function correctly. After several months of using the robot, my posture is better. And it’s plain old good exercise for my arms, shoulders, and core muscles. 

    As for the mental aspect, let me back up to when I was first injured. I did my initial rehab at TIRR (Texas Institute of Research and Rehabilitation) in Houston. In the main facility, along one of the hallways, they have big poster-size photographs of former patients; many of them are standing or walking. Every day when I would roll past those pictures, I would look at them and they would give me hope that someday I could stand up and walk again. A person needs hope! 

    Fast forward several years to when I first got to use the Indego. We did our exoskeleton training along the hallways in the spinal cord injury unit at the VA hospital in Houston. 

    One day as I was walking down the hallway, a friend rolled out of his room in his wheelchair. He saw me walking toward him in the robot. I remember the look in his eyes and his giant grin. It was the excitement and hope that one day he would walk again too. Although it’s with the help of a robot, It’s a huge mental boost. 

    Another mental perk is walking with my robot daily, doing laps around my driveway. Besides the benefit of just being outside and going for a walk, it’s the mental challenge of making my body function in concert with a machine. The more proficient I can make my body function, the more proficient the robot can operate. The combination makes both of us operate better. And that makes me feel good. 

     

    What’s your next Indego goal? 

    One million steps! 

     

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    • 2 Sep 2021
    U.S. Marine Veteran Achieves 500,000 Steps
    Steve Holbert, a U.S. Marine Corps Veteran, was paralyzed in a 2010 motorcycle accident. Since then, his goal is to walk...
  • 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.

    Criteria

     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

    Findings The review focused on three key questions: 1. What is the current technological status of wearable lower-limb exoskeletons for gait rehabilitation?
    • 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.

    2. What is the methodology used in clinical validations of wearable lower limb exoskeletons?
    • 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.

    3. What are the benefits and current evidence on clinical efficacy of wearable lower-limb exoskeletons?
    • 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.

    Key Performance and Clinical Evidence Details Spinal Cord Injury
    • 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.

    Stroke
    • 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.

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

    Exoskeletons included in the literature review

    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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    • 4 May 2021
    Considering an Exoskeleton? Don't Ignore this Crucial Factor
    As a physical therapist and Indego instructor, I’m frequently asked, “Will the Indego really benefit me?” and “What improvements...
  • Navy Veteran Couple Conquers Goals One Step at a TimeIt 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.

    Navy Veteran Couple Conquers Goals One Step at a TimeWhen 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.

    Navy Veteran Couple Conquers Goals One Step at a TimeA 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.”

    Navy Veteran Couple Conquers Goals One Step at a TimeBrandi 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.

    • 16 Mar 2021
    Navy Veteran Couple Conquers Goals One Step at a Time
    It was a chilly morning over three years when Paul Austin and Brandi Koltermann were enjoying their landscaping work together...
  • Blog: How to Fundraise for Indego Personal ExoskeletonIndego Personal exoskeleton is approved for persons with Spinal Cord Injury level T3 and below. Besides Worker’s Comp and veterans, we have seen individuals achieve successful coverage for their Indego personal device through fundraising. Fundraising should be considered as a viable option for any individuals who qualify for Indego Personal. This article will offer some tips and tricks from the Indego team on how to successfully fundraise for your Indego Personal device!
     
    There are several ways to approach fundraising for your own Indego Personal device. Individuals have found success fundraising through established non-profit organizations that help individuals cover medical expenses. Indego works closely with the non-profit charity Help Hope Live (https://helphopelive.org/). Help Hope Live allows family and friends to make a tax deductible charitable donation on behalf of their loved one. The charity helps families manage medical expenses, including the cost of an Indego, for families without endangering their ability to qualify for Medicaid or other financial assistance programs.
     
    Blog: How to Fundraise for Indego Personal ExoskeletonAnother avenue to pursue fundraising for an Indego Personal is by means of fundraising websites, like GoFundMe, or accepting personal donation through PayPal, Venmo, or Zelle.             
       
    While fundraising may feel uncomfortable or embarrassing at first, the Indego staff are here to support your efforts with creative and personal ideas gathered from experience working with our clients. 
     
    One client’s mother, Sharon Drescher, shares a beautiful story of how family, friends and even total strangers supported her son, Rob, in being able to get his Indego Personal. Rob was able to walk in the Indego thanks to a highly successful fundraising event in 2019. We have a section of his story below, but you can read the full story on our blog here.
     
    The fundraiser took place throughout the year, starting in April and ending at the turn of the new year. When the year was ending though, the fundraiser was about $10,000 short, and there was concern that the holidays would negatively affect the campaign efforts.
     
    Blog: How to Fundraise for Indego Personal ExoskeletonIn mid-December, Rob’s mother Sharon was at a gift exchange with her friends and many others. She received a phone call from a family in Richmond that was following their campaign and had fallen in love with Rob’s story. The family donates money once a year to large organizations through their family foundation, but this time, they decided that they wanted to make an impact on one individual. That individual was to be Rob. With their donation of $10,000, the fundraiser was a success.
     
    There Sharon was, in the hallway, crying as her friends gathered around her and asked what was wrong. Everyone learned that the tears were of joy though, and within the next few minutes, Sharon wasn’t the only one that was crying.
     
    Shortly after, Rob was on speakerphone to hear the news. There were cheers, there were many emotions, and it was a moment where it all came together beautifully. Thus, the Indego exoskeleton was shipped to Rob by the end of December.
     
    Blog: How to Fundraise for Indego Personal ExoskeletonFundraising doesn’t have to be daunting, in fact the best fundraising is creative and specific to the individual. Basic fundraising ideas include: car washes, selling personalized t-shirts, virtual or in person 5K race, partnering with organizations like restaurants for a spaghetti dinner or allowing a percentage of the proceeds from one night’s sales to go towards an individual cause, Krispy Kreme donut fundraiser, cake walk, silent auction, and even a walk, run, or bike where individuals participating obtain financial commitments for each mile completed and they go as far as they can! 
     
    Here at Indego, we love to help our clients reach meaningful goals, and we don’t shy away from talking about fundraising if that’s what you are interested in! If you or someone you know might benefit from this exciting technology, please do not hesitate to reach out to us at support.parker@indego.com or by phone at 844.846.3446. 
     
    About the Author:

    can an exoskeleton improve my cardio parker indego michelle martinDr. 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 Cum 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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    • 23 Nov 2020
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  • 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.

    Parker Indego Indego and the Commander In Chief: Steve HolberSteve 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.”

    Parker Indego Indego and the Commander In Chief: Steve HolberUpon 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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    • 9 Nov 2020
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    Steve Holbert, USMC veteran, was paralyzed after a motorcycle accident 10 years ago. Despite that and the new wheelchair...
  • Variable Assist Functionality for Indego Exoskeleton ParkerMany 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. 

    Variable Assist for Rehab 

    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). 

    Using the Variable Assist feature, I can adjust Indego to suit each patient’s unique clinical presentation in order to: 
    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). 
    Variable Assist at Home Variable Assist Functionality for Indego Exoskeleton Parker

    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. 

    Variable Assist Considerations 

    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. 

    Variable Assist Functionality for Indego Exoskeleton ParkerConclusion 

    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. 

     

     

     

    Variable Assist Functionality for Indego Exoskeleton ParkerCasey 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.

    References 
    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. 
    • 16 Jul 2020
    Variable Assist Functionality for Indego Exoskeleton
    Many individuals with spinal cord injury (SCI) require full or partial external support of their legs to be able to walk...
  • Indego Helps with Boredom in QuarantineLaura 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.”

    Indego Helps with Boredom in QuarantineSoon 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!

    About the Author:

    can an exoskeleton improve my cardio parker indego michelle martinDr. 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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    • 2 Jul 2020
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  • Dr. Henry Hasson Uses Indego Exoskelton to Walk Parker IndegoHenry 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.

    Dr. Henry Hasson Uses Indego Exoskelton to Walk Parker IndegoHenry 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.

    • 18 Jun 2020
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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...
  • 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.

    Neuromuscular Reeducation (97112)
    • 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

    Indego Therapy in Outpatient: Billing Recommendations parker indegoIndego Therapy in Outpatient: Billing Recommendations parker indego

    Therapeutic Activities (97530)
    • 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.

    ————————————————————————————————————————————————————

    Indego Therapy in Outpatient: Billing Recommendations Parker IndegoIndego Therapy in Outpatient: Billing Recommendations Parker Indego

    Therapeutic Exercise (97110)
    • 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

     

     

    Indego Therapy in Outpatient: Billing Recommendations parker indegoIndego Therapy in Outpatient: Billing Recommendations parker indego

    Gait Training (97116) or Gait Training with Orthotics (97660)
    • 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

     

     

    Indego Therapy in Outpatient: Billing Recommendations Indego Parker

    Activities of Daily Living (97535)
    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

     

    Indego Therapy in Outpatient: Billing Recommendations Parker IndegoIndego Therapy in Outpatient: Billing Recommendations Parker Indego

    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!

     

    About the Author:

    Can an Exoskeleton Help Strengthen My Bones? Michelle Martin Parker IndegoDr. 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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    Introduction to Indego Motion+ and Therapy+

    Can an Exoskeleton Help Strengthen My Bones?

    Which Exoskeleton is Right for Me?

    Introduction to Advanced Gait

    • 21 May 2020
    Indego Therapy in Outpatient: Billing Recommendations
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  • Let’s talk cardio! Most of you have heard the term cardiopulmonary, which refers to your body’s heart and lungs, who function like an engine that keeps your body powered. The lungs take much needed oxygen from the air and your heart circulates this blood through the body like a pump, causing your muscles, bones, and tissues to receive much needed supplies to continue out daily functions. When a person suffers a stroke, spinal cord injury (SCI), or other debilitating injury, this can cause the cardiopulmonary system to underperform. Often, lack of mobility makes it difficult for a person with these types of injuries to participate in exercise and even simple daily tasks. This creates a vicious cycle where a person’s immobility leads to worsening cardiopulmonary performance and overall health. The Indego exoskeleton is designed to help people with mobility impairments participate in standing and walking activities, by helping to support their body. This blog will help you understand how the Indego exoskeleton can offer individuals an opportunity to flex their most important muscle: the heart.

     

    The cardiopulmonary system can be affected by a stroke, SCI, or other debilitating injuries in the following ways:

    1. Heart rate (HR) and blood pressure (BP) are two common ways to measure how hard the heart is working. 

    a. After an injury leading to mobility impairments, the heart must work harder to do the same amount of work as before the injury. Low blood pressure, hypotension, is common in individuals who spend much of the day sitting or lying down and can cause a lightheaded feeling or passing out when blood pressure drops quickly after standing up.

    b. Exoskeleton training reduced the number of hypotensive episodes during an 8-week period. Training with an exoskeleton has been shown to increase HR and BP to levels associated with safe physical activity.1 

     

    Can an Exoskeleton Improve My Cardio? Parker Indego Average Heart Rates by AgeCan an Exoskeleton Improve My Cardio? Parker Indego  systolic

    2. Oxygen consumption (VO2) and metabolic equivalent (MET) refer to the amount of oxygen a person utilizes during exercise and energy expenditure, respectively. 

    a. Individuals with SCI who have decreased mobility can be limited in their ability to participate in physical exercise that moderately challenges their VO2 and MET levels, which is needed to improve health and fitness.2

    b. Researchers found that cardiorespiratory and metabolic demands of walking with an Indego exoskeleton are consistent with activities performed at a moderate intensity.2 The American College of Sports Medicine (ACSM) recommends adults participate in 150 mins of moderate-intensity exercise per week of cardiorespiratory exercise per week.3

     

    Can an Exoskeleton Improve My Cardio? Parker Indego Sports and Leisure

    3. Rate of perceived exertion (RPE) is a subjective report of how difficult a task feels and the six-minute walk test (6MWT) which measures how far a person can walk in six minutes. 

    a. A debilitating SCI or stroke can cause an increase RPE for a given task and decreased 6MWT.

    b. After exoskeleton training, users reported decreased RPE walking the same distance and were able to walk farther in the same amount of time due to the cardiopulmonary system working more efficiently.1 Researchers have found that exoskeleton training resulted in improved cardiopulmonary function that was maintained six weeks later.4 

     

    There are several ways to use the Indego exoskeleton to address cardiopulmonary fitness. A training program may include sit-to-stand and stand-to-sit movements, maintenance of balance in standing, increasing time on feet in standing, participating in standing exercises, and walking with variable assistance, speed, and distance. Users can change the amount of assistance at their hip or knee while using the Indego to respond to the demands on their cardiopulmonary system. Therapists can assess an individual’s vitals to ensure they are within a safe range for exercise when using the Indego.

     

    Can an Exoskeleton Improve My Cardio? Parker Indego RPE Scale

     

    How can the Indego exoskeleton be used to train the cardiopulmonary system? 
    • Exoskeleton training is safe in first six months cute phase post SCI1

    • Exoskeleton training can increase HR, BP, METS and VO2 to levels consistent with moderate exercise as prescribed by the ACSM for cardiovascular health2

    • Exoskeleton training can improve cardiopulmonary outcome measures1,2,4,5 

    • Exoskeleton training can reduce hypotensive episodes in individuals with SCI1

    • Exoskeleton training can reduce the burden of exercise on the heart for cardiopulmonary patients with lower limb weakness5

     

    Walking, exercise programs, activity participation, standing, and transfer training are great ways to use the Indego exoskeleton to address cardiopulmonary limitations. Many people who suffer debilitating injuries have difficulty recovering their cardiopulmonary fitness. The Indego can help bolster cardio in the rehabilitation setting as well as personal users who take their Indego into their homes and communities. We are here for you if you have any questions or are interested in learning more about how the Indego exoskeleton can benefit your heart!

    If you are interested in learning more about the Indego exoskeleton, please visit our website or give us a call at 1-844-846-3346. 

     

    About the Author:

    can an exoskeleton improve my cardio parker indego michelle martinDr. 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.

     

    References

    1. McIntosh et al. The Safety and Feasibility of Exoskeletal-Assisted Walking in Acute Rehabilitation After Spinal Cord Injury. Arch Phys Med Rehabil. 2020 Jan;101(1):113-120. 
    2. Evans et al. Acute Cardiorespiratory and Metabolic Responses During Exoskeleton-Assisted Walking Overground Among Persons with Chronic Spinal Cord Injury. Top Spinal Cord Inj Rehabil. 2015 Spring; 21(2): 122–132.
    3. Pescatello, L. S. ACSM's guidelines for exercise testing and prescription. 9th ed. 2014;5.
    4. Jang et al. Cardiopulmonary function after robotic exoskeleton-assisted over-ground walking training of a patient with an incomplete spinal cord injury: Case report. Medicine (Baltimore). 2019 Dec;98(50):e18286.
    5. Pak et al. Effects of a cyborg-type robot suit HAL on cardiopulmonary burden during exercise in normal subjects. Eur J Appl Physiol. 2019 Feb;119(2):487-493. 

     

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    • 6 May 2020
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    Let’s talk cardio! Most of you have heard the term cardiopulmonary, which refers to your body’s heart and lungs, who function...