High Intensity Training for Neurological Injury Using Overground Exoskeletons in Inpatient Rehabilitation (HIT Exo IP)

The purpose of this study is to see if it's possible to reach high cardiovascular intensity training parameters (exercise at a rate that elevates heart rate to the level recommended for improving strength and endurance) while walking in a wearable robotic exoskeleton. This study will also evaluate if exercising at high intensity will lead to improvement in walking ability. Participants in this study will be asked to attend 5 walking training sessions using Ekso exoskeleton. There will be two additional sessions, one before and one after the five training sessions. At these two sessions, study participants will be asked to participate in seated balance, walking speed and endurance tests and breathing assessments.

Study Overview

• Status: Completed
• Conditions: Spinal Cord Injuries
• Intervention / Treatment: Device: Ekso

Detailed Description

The purpose of this study is to determine the feasibility and potential efficacy to implement high cardiovascular intensity training parameters (70-80% heart rate reserve) with the use of overground wearable robotic exoskeletons in an inpatient rehabilitation setting for locomotor recovery.

The second aim is to investigate the potential functional improvements in gait after receiving high-intensity locomotor training with an overground exoskeleton, as measured on the 10-meter walk test and six-minute walk test.

• Study Type: Interventional
• Enrollment (Actual): 11
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Texas
    • Houston, Texas, United States, 77030
      • NeuroRecovery Research Center at TIRR Memorial Hermann

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Able to achieve adequate fit within the exoskeleton
• Diagnosis of CVA or motor incomplete SCI (AIS C or D)
• Sufficient range of motion to attain normal, reciprocal gait pattern, and transition from normal sit to stand or stand to sit
• Intact skin on all surfaces in contact with device and load-bearing surfaces
• Weight <220 pounds

Exclusion Criteria:

• Pregnancy
• Spinal instability
• Unhealed limb or pelvic fractures or any condition restricting weight-bearing in limbs
• Diagnosis of other neurological injuries other than CVA or SCI
• Uncontrolled spasticity (≥3 on Modified Ashworth Scale)
• Colostomy
• Decreased range of motion or contractures in legs (>10° at hips, knees, or ankles)
• Uncontrolled autonomic dysreflexia
• Unresolved deep vein thrombosis
• Inability to tolerate standing due to cardiovascular issues or orthostatic hypotension
• Inability to follow 3 step commands
• Severe comorbidities: active infections, heart, lung, or circulatory conditions
• Pressure sores, impaired skin integrity
• Use of mechanical ventilation for respiratory support

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Exoskeleton; 5 sessions of overground ambulation with wearable exoskeleton where heart rate is monitored over each session.	Device: Ekso; Exoskeleton walking

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percentage of Heart Rate Readings Within the Target Zone Achieved During HIT Gait Training Session	Heart rate will be monitored continuously and recorded every 5 minutes throughout the session (each session lasts about 60 minutes). Heart rate reserve (HRR) is maximum heart rate (HRmax) minus resting heart rate (HRrest). Target HR ranges will be calculated using age-predicted maximum heart rate (HRmax = 208 - {0.7 * age]) and Karvonen formula (target HRR (70%) = ([0.7 * (HRmax - HRrest)] + HRrest) and (target HRR (80%) = (0.8 * (HRmax - HRrest)] + HRrest). The percentage of HRR achieved during the exoskeleton session is calculated as the percentage of HR readings during the session that are within the 70-80% target HR zone.	During session 1 (about day 2)
Percentage of Heart Rate Readings Within the Target Zone Achieved During HIT Gait Training Session	Heart rate will be monitored continuously and recorded every 5 minutes throughout the session (each session lasts about 60 minutes). Heart rate reserve (HRR) is maximum heart rate (HRmax) minus resting heart rate (HRrest). Target HR ranges will be calculated using age-predicted maximum heart rate (HRmax = 208 - {0.7 * age]) and Karvonen formula (target HRR (70%) = ([0.7 * (HRmax - HRrest)] + HRrest) and (target HRR (80%) = (0.8 * (HRmax - HRrest)] + HRrest). The percentage of HRR achieved during the exoskeleton session is calculated as the percentage of HR readings during the session that are within the 70-80% target HR zone.	During session 2 (about day 4)
Percentage of Heart Rate Readings Within the Target Zone Achieved During HIT Gait Training Session	Heart rate will be monitored continuously and recorded every 5 minutes throughout the session (each session lasts about 60 minutes). Heart rate reserve (HRR) is maximum heart rate (HRmax) minus resting heart rate (HRrest). Target HR ranges will be calculated using age-predicted maximum heart rate (HRmax = 208 - {0.7 * age]) and Karvonen formula (target HRR (70%) = ([0.7 * (HRmax - HRrest)] + HRrest) and (target HRR (80%) = (0.8 * (HRmax - HRrest)] + HRrest). The percentage of HRR achieved during the exoskeleton session is calculated as the percentage of HR readings during the session that are within the 70-80% target HR zone.	During session 3 (about day 6)
Percentage of Heart Rate Readings Within the Target Zone Achieved During HIT Gait Training Session	Heart rate will be monitored continuously and recorded every 5 minutes throughout the session (each session lasts about 60 minutes). Heart rate reserve (HRR) is maximum heart rate (HRmax) minus resting heart rate (HRrest). Target HR ranges will be calculated using age-predicted maximum heart rate (HRmax = 208 - {0.7 * age]) and Karvonen formula (target HRR (70%) = ([0.7 * (HRmax - HRrest)] + HRrest) and (target HRR (80%) = (0.8 * (HRmax - HRrest)] + HRrest). The percentage of HRR achieved during the exoskeleton session is calculated as the percentage of HR readings during the session that are within the 70-80% target HR zone.	During session 4 (about day 9)
Percentage of Heart Rate Readings Within the Target Zone Achieved During HIT Gait Training Session	Heart rate will be monitored continuously and recorded every 5 minutes throughout the session (each session lasts about 60 minutes). Heart rate reserve (HRR) is maximum heart rate (HRmax) minus resting heart rate (HRrest). Target HR ranges will be calculated using age-predicted maximum heart rate (HRmax = 208 - {0.7 * age]) and Karvonen formula (target HRR (70%) = ([0.7 * (HRmax - HRrest)] + HRrest) and (target HRR (80%) = (0.8 * (HRmax - HRrest)] + HRrest). The percentage of HRR achieved during the exoskeleton session is calculated as the percentage of HR readings during the session that are within the 70-80% target HR zone.	During session 5 (about day 11)
Change in Self Selected Gait Speed as Assessed by the 10 Meter Walk Test (10MWT)	During the 10 Meter Walk Test, four marks will be placed on the ground at 0,2,12 and 14 meters. Subjects will walk a total of 14 meters, where the middle 10 meters (between marks 2 and 12 meters) will be timed and recorded as their gait speed. Subjects will complete two attempts at their self-selected pace. The two trials will be averaged and reported as self-selected speed. The change in self-selected speed will be reported as [(average self-selected speed at 1 day after session 5 (about day 12)) - (average self-selected speed at pre intervention about 1 day prior to intervention)]	Pre Intervention (about 1 day prior to intervention) and 1 Day after session 5 (about day 12)
Change in Fast Gait Speed as Assessed by the 10 Meter Walk Test (10MWT)	During the 10 Meter Walk Test, four marks will be placed on the ground at 0,2,12 and 14 meters. Subjects will walk a total of 14 meters, where the middle 10 meters (between marks 2 and 12 meters) will be timed and recorded as their gait speed. Subjects will complete two attempts at their fastest pace. The two trials will be averaged and reported as fast gait speed. The change in fast gait speed will be reported as [(average fast gait speed at 1 day after session 5 (about day 12)) - (average fast gait speed at pre intervention about 1 day prior to intervention)]	Pre Intervention (about 1 day prior to intervention) and 1 Day after session 5 (about day 12)
Change in Walking Endurance as Assessed by the 6 Minute Walk Test (6MWT)	The 6 Minute Walk Test will measure the distance subjects can walk over six minutes. Subjects will walk along a 100-foot hallway as many times as they can in 6 minutes. Subjects are allowed to rest as needed; however, the timer continues to run for 6 minutes consecutively, whether they are standing or walking. The change in walking endurance will be reported as [(total distance walked in 6 minutes at 1 day after session 5 (about day 12)) - (total distance walked in 6 minutes at pre intervention about 1 day prior to intervention)]	Pre Intervention (about 1 day prior to intervention) and 1 Day after session 5 (about day 12)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Seated Dynamic Reach as Assessed by the Modified Functional Reach Test	The Modified Functional Reach Test measures the maximum distance an individual can reach forward from a seated position. This will be reported as an average of three trials. Change in seated dynamic reach is reported as [(average reach distance at 1 day after session 5 (about day 12)) - (average reach distance at pre intervention (about 1 day prior to intervention))]	Pre Intervention (about 1 day prior to intervention) and 1 Day after session 5 (about day 12)
Change in Spatial-Temporal Gait Parameters as Assessed by the GAITRite Pressure Map (Step Length Parameter)	The GAITRite pressure map will be used during the 10MWT. This pressure map will digitally record the subject's footprints' placement and pressure as they walk over it during the 10MWT. This assessment will indicate several temporospatial gait parameters. The Change in average step length (measured in centimeters) will be reported as [(average step length at 1 day after session 5 (about day 12)) - (average step length at pre intervention about 1 day prior to intervention)]	Pre Intervention (about 1 day prior to intervention) and 1 Day after session 5 (about day 12)
Change in Spatial-Temporal Gait Parameters as Assessed by the GAITRite Pressure Map (Stride Length Parameter)	The GAITRite pressure map will be used during the 10MWT. This pressure map will digitally record the subject's footprints' placement and pressure as they walk over it during the 10MWT. This assessment will indicate several temporospatial gait parameters. The Change in average stride length (measured in centimeters) will be reported as [(average stride length at 1 day after session 5 (about day 12)) - (average stride length at pre intervention about 1 day prior to intervention)]	Pre Intervention (about 1 day prior to intervention) and 1 Day after session 5 (about day 12)
Change in Spatial-Temporal Gait Parameters as Assessed by the GAITRite Pressure Map (Single Support Parameter)	The GAITRite pressure map will be used during the 10MWT. This pressure map will digitally record the subject's footprints' placement and pressure as they walk over it during the 10MWT. This assessment will indicate several temporospatial gait parameters. The Change in average time spent in single limb support (measured in seconds) will be reported as [(average time spent in single limb support at 1 day after session 5 (about day 12)) - (average time spent in single limb at pre intervention about 1 day prior to intervention)] - negative value indicates a reduction in single limb support time post intervention.	Pre Intervention (about 1 day prior to intervention) and 1 Day after session 5 (about day 12)
Change in Spatial-Temporal Gait Parameters as Assessed by the GAITRite Pressure Map (Double Support Parameter)	The GAITRite pressure map will be used during the 10MWT. This pressure map will digitally record the subject's footprints' placement and pressure as they walk over it during the 10MWT. This assessment will indicate several temporospatial gait parameters. The Change in average time spent in double limb support (measured in seconds) will be reported as [(average time spent in double limb support at 1 day after session 5 (about day 12)) - (average time spent in double limb at pre intervention about 1 day prior to intervention)]	Pre Intervention (about 1 day prior to intervention) and 1 Day after session 5 (about day 12)
Change in Spatial-Temporal Gait Parameters as Assessed by the GAITRite Pressure Map (Swing Time Parameter)	The GAITRite pressure map will be used during the 10MWT. This pressure map will digitally record the subject's footprints' placement and pressure as they walk over it during the 10MWT. This assessment will indicate several temporospatial gait parameters. The Change in average time spent in swing phase (measured in seconds) will be reported as [(average time spent in swing phase at 1 day after session 5 (about day 12)) - (average time spent in swing phase at pre intervention about 1 day prior to intervention)]	Pre Intervention (about 1 day prior to intervention) and 1 Day after session 5 (about day 12)
Change in Spatial-Temporal Gait Parameters as Assessed by the GAITRite Pressure Map (Stance Time Parameter)	The GAITRite pressure map will be used during the 10MWT. This pressure map will digitally record the subject's footprints' placement and pressure as they walk over it during the 10MWT. This assessment will indicate several temporospatial gait parameters. The Change in average time spent in stance phase (seconds) will be reported as [(average time spent in stance phase at 1 day after session 5 (about day 12)) - (average time spent in stance phase at pre intervention about 1 day prior to intervention)]	Pre Intervention (about 1 day prior to intervention) and 1 Day after session 5 (about day 12)
Change in Spatial-Temporal Gait Parameters as Assessed by the GAITRite Pressure Map (Heel to Heel Base of Support Time Parameter)	The GAITRite pressure map will be used during the 10MWT. This pressure map will digitally record the subject's footprints' placement and pressure as they walk over it during the 10MWT. This assessment will indicate several temporospatial gait parameters. The Change in average heel to heel base of support (measured in centimeters) will be reported as [(average heel to heel base of support at 1 day after session 5 (about day 12)) - (average heel to heel base of support at pre intervention about 1 day prior to intervention)] - a negative values indicates reduction in base of support which indicates improvement in gait.	Pre Intervention (about 1 day prior to intervention) and 1 Day after session 5 (about day 12)
Change in Metabolic Expenditure During 10MWT, as Assessed by Oxygen Consumption	Change in metabolic expenditure during 10MWT will be indicated by energy expenditure. Energy Expenditure will be measured by the K4 b2 Cosmed as follows: Oxygen cost will be calculated from oxygen consumption as the product of gait speed and body weight. Oxygen consumption will be collected on a breath-by-breath basis measured by a portable metabolic system (K4 b2 Cosmed). Prior to the testing, the system will be calibrated using room air and reference gas mixture. During the testing, the subject will wear a face mask and a heart rate monitor at all times and will be asked to breathe normally. The change in oxygen cost from baseline will be reported as VO2 peak during 10MWT.	Pre Intervention (about 1 day prior to intervention) and 1 Day after session 5 (about day 12)
Change in Metabolic Expenditure During 6MWT, as Assessed by Oxygen Consumption	Change in metabolic expenditure during 6MWT will be indicated by energy expenditure. Energy Expenditure will be measured by the K4 b2 Cosmed as follows: Oxygen cost will be calculated from oxygen consumption as the product of gait speed and body weight. Oxygen consumption will be collected on a breath-by-breath basis measured by a portable metabolic system (K4 b2 Cosmed). Prior to the testing, the system will be calibrated using room air and reference gas mixture. During the testing, the subject will wear a face mask and a heart rate monitor at all times and will be asked to breathe normally. The change in oxygen cost from baseline will be reported as VO2 peak during 6MWT.	Pre Intervention (about 1 day prior to intervention) and 1 Day after session 5 (about day 12)

Collaborators and Investigators

• Sponsor: The University of Texas Health Science Center, Houston
• Investigators: Principal Investigator: Shuo-Hsiu (James) Chang, The University of Texas Health Sciences Center at Houston

Publications and helpful links

General Publications

• Brazg G, Fahey M, Holleran CL, Connolly M, Woodward J, Hennessy PW, Schmit BD, Hornby TG. Effects of Training Intensity on Locomotor Performance in Individuals With Chronic Spinal Cord Injury: A Randomized Crossover Study. Neurorehabil Neural Repair. 2017 Oct-Nov;31(10-11):944-954. doi: 10.1177/1545968317731538. Epub 2017 Oct 30.
• Lotter JK, Henderson CE, Plawecki A, Holthus ME, Lucas EH, Ardestani MM, Schmit BD, Hornby TG. Task-Specific Versus Impairment-Based Training on Locomotor Performance in Individuals With Chronic Spinal Cord Injury: A Randomized Crossover Study. Neurorehabil Neural Repair. 2020 Jul;34(7):627-639. doi: 10.1177/1545968320927384. Epub 2020 Jun 1.
• Hornby TG, Henderson CE, Plawecki A, Lucas E, Lotter J, Holthus M, Brazg G, Fahey M, Woodward J, Ardestani M, Roth EJ. Contributions of Stepping Intensity and Variability to Mobility in Individuals Poststroke. Stroke. 2019 Sep;50(9):2492-2499. doi: 10.1161/STROKEAHA.119.026254. Epub 2019 Aug 22.
• Holleran CL, Rodriguez KS, Echauz A, Leech KA, Hornby TG. Potential contributions of training intensity on locomotor performance in individuals with chronic stroke. J Neurol Phys Ther. 2015 Apr;39(2):95-102. doi: 10.1097/NPT.0000000000000077.
• Holleran CL, Straube DD, Kinnaird CR, Leddy AL, Hornby TG. Feasibility and potential efficacy of high-intensity stepping training in variable contexts in subacute and chronic stroke. Neurorehabil Neural Repair. 2014 Sep;28(7):643-51. doi: 10.1177/1545968314521001. Epub 2014 Feb 10.
• Leech KA, Hornby TG. High-Intensity Locomotor Exercise Increases Brain-Derived Neurotrophic Factor in Individuals with Incomplete Spinal Cord Injury. J Neurotrauma. 2017 Mar 15;34(6):1240-1248. doi: 10.1089/neu.2016.4532. Epub 2017 Jan 18.
• Hornby TG, Holleran CL, Hennessy PW, Leddy AL, Connolly M, Camardo J, Woodward J, Mahtani G, Lovell L, Roth EJ. Variable Intensive Early Walking Poststroke (VIEWS): A Randomized Controlled Trial. Neurorehabil Neural Repair. 2016 Jun;30(5):440-50. doi: 10.1177/1545968315604396. Epub 2015 Sep 3.
• Holleran CL, Hennessey PW, Leddy AL, Mahtani GB, Brazg G, Schmit BD, Hornby TG. High-Intensity Variable Stepping Training in Patients With Motor Incomplete Spinal Cord Injury: A Case Series. J Neurol Phys Ther. 2018 Apr;42(2):94-101. doi: 10.1097/NPT.0000000000000217.
• Moore JL, Nordvik JE, Erichsen A, Rosseland I, Bo E, Hornby TG; FIRST-Oslo Team. Implementation of High-Intensity Stepping Training During Inpatient Stroke Rehabilitation Improves Functional Outcomes. Stroke. 2020 Feb;51(2):563-570. doi: 10.1161/STROKEAHA.119.027450. Epub 2019 Dec 30.

Study record dates

Study Major Dates

• Study Start (Actual): October 6, 2021
• Primary Completion (Actual): May 25, 2023
• Study Completion (Actual): May 25, 2023

Study Registration Dates

• First Submitted: July 13, 2021
• First Submitted That Met QC Criteria: July 13, 2021
• First Posted (Actual): July 22, 2021

Study Record Updates

• Last Update Posted (Actual): April 15, 2026
• Last Update Submitted That Met QC Criteria: March 26, 2026
• Last Verified: February 1, 2025

More Information

Terms related to this study

• Keywords: spinal cord injury; exoskeleton; high intensity
• Additional Relevant MeSH Terms: Central Nervous System Diseases; Nervous System Diseases; Wounds and Injuries; Trauma, Nervous System; Spinal Cord Diseases; Spinal Cord Injuries
• Other Study ID Numbers: HSC-MS-21-0262

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: Yes
• product manufactured in and exported from the U.S.: Yes