Table 2.

(A) WISE trial Ekso training progression strategy. (B) WISE trial Active Control training progression strategy.

(A)
General rules for Ekso Active Group:
(1) Sessions are divided into three 15-min segments. This includes any rest breaks required, as well as a 5-min warm-up and 2-min cool down per session required by week 2.
(2) Sessions begin with a goal of a minimum of 300 steps per session in Ekso within trajectory. Then can do outside of trajectory.
(3) All sessions after session #3 must include a 5-min warm-up and end with a 2-min cool down in Bilateral/Adaptive.
(4) All exoskeleton and assistive device progressions should be done in Bilateral/Adaptive. (Examples: FRW to Crutches; step length increase; step height decrease; target adjustment; turning mode or technique).
(5) Each leg may be considered individually when considering reducing Fixed assist level, or choosing high/low assistance/resistance in 2Free. No unilateral trajectory-free stepping is allowed to avoid promoting gait asymmetries.
(6) If the participant is exceeding 750 steps per session, the therapist should increase the challenge to the participant.
(7) Excluding Ekso donning and doffing time, each session will last a total of 45 min, which will include standing/up time, walking time, and seated rest breaks.
(8) Overground walking will be included when the participant requires only minimal assistance of one therapist and the assistance of one aide to control the assistive device for at least 10 m.
(9) If participant is not yet performing overground gait training, all 45 min of session will be done in Ekso.
(10) If participant is performing overground gait training, session will consist of 30 min of gait training in the Ekso, followed by 15 min performing overground gait training for a total of 45 min.
(11) Step monitors are to be used during any OG gait training.
Timeline and settings	Assist	Swing assist	Progression and adjustments	Considerations
Sessions 1–3	Bilateral	Trajectory controlled: adaptive	Pre-gait weight shifting Stance support remains at “Full” Minimize upper extremity loading. Optimize step height; swing time; step length; targets; etc.	Balance and gait progression Consistently hitting >300 steps per session Adjust targets/swing time/step length as appropriate
Anytime session 3+	Bilateral	Trajectory controlled: adaptive	Pre-gait weight shifting when needed. Once participant has consistently managed >300 steps/session, progress to crutches if appropriate and encourage minimal UE loading	Adjust targets/swing time/step length as appropriate Step count with crutches should be at least 80% of step count with walker.
Training guidelines	Bilateral	Trajectory controlled: adaptive to fixed Trajectory free: 2Free	PT may progress the participant by lowering the fixed assist for each leg, as tolerated and clinically appropriate. Stance support may be changed from “Full” to “Flex”. Once initial 300 steps in trajectory are completed, PT may progress the participant via trajectory-free stepping using “2Free”. Stance support should begin at appropriate level. As participant improves stance control, support may be reduced as tolerated and clinically appropriate. Swing support should be assessed at “neutral”. If a leg is not able to complete a step, “high”/”low assistance” may be provided for more normalized stepping. If a leg is stepping far outside of the general trajectory, “high”/”low resistance” may be provided for more normalized stepping. Progress to more symmetrical gait.	Step count must be at least 300 within trajectory. Must include 5 min warm-up at beginning and 2 min cool down at end in bilateral adaptive. Borg range 12-17 to prevent fatigue early in the session No more than 3 swing completes per minute in Fixed assist. (If so, then increase Fixed swing assist by 10 or reduce swing complete time) No unilateral trajectory-free stepping to avoid promoting gait asymmetries.
Progression guidelines	Bilateral	Trajectory controlled: adaptive to fixed Trajectory free: 2Free	If initial 300 steps within trajectory is achieved/projected, the therapist may challenge the participant by the following, as tolerated and clinically appropriate: Lower the Fixed assist bilaterally as appropriate Stance support may be changed from “Full” to “Flex”. Once initial 300 steps in trajectory are completed, set swing support at appropriate assistance/resistance for an appropriate clinical challenge	Step count must be at least 300 within trajectory. Must include 5 min warm-up at beginning and 2 min cool down at end in bilateral adaptive. Borg range 12-17 to prevent fatigue early in the session No more than 3 swing completes per minute in Fixed assist (If so, then increase Fixed swing assist by 10 or reduce swing complete time) No unilateral trajectory-free stepping to avoid promoting gait asymmetries.

(B)
General rules for Active Controls:
(1) Sessions are divided into three 15-min segments. This includes any rest breaks required, as well as a 5-min warm-up and 2-min cool down per session required by week 2.
(2) Participants will perform gait training with BWSTT for the full session (all 3 segments) until the OG criterion is met. This gait training must continue for a minimum of 300 steps at the beginning of each session.
(3) Manual assistance from the physical therapy team to facilitate normal stepping kinematics is permissible.
(4) BWS and speed are to be determined by the physical therapist based on appropriate stepping kinematics, level of challenge to the participant, and safety of the participant and trainer(s).
(5) Participants will perform gait training with BWSTT for the full session (all 3 segments) until the OG criterion is met. Participants may proceed to overground gait training without BWS only when they require minimal physical assistance of the physical therapist, plus assistive device control or supervision of another team member for at least 10 m.
(6) Once the OG criterion is achieved:
a. If the initial 300 steps are not completed by the end of the first segment, the middle 15-min segment must be gait training in BWSTT, and the final 15-min segment must be OG gait training.
b. If the initial 300 steps are completed by the end of the first segment, the middle 15-min segment can be continued gait training in BWSTT or OG gait training, per PT choice. The final 15-min segment must be OG gait training.
(7) Step monitors are to be used during the full 45 min= of gait training.
	Focus	Progression and adjustments as tolerateda	Considerations
Sessions 1–3	• Determine parameters for best kinematics • Participant familiarization • Posture	Determine comfortable BWS, stepping range of speeds, amount of physical assistance at each location, and bout length	Educate and engage posture and basic stepping Educate and ensure joint protection
Sessions 4–6	• Posture • Good stepping kinematics • Increase load as toleratedb • Increase range of speeds as tolerated All sessions should have 5-min warm-up and 2-min cool down.	• Decrease BWS if tolerated • Increase/decrease speed • Increase bout lengths	Engage posture and both swing/stance phases of stepping Ensure good posture, stepping kinematics, and joint protection. Borg range 12–17 to prevent fatigue early in the session
Sessions 7–18	• Increase load weekly if toleratedb • Increase range of speeds as tolerated • Increase independence • Increase endurance All sessions should have 5-min warm-up and 2-min cool down.	• Decrease BWS if tolerated • Increase/decrease speed • Decrease physical assistance • Increase bout lengths, decrease rest breaks • Introduce walking sideways, backwards, stepping over obstacles, quick speed changes, quick start/stops if tolerated	Engage hip control and motor control (concentric/eccentric) of stepping, arm-swing Ensure good posture, stepping kinematics, and joint protection. Borg range 12–17 to prevent fatigue early in the session
Sessions 19–36	• Increase load weekly if toleratedb • Increase range of speeds by as tolerated • Increase independence • Increase endurance • Increase adaptability All sessions should have ~5-min warm-up and ~2-min cool down.	• Decrease BWS if tolerated • Increase/decrease speed • Decrease physical assistance • Increase bout lengths, decrease rest breaks • Continue or introduce walking sideways, backwards, stepping over obstacles, quick speed changes, quick start/stops	Engage motor control of posture, hips, symmetric stepping, arm swing (when evaluable) Ensure good posture, stepping kinematics, and joint protection. Borg range 12–17 to prevent fatigue early in the session

BWS body weight support, BWSTT Body Weight Supported Treadmill Training, OG overground.

^aPT can adjust one or multiple parameters at a time. PT can adjust parameters for interval training, e.g. lower BWS for 5 min.

^bTraining intensity should be increased first by increasing loading. If amount of loading puts participant or trainers at risk for injury, then increasing range of speeds or independence can be the focus of increasing intensity.