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Visual-audio EMG biofeedback therapy using a conventional biofeedback device with an elbow flexion power classified as MRC grade 1 in case 2. He learned the timing of his biceps muscle activity through visual-audio information of the surface electrode on his biceps, but he could not perform elbow motion. MRC: Medical Research Council; EMG: electromyographic.
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This study aimed to evaluate the effectiveness and safety of using the upper limb single-joint Hybrid Assistive Limb (upper limb HAL-SJ) during elbow flexion training following elbow flexor reconstruction for brachial plexus injury (BPI). We present the cases of two patients in whom the upper limb HAL-SJ was implemented 5 and 7 months postoperative...
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... adverse events during HAL-SJ training were care- fully observed and evaluated at every session. In addition, a clinical evaluation of the MRC grade for elbow flexion power, active flexion ROM of the elbow joint, the DASH questionnaire, and the limb girth of the upper arm was performed similar to case 1. In the conventional visual- audio EMG biofeedback therapy ( Figure 6; Myotrace 400, EM-501; Noraxon USA Inc., Scottsdale, Arizona, USA and SAKAI Medical Co., Ltd, Japan) in the 11th session of HAL-SJ training in case 2, the muscle activity Table 1. MRC grade, active flexion ROM of the elbow joint, DASH questionnaire, and limb girth of the upper arm at pre- and post-upper limb HAL-SJ training in cases 1 and 2. of the biceps and triceps during elbow flexion exercises was evaluated using a Trigo™ Lab Wireless Surface EMG system (Delsys Inc., Boston, Massachusetts, USA). The use of the upper limb HAL-SJ shows feasibility and safety during voluntary elbow flexion training even for MRC grade 1. HAL-SJ could be implemented for 34 ses- sions once every 2 weeks with no serious adverse events from 7 months to 17 months postoperatively. Remarkable improvements in elbow flexion power were observed, as indicated by improvements in MRC grades from 1 to 3, after 32 sessions using the upper limb HAL-SJ at 16 months postoperatively (Figure 7). Seventeen months postopera- tively, the patient could actively flex his elbow three times for 10 s after the final 34 sessions. He could also support 500 g for 15 s on the arm at 90 of elbow flexion at 16 months postoperatively. Active flexion ROM of the elbow joint at 10, 14, and 16 months postoperatively was 30 , 80 , and 115 , respectively ( Figure 8 and Table 1). He could also support 1 kg for 10 s (MRC grade 3) on the arm at 90 of elbow flexion at the final evaluation (20 months postoperatively and 3 months after HAL-SJ training). Table 1 shows the DASH questionnaire and the limb girth of the upper arm. Compared to the conventional visual- audio EMG biofeedback therapy, the upper limb HAL-SJ training decreasing the muscle activity of the triceps during elbow flexion exercises was observed (Figure 9). The muscle activity of the biceps was observed to be equal in both training methods (Figure 9). Twenty-one months postoperatively, arthrodesis of the shoulder was performed for the improvement of elbow ...
Citations
... However, the HAL-SJ has shown an immediate improvement in the active ROM of the elbow joint, even after a period of about 1 year from the BoNT injection, but only in the proximal region of the upper limb [95]. Despite these limitations, the combination therapy of conventional rehabilitation with robot-assisted training has been shown to be superior to BoNT injections with conventional rehabilitation alone [97][98][99]. ...
Spasticity is a very common sign in the neurological field. It can be defined as “a motor disorder marked by a velocity-dependent increase in muscle tone or tonic stretch reflexes” associated with hypertonia. It leads to a high risk of limb deformities and pain that prejudices residual motor function, impairing quality of life”. The treatment of spasticity depends on its severity and its location and, in general, it is based on rehabilitation, oral therapies (the gamma-aminobutyric acid b agonist baclofen) and injectable medications (i.e., botulin toxins, acting on polysynaptic reflex mechanisms). The botulin toxin type A (BoNT-A) injection has been effectively used to improve different types of spasticity. However, when BoNT-A is not sufficient, a combination of nonpharmacological approaches could be attempted. Therefore, additional intervention, such as conventional physical therapy by itself or further combined with robotic gait training, may be needed. Indeed, it has been shown that combination of BoNT-A and robotics has a positive effect on activity level and upper limb function in patients with stroke, including those in the chronic phase. The aim of this review is to evaluate the efficacy of pharmacological or nonpharmacological treatment in combination with BoNT-A injections on spasticity. The combined therapy of BoNT with conventional or adjunct activities or robot-assisted training, especially with end-effectors, is a valid tool to improve patients’ performance and outcomes. The combined strategies might rise the toxin’s effect, lowering its dosages of botulinum and reducing side effects and costs.
... Improvement of upper limb function using HAL-SJ has only been reported in adult patients. 11,12) For patients with CP, use of HAL-SJ has been reported to reduce muscle co-contraction and improve upper limb function and performance of activities of daily living (ADL) by using simple exercises such as repeat flexion/extension movements of the elbow joint. 13) However, in the previous report, only simple exercises such as elbow flexion and extension were performed using HAL-SJ. ...
... 26) In previous reports using HAL-SJ, the training was limited to simple movements such as elbow flexion and extension, and there are no reports of upper limb training with combined movements of the shoulder, elbow, and finger, as in this study. 11,12,26) In our patients, upper limb function and ADL ability improved through upper limb task practice using HAL, indicating its effectiveness. Moreover, for patient 3 with severe CP, who had insufficient ability to move his wrist and perform finger extension, we performed an intervention using a combination of IVES and HAL. ...
... Moreover, in previous reports using HAL-SJ, the training was limited to simple movements, such as elbow flexion and extension, and there have been no reports of upper limb training using the HAL-SJ for the elbow joint during task practices in various limb positions as demonstrated in the present study. 12,13) Therefore, this intervention was more effective because training focused on functional improvements by promoting brain plasticity through the use of HAL or IVES in assisting the voluntary movements of patients. In this study, VAUT using a combination of HAL and IVES was extremely effective as a new rehabilitation method. ...
Background: Constraint-induced movement therapy (CIMT) improves the motor function of paralyzed upper limbs of adults after stroke. However, in patients with severe spastic cerebral palsy (CP), the use of CIMT is not warranted. Our aim was to investigate the feasibility and effectiveness of repetitive voluntary-assisted upper limb training (VAUT) for three patients with severe CP using a combination of robotics [Hybrid Assistive Limb (HAL)] and functional electrical stimulation [Integrated Volitional Control Electrical Stimulation (IVES)].
Case: Three patients with CP were enrolled. Patients 1, 2, and 3 were 8-, 19-, and 18-year-old males, respectively. Patient 1 had spastic hemiplegia, while patients 2 and 3 had spastic quadriplegia. VAUT using single-joint HAL was performed for 1 or 2 sessions/month for 50 min/session over an 8-month period for 9–13 sessions in total. One patient’s voluntary hand movement was insufficient, affecting his upper limb exercise performance; therefore, IVES was required in addition to HAL. Outcome measures included motor function of the upper limbs and use of paralyzed hands, which were measured before and after intervention. No adverse events were observed during VAUT. After intervention, the Action Research Arm Test scores showed improvements in all three patients. The Children’s Hand-use Experience Questionnaire showed improvements in two patients.
Discussion: The use of VAUT, together with new systems such as HAL and IVES, for severe CP is safe and may be effective. Our study suggested that upper limb function can be improved for patients with severe CP.
... HAL-SJ [37] is short for single-joint hybrid assistive limb which is a wearable robot for the elbow joint. The exoskeleton enables real-time elbow flexion caused by muscle bioelectric signals measured by surface electrodes attached to the anterior and posterior of the arm skin. ...
Impairments in the sensorimotor system negatively impact the ability of individuals to perform daily activities autonomously. Upper limb rehabilitation for stroke survivors and cerebral palsy (CP) children is essential to enhance independence and quality of life. Robot assisted therapy has been a bright solution in the last two decades to promote the recovery process for neurological disorders patients. Nevertheless, defining the optimum intervention of robot assisted therapy (RAT) in different cases is not clear yet. With this aim, the presented study reviewed the current literature on RAT protocols for upper limb impairments and the effects of RAT on recovery outcomes. A literature search was conducted using different search engines, reviews, and studies. This study presents an overview of fourteen robotic devices used in the rehabilitation field and seventeen clinical trials using commercially available devices during the last three years. A discussion about reaching an efficient rehabilitation process based on different aspects such as clinical setting and training modes has been introduced. This review identifies the limitations of RAT to lay the foundation for more effective neuromotor disorders rehabilitation. Finally, using virtual reality (VR) as an assisting feature in RAT improves the whole process of recovering motor functionality.
... These are detected from the lower limb muscle groups using actuators and surface electrode sensors mounted on both hips and knees 6) . There are various versions of HALs, such as a double-leg version 7) , single-leg version 8) , single-joint version (for a shoulder, elbow, or knee) [9][10][11] , and a version for hips 12) . Indeed, previous studies showed the benefits of HAL gait training in cases of spinal cord injury 13) , acute and chronic myelopathy 7,14,15) , spinal dural arteriovenous fistula 16) , and spinal cord infarction 17) . ...
[Purpose] An ankle disorder (foot drop) caused by common peroneal nerve palsy or cerebrovascular accident (stroke) interferes with patients' ability to walk and hinders in activities of daily living. A new robotic ankle, the Hybrid Assistive Limb, has been developed for the treatment of foot drop caused by common peroneal nerve palsy or sequelae of stroke. The purpose in this study was to report and examine the efficacy and feasibility of a case who was treated with voluntary ankle dorsiflexion training with the ankle Hybrid Assistive Limb. [Participant and Method] A 60-year-old man with foot drop due to peroneal nerve palsy that occurred without a contributory cause was treated via ankle dorsiflexion training with the use of a new robotic ankle, the "Ankle Hybrid Assistive Limb". [Results] Following total ankle rehabilitation training with the Ankle Hybrid Assistive Limb, improvements in ankle dorsiflexor strength, gait, and sensory function of the lower leg and foot were observed. [Conclusion] The newly developed ankle Hybrid Assistive Limb could be an effective training tool for foot drop caused by common peroneal nerve palsy.
... The hybrid assistive limb (HAL) is a wearable exoskeleton robot that provides realtime assistance to a wearer's motion, such as walking and limb movements via actuators mounted on both the hip and knee joints and bioelectrical signals (muscle action potentials) that detect the electrical activities in the lower limb muscles via surface electrode sensors [7]. There are several types of HAL robots, such as bilateral-limb [8], lateral-limb [9], singlejoint [10][11][12], and lumbar robots [13]. We developed an ankle joint HAL for patients with ankle-foot impairment. ...
... Medicina 2022, 58, x FOR PEER REVIEW The hybrid assistive limb (HAL) is a wearable exoskeleton robot that provides r time assistance to a wearer's motion, such as walking and limb movements via actua mounted on both the hip and knee joints and bioelectrical signals (muscle action po tials) that detect the electrical activities in the lower limb muscles via surface electr sensors [7]. There are several types of HAL robots, such as bilateral-limb [8], lateral-l [9], single-joint [10][11][12], and lumbar robots [13]. We developed an ankle joint HAL patients with ankle-foot impairment. ...
Foot and ankle disabilities (foot drop) due to common peroneal nerve palsy and stroke negatively affect patients’ ambulation and activities of daily living. We developed a novel robotics ankle hybrid assistive limb (HAL) for patients with foot drop due to common peroneal nerve palsy or stroke. The ankle HAL is a wearable exoskeleton-type robot that is used to train plantar and dorsiflexion and for voluntary assistive training of the ankle joint of patients with palsy using an actuator, which is placed on the lateral side of the ankle joint and detects bioelectrical signals from the tibialis anterior (TA) and gastrocnemius muscles. Voluntary ankle dorsiflexion training using the new ankle HAL was implemented in a patient with foot drop due to peroneal nerve palsy after lumbar surgery. The time required for ankle HAL training (from wearing to the end of training) was approximately 30 min per session. The muscle activities of the TA on the right were lower than those on the left before and after ankle HAL training. The electromyographic wave of muscle activities of the TA on the right was slightly clearer than that before ankle HAL training in the resting position immediately after ankle dorsiflexion. Voluntary ankle dorsiflexion training using the novel robotics ankle HAL was safe and had no adverse effect in a patient with foot drop due to peroneal nerve palsy.
... 16 Apart from rMS, there are also few case reports on use of robotic devices for brachial plexus injury post-surgical repair, which have shown to be effective and safe. 17,18 However to date, there is no evidence for use of robotic device in lumbosacral plexopathy. ...
An endoleak is a complication that can occur after an endovascular aneurysm repair. We report a rare case of ischemic lumbosacral plexopathy post embolization of type 2 endoleak, including its presentation, neurological progress, rehabilitation strategy and functional outcome. Ischemic lumbosacral plexopathy is a devastating complication, and rehabilitation is essential to optimize function. More research is required to further refine the evidence for rehabilitation of lesions involving peripheral nervous system.
... Several pilot and case studies investigated the use of the HAL-SJ in the rehabilitation after knee and elbow injuries, but of these only a few studies analysed the effects after TKA [17][18][19][20][21][22][23]. While the HAL-SJ may shorten the rehabilitation regarding time and effort (by improving mobility and agility more quickly), there are no insights regarding a possible improvement of the functional outcome especially with regard to activities of daily living yet. ...
Introduction
The first weeks after total knee arthroplasty (TKA) are crucial for the functional outcome. To improve knee mobility, a continuous passive motion (CPM) motor rail is commonly used during in-hospital rehabilitation. The single-joint hybrid assistive limb (HAL-SJ) is a new therapy device. The aim of the study was to improve patients’ range of motion (ROM), mobility, and satisfaction using the active-assistive support of the HAL-SJ.
Materials and methods
Between 09/2017 and 10/2020, 34 patients, who underwent TKA and matched the inclusion criteria, were randomized into study (HAL-SJ) and control (CPM) group. Treatment began after drain removal and was carried out until discharge. Primary outcome parameters were raised pre- and postoperatively and included the Oxford knee score (OKS), visual analog scale (VAS), and acquired range of motion. Furthermore complications caused by the device were recorded.
Results
OKS increased in both groups postoperatively, but only significantly in the HAL-SJ group. Postoperative pain improved in both groups without significant differences. Flexion improvement was significant in both groups between days 3/7 and 8 weeks postoperatively. We did not encounter any complications related to HAL-SJ.
Conclusions
In conclusion, use of the HAL-SJ during rehabilitation in the early postoperative period after TKA was safe without disadvantages compared to the control group and seems to have advantages in terms of daily life impairment.
... HAL-SJ is an exoskeleton structure consisting of an upper arm mounting part and a forearm supporter, so it is difficult to use for distal rehabilitation. [44][45][46] The results of this study suggest that rehabilitation with HAL-SJ after injection of BTX-A toxin may improve upper limb function. However, this study has important limitations. ...
Combining single-joint hybrid assistive limb (HAL-SJ) with botulinum toxin A (BTX-A) therapy is novel and has great therapeutic potential for the rehabilitation of stroke patients with upper limb paralysis. The purpose of this observational case series study was to evaluate the effect of BTX-A and HAL-SJ combination therapy on different exoskeleton robots used for treating upper limb paralysis. The HAL-SJ combination received a BTX-A injection followed by HAL-SJ-assisted rehabilitation for 60 min per session, 10 times per week, during 2 weeks of hospitalization. Clinical evaluations to assess motor function, limb functions used during daily activities, and spasticity were performed prior to injection, at 2-week post-treatment intervention, and at the 4-month follow-up visit. The total Fugl-Meyer assessment-upper limb (FMA-UE), proximal FMA-UE, action research arm test (ARAT), Motor Activity Log (MAL), and Disability Assessment Scale (DAS) showed a statistically significant difference, and a large effect size. However, the FMA distal assessment at 2-week post-treatment intervention showed no significant difference and a moderate effect size. The FMA-UE scores of the extracted systematic review articles showed that our design improved upper limb function. The change in the total FMA-UE score in this study showed that, compared to previous reports in the exoskeletal robotic therapy group, our combination therapy had a higher score than five of the seven references. Our results suggest that BTX-A therapy and HAL-SJ combination therapy may improve upper limb function, similar to other treatment methods in the literature.
... Among the existing rehabilitation symptoms, elbow joint rehabilitation occurred most often, such as tennis elbow [12][13][14]. After discussion with orthopedists, the elbow joint rehabilitation most often occurred and could be executed at home without in-hospital rehabilitation as is the case with other rehabilitation symptoms [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29]. ...
In this paper, we propose a wearable device for residential elbow joint rehabilitation with voice prompts and a tracking feedback app (WDRTFAPP). We have developed the app as well as the Arduino embedded system, which we have integrated together. In this research, the patients were simulated by our team not real patients. By using this wearable device, the elbow joint rehabilitation could be executed at home for the simulated patients with mild and moderately mild elbow joint symptoms. During the rehabilitation, data captured by the wearable device were sent to the tracking feedback APP, using automatic real time via Bluetooth transmission. After TFAPP received the rehabilitation data from the wearable device, the rehabilitation data was sent to the cloud database by Wi-Fi or 5G communication automatically in real time. When the performance of the elbow joint rehabilitation was incorrect the patients received a voice prompt by TFAPP. The simulated patients could query their rehabilitation data using different search strategies, namely by date or TFAPP, at any time or location. In the experimental results, it showed that the correct detecting rate of elbow joint rehabilitation could be up to 90% by WDRTFAPP. The medical staff also could track the rehabilitation status of each simulated patient by the tracking feedback APP (TFAPP) with remote accessing, such as the Internet. Moreover, the rehabilitation appointments could be set up by the clinical staff with TFAPP, using the Internet. Furthermore, the medical staff could track the rehabilitation status of each simulated patient and give feedback at any time and location. The costs of the rehabilitation could be reduced (in terms of time and money spent by the simulated patients) and the manpower required by the hospital.
... It can provide voluntary joint motion assist with the reaction to the wearer's intention of standing up by detecting nerve and muscle action potentials of the lumbar erector spinae muscles through electrodes attached on the skin. To date, several types of HAL (HAL for lower limbs and HAL for single joints) have been applied for several musculoskeletal and neurological disorders [10][11][12][13][14]. It has been reported that the lower limb type HAL, which can assist hip and knee joint motion, might improve gait function for myelopathy [10], cerebral infarction [11], and cerebral palsy [12]. ...
... The single-joint type HAL can assist knee and elbow joint motion. Several clinical case reports of exercise therapy using the single-joint type HAL for cerebral palsy and brachial plexus injury have been reported [13,14]. ...
Background
With a rapidly aging population in Japan, locomotive syndrome is becoming an increasingly serious social problem. Exercise therapy using the lumbar type HAL, which is a wearable robot suit that can assist voluntary hip joint motion, would be expected to cause some beneficial effects for people with locomotive syndrome. The purpose of this study was to assess whether the deterioration of low back pain and any other adverse events would occur following HAL exercise therapy. Moreover, the changes of motor ability variables were evaluated.
Methods
We enrolled 33 participants (16 men, 17 women) with locomotive syndrome in this study. They received exercise training (sit-to-stand, lumbar flexion-extension, and gait training) with HAL (in total 12 sessions). We assessed the change of low back pain (lumbar VAS). More than 50% and 25 mm increase compared to baseline was defined as adverse events. One-leg standing time (OLST), 10-m walking test (10MWT), Timed Up and Go test (TUG), 1-min sit-to-stand test (1MSTS), FIM mobility scores and EQ-5D were measured.
Results
Of the 33 participants, 32 (16 men, 16 women) (97.0%) completed all 12 exercise training sessions using the lumbar type HAL. One woman aged 82 years withdrew because of right upper limb pain after the second session regardless of the use of HAL. There was no participant who had deterioration of low back pain. Any other adverse events including external injuries and/or falling, skin disorders, uncontrollable cardiovascular or respiratory disorders, and other health disorders directly related to this exercise therapy did not occur. Several outcome measures of motion ability including OLST, TUG and 1MSTS, EQ VAS and lumbar pain improved significantly after this HAL training.
Conclusions
Almost all patients with locomotive syndrome completed this exercise training protocol without any adverse events related to HAL. Furthermore, balance function variables including OLST, TUG and 1MSTS improved after this HAL exercise therapy even though mobility function variables including 10MWT and FIM mobility scores did not show any significant change. These findings suggest that the exercise therapy using the lumbar type HAL would be one of the options for the intervention in locomotive syndrome.
