Robot-assisted training using Hybrid Assistive Limb® for cerebral palsy

Use of Artificial Intelligence Techniques to Assist Individuals with Physical Disabilities

Assistive technologies (AT) enable people with disabilities to perform activities of daily living more independently, have greater access to community and healthcare services, and be more productive performing educational and/or employment tasks. Integrating artificial intelligence (AI) with various agents, including electronics, robotics, and software, has revolutionized AT, resulting in groundbreaking technologies such as mind-controlled exoskeletons, bionic limbs, intelligent wheelchairs, and smart home assistants. This article provides a review of various AI techniques that have helped those with physical disabilities, including brain-computer interfaces, computer vision, natural language processing, and human-computer interaction. The current challenges and future directions for AI-powered advanced technologies are also addressed.

Feasibility and safety study of wearable cyborg Hybrid Assistive Limb for pediatric patients with cerebral palsy and spinal cord disorders

Introduction

The wearable cyborg Hybrid Assistive Limb (HAL) is the world's first cyborg-type wearable robotic device, and it assists the user's voluntary movements and facilitates muscle activities. However, since the minimum height required for using the HAL is 150 cm, a smaller HAL (2S size) has been newly developed for pediatric use. This study aimed to (1) examine the feasibility and safety of a protocol for treatments with HAL (2S size) in pediatric patients and (2) explore the optimal method for assessing the efficacy of HAL.

Methods

This clinical study included seven pediatric patients with postural and motor function disorders, who received 8-12 sessions of smaller HAL (2S size) treatment. The primary outcome was the Gross Motor Function Measure-88 (GMFM-88). The secondary outcomes were GMFM-66, 10-m walk test, 2- and 6-min walking distances, Canadian Occupational Performance Measure (COPM), a post-treatment questionnaire, adverse events, and device failures. Statistical analyses were performed using the paired samples t-test or Wilcoxon signed-rank test.

Results

All participants completed the study protocol with no serious adverse events. GMFM-88 improved from 65.51 ± 21.97 to 66.72 ± 22.28 (p = 0.07). The improvements in the secondary outcomes were as follows: GMFM-66, 53.63 ± 11.94 to 54.96 ± 12.31, p = 0.04; step length, 0.32 ± 0.16 to 0.34 ± 0.16, p = 0.25; 2-MWD, 59.1 ± 57.0 to 62.8 ± 63.3, p = 0.54; COPM performance score, 3.7 ± 2.0 to 5.3 ± 1.9, p = 0.06; COPM satisfaction score, 3.3 ± 2.1 to 5.1 ± 2.1, p = 0.04.

Discussion

In this exploratory study, we applied a new size of wearable cyborg HAL (2S size), to children with central nervous system disorders. We evaluated its safety, feasibility, and identified an optimal assessment method for multiple treatments. All participants completed the protocol with no serious adverse events. This study suggested that the GMFM would be an optimal assessment tool for validation trials of HAL (2S size) treatment in pediatric patients with posture and motor function disorders.

Satisfaction analysis of overground gait exoskeletons in people with neurological pathology. a systematic review

BACKGROUND

People diagnosed with neurological pathology may experience gait disorders that affect their quality of life. In recent years, research has been carried out on a variety of exoskeletons in this population. However, the satisfaction perceived by the users of these devices is not known. Therefore, the objective of the present study is to evaluate the satisfaction perceived by users with neurological pathology (patients and professionals) after the use of overground exoskeletons.

METHODS

A systematic search of five electronic databases was conducted. In order to be included in this review for further analysis, the studies had to meet the following criteria: [1] the study population was people diagnosed with neurological pathology; [2] the exoskeletons had to be overground and attachable to the lower limbs; and [3]: the studies were to include measures assessing either patient or therapist satisfaction with the exoskeletons.

RESULTS

Twenty-three articles were selected, of which nineteen were considered clinical trials. Participants diagnosed with stroke (n = 165), spinal cord injury (SCI) (n = 102) and multiple sclerosis (MS) (n = 68). Fourteen different overground exoskeleton models were analysed. Fourteen different methods of assessing patient satisfaction with the devices were found, and three ways to evaluate it in therapists.

CONCLUSION

Users' satisfaction with gait overground exoskeletons in stroke, SCI and MS seems to show positive results in safety, efficacy and comfort of the devices. However, the worst rated aspects and therefore those that should be optimized from the users' point of view are ease of adjustment, size and weight, and ease of use.

Benefits of a Wearable Cyborg HAL (Hybrid Assistive Limb) in Patients with Childhood-Onset Motor Disabilities: A 1-Year Follow-Up Study

Rehabilitation robots have shown promise in improving the gait of children with childhood-onset motor disabilities. This study aimed to investigate the long-term benefits of training using a wearable Hybrid Assistive Limb (HAL) in these patients. Training using a HAL was performed for 20 min a day, two to four times a week, over four weeks (12 sessions in total). The Gross Motor Function Measure (GMFM) was the primary outcome measure, and the secondary outcome measures were gait speed, step length, cadence, 6-min walking distance (6MD), Pediatric Evaluation of Disability Inventory, and Canadian Occupational Performance Measure (COPM). Patients underwent assessments before the intervention, immediately after the intervention, and at 1-, 2-, 3-month and 1-year follow-ups. Nine participants (five males, four females; mean age: 18.9 years) with cerebral palsy (n = 7), critical illness polyneuropathy (n = 1), and encephalitis (n = 1) were enrolled. After training using HAL, GMFM, gait speed, cadence, 6MD, and COPM significantly improved (all p < 0.05). Improvements in GMFM were maintained one year after the intervention (p < 0.001) and in self-selected gait speed and 6MD three months after the intervention (p < 0.05). Training using HAL may be safe and feasible for childhood-onset motor disabilities and may maintain long-term improvements in motor function and walking ability.

Safety and Feasibility of Robot-assisted Gait Training in Adults with Cerebral Palsy in an Inpatient Setting - an Observational Study

BACKGROUND

To investigate the safety and feasibility of six sessions of Hybrid Assistive Limb (HAL) robot-assisted gait training (RAGT) integrated into an inpatient therapy concept and their influence on walking speed and gait parameters in adult CP patients.

METHODS

Eleven subjects (male = 8, female = 3, mean age: 23 years and 2 months, ± 4.5 years) with spastic CP underwent six 20-minute RAGT sessions with the HAL during an 11-day hospital stay. Additionally, physiotherapy, physician-performed manual medicine, massage and exercise therapy were provided. Pre- (T1) and post- (T2) intervention assessments were: 10-metre walking test (10MWT), 6-minute walking test (6MWT), Gross Motor Function Measure (GMFM-88) and lower extremities passive range of motion (pROM).

RESULTS

All subjects completed the study. No adverse events were noted. Walking speed in the 10MWT test increased from 32.5 s (± 24.5 s) at T1 to 27.5 s (± 21.4 s) at T2, without significance. Slight, but non-significant improvements were detected in the 6MWT, GMFM and pROM. Confounding factors did not significantly affect the results. Conclusion: Intensive therapy including HAL training leads to non-significant improvements. Further studies with more patients and longer intervention time could provide further insights into the RAGT therapy of adult patients with CP. Registration DRKS-ID: DRKS00020275.

Use of Robot-Assisted Gait Training in Pediatric Patients with Cerebral Palsy in an Inpatient Setting-A Randomized Controlled Trial

Robot-assisted gait training (RAGT) provides a task-based support of walking using exoskeletons. Evidence shows moderate, but positive effects in the therapy of patients with cerebral palsy (CP). This study investigates the impact of RAGT on walking speed and gait parameters in pediatric CP patients. Thirty subjects (male = 23; female = 7), with a mean age of 13.0 ± 2.5 (9-17) years, and with spastic CP, were recruited. The intervention group (n = 15) underwent six 20-minute RAGT sessions with the Hybrid Assistive Limb (HAL) during an 11-day hospital stay. Additionally, a therapy concept including physiotherapy, physician-performed manual medicine, massage and exercise therapy was provided. The control group (n = 15) was treated with the therapy concept only. The outcome was based on a 10-Metre Walking Test (10MWT), 6-Minute Walking Test (6MWT), Gross Motor Function Measure (GMFM-88) and lower extremities passive range of motion. The intervention group achieved a mean increase in walking speed in the 10MWT (self-selected walking speed SSW) of 5.5 s (p = 0.378). There were no significant differences between the groups in the 10MWT (max) (p = 0.123) and the 6MWT (p = 0.8). Changes in the GMFM (total) and in the dimension standing and walking, running and jumping (D + E) showed clinically relevant significant results (p = 0.002 and p = 0.046). RAGT as a supplement to an inpatient therapy stay appears to have a positive, yet not significant impact on the gait parameters of pediatric CP patients as well as motivating them to practice walking. Further studies with adapted study designs are needed to evaluate different influencing factors.

Short-Term Outcome of Rehabilitation Program with Hybrid Assistive Limb after Tendon Lengthening in Patients with Cerebral Palsy

In this study, we aimed to evaluate the short-term outcomes of a rehabilitation program with the Hybrid Assistive Limb® after soft tissue lengthening in young patients with cerebral palsy. We assessed six patients with cerebral palsy who underwent soft tissue surgery followed by gait training using the Hybrid Assistive Limb®. Clinical assessments were conducted preoperatively, before, immediately after, and at 1, 2, and 3 months after gait training. Gross Motor Function Measure was improved 5.93 ± 6.11% (mean ± standard deviation, p < 0.05), Canadian Occupational Performance Measure performance was improved 3.12 ± 1.53 points, and satisfaction was improved 3.80 ± 2.14 points (p < 0.05). The knee extension strength on the operated side was changed 7.75 ± 4.97 Nm after the intervention (p = 0.07). In ambulatory patients, gait speed was changed 8.37 ± 1.72 m/min, stride length was changed 10 ± 6.16 cm, and 6 min walking distance was changed 52 ± 16 m after the intervention. Training with the Hybrid Assistive Limb® may improve walking ability and clinical outcomes in young patients with cerebral palsy after soft tissue lengthening.

Electromechanical and Robotic Devices for Gait and Balance Rehabilitation of Children with Neurological Disability: A Systematic Review

In the last two decades, a growing interest has been focused on gait and balance robot-assisted rehabilitation in children with neurological disabilities. Robotic devices allow the implementation of intensive, task-specific training fostering functional recovery and neuroplasticity phenomena. However, limited attention has been paid to the protocols used in this research framework. This systematic review aims to provide an overview of the existing literature on robotic systems for the rehabilitation of gait and balance in children with neurological disabilities and their rehabilitation applications. The literature search was carried out independently and synchronously by three authors on the following databases: MEDLINE, Cochrane Library, PeDro, Institute of Electrical and Electronics Engineers, ScienceDirect, and Google Scholar. The data collected included three subsections referring to clinical, technical, and regulatory aspects. Thirty-one articles out of 81 found on the primary literature search were included in the systematic review. Most studies involved children with cerebral palsy. Only one-third of the studies were randomized controlled trials. Overall, 17 devices (nine end-effector systems and eight exoskeletons) were investigated, among which only 4 (24%) were bore the CE mark. Studies differ on rehabilitation protocols duration, intensity, and outcome measures. Future research should improve both rehabilitation protocols’ and devices’ descriptions.

Wearable Lower-Limb Exoskeleton for Children With Cerebral Palsy: A Systematic Review of Mechanical Design, Actuation Type, Control Strategy, and Clinical Evaluation

Children with a neurological disorder such as cerebral palsy (CP) severely suffer from a reduced quality of life because of decreasing independence and mobility. Although there is no cure yet, a lower-limb exoskeleton (LLE) has considerable potential to help these children experience better mobility during overground walking. The research in wearable exoskeletons for children with CP is still at an early stage. This paper shows that the number of published papers on LLEs assisting children with CP has significantly increased in recent years; however, no research has been carried out to review these studies systematically. To fill up this research gap, a systematic review from a technical and clinical perspective has been conducted, based on the PRISMA guidelines, under three extended topics associated with "lower limb", "exoskeleton", and "cerebral palsy" in the databases Scopus and Web of Science. After applying several exclusion criteria, seventeen articles focused on fifteen LLEs were included for careful consideration. These studies address some consistent positive evidence on the efficacy of LLEs in improving gait patterns in children with CP. Statistical findings show that knee exoskeletons, brushless DC motors, the hierarchy control architecture, and CP children with spastic diplegia are, respectively, the most common mechanical design, actuator type, control strategy, and clinical characteristics for these LLEs. Clinical studies suggest ankle-foot orthosis as the primary medical solution for most CP gait patterns; nevertheless, only one motorized ankle exoskeleton has been developed. This paper shows that more research and contribution are needed to deal with open challenges in these LLEs.

The Effects of Over-Ground Robot-Assisted Gait Training for Children with Ataxic Cerebral Palsy: A Case Report

Poor balance and ataxic gait are major impediments to independent living in ataxic cerebral palsy (CP). Robot assisted-gait training (RAGT) has been shown to improve the postural balance and gait function in children with CP. However, there is no report on the application of RAGT for children with ataxic CP. Here, we report two cases of children with ataxic CP who underwent over-ground RAGT along with conventional therapy for 4 weeks. Outcome measures including the gross motor function measure (GMFM), pediatric balance scale, pediatric reach scale, one-minute walk test, and Timed Up and Go test were assessed before and after the 4-week intervention. Both cases were well adapted to the RAGT system without any significant adverse event. Improvements in the GMFM after RAGT, compared with that in the GMFM, after intensive conventional therapy have been reported previously. It is noteworthy that over-ground RAGT improved areas of the GMFM that did not improve with conventional therapy. In addition, over-ground RAGT with conventional therapy led to improvements in functional balance and walking capacity. These findings suggest that over-ground RAGT is feasible and may be a potential option for enhancing balance and functional walking capacity in children with ataxic CP.

Gait training using a hybrid assistive limb after botulinum toxin treatment for cerebral palsy: a case report

[Purpose] Hybrid Assistive Limb^® (HAL; Cyberdyne, Tsukuba, Japan) is a wearable robot that assists patients based on their voluntary movements. We report gait training with HAL after botulinum toxin treatment for spasticity of the lower limb in cerebral palsy (CP). [Participant and Methods] The participant was a 36 year-old male with spastic diplegia due to periventricular leukomalacia, with Gross Motor Function Classification System (GMFCS) level II. HAL training was performed in 20-minute sessions (3 sessions/week for 4 weeks). The outcome measures were range of motion, spasticity, walking ability, muscle strength, gross motor function measure (GMFM), Canadian Occupational Performance Measure (COPM), and Pediatric Evaluation of Disability Inventory measured before, immediately after, and one, two, and three months after HAL training. [Results] No adverse events were observed during training. After the HAL intervention, gait speed, step length, cadence, 6-min walking distance (6MD), knee extension strength, GMFM, and COPM increased, and Physiological Cost Index declined. Three months post-intervention, gait speed, step length, cadence, 6MD, and GMFM remained higher than those observed within the first two months. [Conclusion] Gait training with HAL can be a safe and feasible method for patients with CP who undergo botulinum toxin treatment to improve walking ability and motor function.

Effectiveness of powered exoskeleton use on gait in individuals with cerebral palsy: A systematic review

Background

Cerebral palsy (CP) is a leading cause of childhood disability. The motor impairments of individuals with CP significantly affect the kinematics of an efficient gait pattern. Robotic therapies have become increasingly popular as an intervention to address this. Powered lower limb exoskeletons (PoLLE) are a novel form of robotic therapy that allow the individual to perform over-ground gait training and yet its effectiveness for CP is unknown.

Purpose

To determine the effectiveness of PoLLE use on gait in individuals with CP.

Method

A systematic search of eight electronic databases was conducted in March 2020. Studies included children (0–18 years) and or adults (18+ years) diagnosed with CP who used a PoLLE for gait training. This review was conducted and reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement, with the methodology registered with PROSPERO (CRD42020177160). A modified version of the McMaster critical review form for quantitative studies was used to assess the methodological quality. Due to the heterogeneity of the included studies, a descriptive synthesis using the National Health & Medical Research Council (NHMRC) FORM framework was undertaken.

Results

Of the 2089 studies screened, ten case series and three case studies met the inclusion criteria highlighting the current evidence base is emerging and low level. A range of PoLLEs were investigated with effectiveness measured by using a number of outcome measures. Collectively, the body of evidence indicates there is some consistent positive evidence on the effectiveness of PoLLE in improving gait in individuals with CP, with minimal adverse effects. While this is a positive and encouraging finding for an emerging technology, methodological concerns also need to be acknowledged.

Conclusion

With rapidly evolving technology, PoLLEs could play a transformative role in the lives of people impacted by CP. Ongoing research is required to further strengthen the evidence base and address current methodological concerns.

Effectiveness of robotic-assisted therapy for upper extremity function in children and adolescents with cerebral palsy: a systematic review protocol

INTRODUCTION

The application of advanced technologies in paediatric rehabilitation to improve performance and enhance everyday functioning shows considerable promise. The aims of this systematic review are to investigate the effectiveness of robotic-assisted therapy for upper extremity function in children and adolescents with cerebral palsy and to extend the scope of intervention from empirical evidence.

METHODS AND ANALYSIS

Multiple databases, including MEDLINE (Ovid), PubMed, CINAHL, Scopus, Web of Science, Cochrane Library and IEEE Xplore, will be comprehensively searched for relevant randomised controlled trials and non-randomised studies. The grey literature will be accessed on the ProQuest Dissertations & Theses Global database, and a hand search from reference lists of previous articles will be performed. The papers written in English language will be considered, with no limitation on publication date. Two independent reviewers will identify eligible studies, evaluate the level of evidence (the Oxford Centre for Evidence-Based Medicine) and appraise methodological quality and risk of bias (the Standard quality assessment criteria for evaluating primary research papers from a variety of fields (QualSyst tool); the Grading of Recommendations Assessment, Development and Evaluation). Data will be appropriately extracted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. A narrative synthesis will be provided to summarise the results, and a meta-analysis will be conducted if there is sufficient homogeneity across outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020205818.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study. The findings will be disseminated via a peer-reviewed journal and international conferences.

Overground Robot-Assisted Gait Training for Pediatric Cerebral Palsy

The untethered exoskeletal robot provides patients with the freest and realistic walking experience by assisting them based on their intended movement. However, few previous studies have reported the effect of robot-assisted gait training (RAGT) using wearable exoskeleton in children with cerebral palsy (CP). This pilot study evaluated the effect of overground RAGT using an untethered torque-assisted exoskeletal wearable robot for children with CP. Three children with bilateral spastic CP were recruited. The robot generates assistive torques according to gait phases automatically detected by force sensors: flexion torque during the swing phase and extension torque during the stance phase at hip and knee joints. The overground RAGT was conducted for 17~20 sessions (60 min per session) in each child. The evaluation was performed without wearing a robot before and after the training to measure (1) the motor functions using the gross motor function measure and the pediatric balance scale and (2) the gait performance using instrumented gait analysis, the 6-min walk test, and oxygen consumption measurement. All three participants showed improvement in gross motor function measure after training. Spatiotemporal parameters of gait analysis improved in participant P1 (9-year-old girl, GMFCS II) and participant P2 (13-year-old boy, GMFCS III). In addition, they walked faster and farther with lower oxygen consumption during the 6-min walk test after the training. Although participant P3 (16-year-old girl, GMFCS IV) needed the continuous help of a therapist for stepping at baseline, she was able to walk with the platform walker independently after the training. Overground RAGT using a torque-assisted exoskeletal wearable robot seems to be promising for improving gross motor function, walking speed, gait endurance, and gait efficiency in children with CP. In addition, it was safe and feasible even for children with severe motor impairment (GMFCS IV).

Systematic review on wearable lower-limb exoskeletons for gait training in neuromuscular impairments

Gait disorders can reduce the quality of life for people with neuromuscular impairments. Therefore, walking recovery is one of the main priorities for counteracting sedentary lifestyle, reducing secondary health conditions and restoring legged mobility. At present, wearable powered lower-limb exoskeletons are emerging as a revolutionary technology for robotic gait rehabilitation. This systematic review provides a comprehensive overview on wearable lower-limb exoskeletons for people with neuromuscular impairments, addressing the following three questions: (1) what is the current technological status of wearable lower-limb exoskeletons for gait rehabilitation?, (2) what is the methodology used in the clinical validations of wearable lower-limb exoskeletons?, and (3) what are the benefits and current evidence on clinical efficacy of wearable lower-limb exoskeletons? We analyzed 87 clinical studies focusing on both device technology (e.g., actuators, sensors, structure) and clinical aspects (e.g., training protocol, outcome measures, patient impairments), and make available the database with all the compiled information. The results of the literature survey reveal that wearable exoskeletons have potential for a number of applications including early rehabilitation, promoting physical exercise, and carrying out daily living activities both at home and the community. Likewise, wearable exoskeletons may improve mobility and independence in non-ambulatory people, and may reduce secondary health conditions related to sedentariness, with all the advantages that this entails. However, the use of this technology is still limited by heavy and bulky devices, which require supervision and the use of walking aids. In addition, evidence supporting their benefits is still limited to short-intervention trials with few participants and diversity among their clinical protocols. Wearable lower-limb exoskeletons for gait rehabilitation are still in their early stages of development and randomized control trials are needed to demonstrate their clinical efficacy.

Effect of the Hybrid Assistive Limb on the Gait Pattern for Cerebral Palsy

Background and objectives: Cerebral palsy (CP) is the most frequent childhood motor disability. Achieving ambulation or standing in children with CP has been a major goal of physical therapy. Recently, robot-assisted gait training using the Hybrid Assistive Limb^® (HAL) has been effective in improving walking ability in patients with CP. However, previous studies have not examined in detail the changes in gait pattern after HAL training for patients with spastic CP, including gait symmetry. This study aimed to evaluate the immediate effect of HAL training on the walking ability and the changes in gait pattern and gait symmetry in patients with spastic CP. Materials and Methods: We recruited 19 patients with spastic CP (13 male and six female; mean age, 15.7 years). Functional ambulation was assessed using the 10-Meter Walk Test and gait analysis in the sagittal plane before and after a single 20-min HAL intervention session. Results: The walking speed and stride length significantly increased after HAL intervention compared to the pre-intervention values. Two-dimensional gait analysis showed improvement in equinus gait, increase in the flexion angle of the swing phase in the knee and hip joints, and improvement in gait symmetry. Immediate improvements in the walking ability and gait pattern were noted after HAL training in patients with spastic CP. Conclusions: The symmetry of the joint angle of the lower limb, including the trunk, accounts for the improvement in walking ability after HAL therapy.

The Effect of Robot-Assisted Gait Training on Locomotor Function and Functional Capability for Daily Activities in Children with Cerebral Palsy: A Single-Blinded, Randomized Cross-Over Trial

Purpose: The effectiveness of robot-assisted gait training (RAGT) in children with cerebral palsy (CP), especially in terms of improving the performance of daily activities, remains unclear. Therefore, we aimed to investigate the effectiveness of RAGT in children with CP. Methods: In this single-center, single-blinded, randomized cross-over trial, we enrolled 20 children with CP with Gross Motor Function Classification System (GMFCS) levels II–IV (13 males; age range, 6.75 ± 2.15 years). The participants were randomized into the RAGT/standard care (SC) (n = 10) and SC/RAGT/SC sequence groups (n = 10). Using a Walkbot-K system, the RAGT program comprised 3 × 30-min sessions/week for 6 weeks with a continued SC program. The SC program comprised 2–4 conventional physiotherapy sessions/week for 6 weeks. The Gross Motor Function Measure-88 (GMFM-88), the pediatric functional independence measure (WeeFIM), and the Canadian occupational performance measure (COPM) scores were assessed pre- and post-RAGT or SC periods and treatment, period, follow-up, and carry-over effects were analyzed. Energy expenditure and body composition were measured pre- and post-RAGT. Results: Significant treatment effects were observed in dimensions D and E of the GMFM (D: p = 0.018; E: p = 0.021) scores, WeeFIM mobility subtotal (p = 0.007), and COPM performance (p < 0.001) and satisfaction (p = 0.001) measure scores. The period, follow-up, and carry-over effects were not statistically significant. The gross energy cost significantly decreased (p = 0.041) and the skeletal muscle mass increased (p = 0.014) at post-RAGT assessment. The factors associated with functional outcomes showed significant improvements in the GMFM D scores and were mainly observed in children with GMFCS levels II–III compared to those classified at level IV (p = 0.038). Conclusion: RAGT had training benefits for children with CP. Specifically, it improved locomotor function and functional capability for daily activities. These effects were better in ambulatory children with CP. However, as SC interventions continued during the RAGT period, these improvements may be also related to multiple treatment effects.

Robot-assisted gait training using a very small-sized Hybrid Assistive Limb® for pediatric cerebral palsy: A case report

PURPOSE

Gait parameters and gross motor function improve after 12 sessions of small-sized Hybrid Assistive Limb® (S-HAL) training in adult cerebral palsy (CP) patients. However, there are no reports on repetitive robot-assisted gait training using the newly developed very small-sized HAL (2S-HAL). This study aimed to examine the effect of using 2S-HAL on a pediatric CP patient.

METHODS

The subject was an 11-year-old boy (height = 138 cm, weight = 30 kg) with spastic quadriplegia due to periventricular leukomalacia, with Gross Motor Function Classification System level IV. HAL training was performed for 2-4 sessions/week for 20 min/session (i.e., 4-week period with 12 sessions). Outcome measures were walking ability, gross motor function, Canadian Occupational Performance Measure (COPM), and Pediatric Evaluation of Disability Inventory measured before, after, and at 1, 2, and 3 months after HAL-assisted gait training.

RESULTS

After HAL intervention, gait speed, step length, cadence, 6-min walking distance (6MD), Gross Motor Function Measure (GMFM), and COPM increased and physiological cost index (PCI) declined compared to those before intervention. The peaks of gait speed, step length, and cadence were 2 month, 1 month, and 3 month, respectively. 6MD, PCI, and GMFM at 1-3 months post-intervention were maintained. COPM peaked at 1 month post-intervention but remained higher than that before intervention.

CONCLUSION

This is the first report of repetitive intervention using 2S-HAL in a pediatric CP patient. Gait training using 2S-HAL may be effective in CP patients as it improves post-training walking ability and gross motor function.

Safety and immediate effects of Hybrid Assistive Limb in children with cerebral palsy: A pilot study

PURPOSE

Early intervention is effective for developing motor ability and preventing contractures and deformities in patients with cerebral palsy (CP). Gait training using the newly developed Hybrid Assistive Limb (HAL) shows promise as an intervention to prevent deterioration in walking ability and deformities in pediatric CP patients. The purpose of this pilot study was to examine the safety and immediate effects on walking ability after gait training using the HAL in pediatric CP patients.

METHODS

Nineteen patients (six females, 13 males; mean age 8.5 years; mean height 120.5 cm; mean weight 23.2 kg) were enrolled. The Gross Motor Functional Classification Scale level was I in two patients, II in two, III in eight, and IV in seven. The HAL was used for a single session of gait training. The primary outcome was safety of the HAL for use in pediatric CP patients. The secondary outcome was the immediate effect after gait training with HAL, evaluated by passive range of motion (ROM) and gait parameters, including gait speed (m/s), step length (cm), and cadence (step/min).

RESULTS

All 19 patients were able to carry out the gait training without any severe adverse events. Significant improvements were observed for mean internal/external rotation and abduction angles of the hip joint, and ankle dorsiflexion angles (n = 19). Significant improvements were observed for mean gait speed and step length based on expansion of the hip flexion-extension range (n = 11).

CONCLUSION

Gait training using the HAL is safe and can produce immediate improvements in ROM and walking ability in pediatric patients with CP.

Improvement and sustainability of walking ability with hybrid assistive limb training in a patient with cerebral palsy after puberty: a case report

[Purpose] Cerebral palsy is one of the most common causes of childhood physical disability affecting motor development. Gait training with a wearable-robot, such as the Hybrid Assistive Limb, has been reported to improve gait ability in patients with chronic motor disabilities; however, there are no reports concerning the sustained improvement of walking ability with its use in patients with cerebral palsy. We present our observations for the use of Hybrid Assistive Limb gait training in a postpubescent cerebral palsy patient. [Participant and Methods] A 17-year-old male with spastic cerebral palsy could only ambulate slightly using a crouch gait posture and with the aid of a walker. Hybrid Assistive Limb training was performed thrice weekly for 4 weeks (total of 12 sessions) along with concurrent daily physical therapy. The follow-up period was 7 months after the intervention. [Results] The intervention resulted in improvements in the patient’s gait speed, proportion of the stance phase in a gait cycle, step length, and the flexion angle of the knees at initial contact and during late stance phase, which was sustained for 7 months following the intervention. [Conclusion] Our observations suggest that Hybrid Assistive Limb training may effectively improve and sustain walking ability even among postpubescent cerebral palsy patients who have a decreased walking ability.

Newly developed hybrid assistive limb for pediatric patients with cerebral palsy: a case report

[Purpose] The effect of fitness training on improving walking ability in cerebral palsy is controversial. However, gait training with a wearable robot (hybrid assistive limb) has been reported to improve gait ability in patients with cerebral palsy. For pediatric patients, a smaller, lighter-weight hybrid assistive limb has been newly developed. We describe the immediate effect of this newly developed smaller hybrid assistive limb on the gait ability of a pediatric patient with cerebral palsy and examine its safety and feasibility. [Participant and Methods] An 11-year-old male with spastic cerebral palsy (height, 130 cm; weight, 29.0 kg) who could ambulate using an elbow crutch participated in this study. A single session of hybrid assistive limb training comprising pre-exercise of the hip and knee joints and walking for 20 minutes was conducted. [Results] The intervention immediately improved his gait speed, stride length, and cadence according to the 10-m walking test. Co-contraction of agonist/antagonist muscles during walking improved, and the flexion angle of the right hip during the swing phase increased, which resulted in symmetry of movement of both legs. [Conclusion] Gait training using the new, smaller hybrid assistive limb for a pediatric patient was safe and feasible, and the newly developed hybrid assistive limb has the potential to immediately improve walking ability even among young children with cerebral palsy.