Successful Use of the Hybrid Assistive Limb for Care Support to Reduce Lumbar Load in a Simulated Patient Transfer

Investigating proficiency using a lift-type transfer support device for effective care: comparison of skilled and unskilled nursing homes

PURPOSE

The purpose of the study was to investigate whether the sustained use of the "Hug," a "hugging" type robotic transfer support device, could increase the level of quality of care.

METHODS

The effect of proficiency on using the device was examined in terms of time spent for transfer, ratio of transfers using the device, and range of targets. The results were compared between skilled care facilities that had used the device for >24 months and unskilled facilities.

RESULTS

The time spent for transfer at the unskilled facility was 4.6 min (2nd week after introduction), was reduced to 3.0 min (5th week), and 1.5 min at the skilled facility. The usage ratio at the unskilled facility was 13% and 30% (2nd and 5th week, respectively), while it was 97% in the skilled facility. Further, we identified wider in the range of target care recipients in the skilled facility.

CONCLUSION

It takes time to master the use of Hug; however, its use was associated with many positive aspects, especially from the perspective of care recipients, e.g., better care, use of their own legs, and reduced time for transfers. These findings suggest that the widespread use of Hug would improve the quality of care.IMPLICATIONS FOR REHABILITATIONLess physically burdened on the caregivers using Hug, they can afford to talk to the care recipients.Using recipient's own legs during transfers, it prevents leg muscle disuse.As reduced time for transfers, recipients will have more opportunities to get out of bed.

Exoskeleton technology in nursing practice: assessing effectiveness, usability, and impact on nurses' quality of work life, a narrative review

The use of exoskeletons in nursing practice has gained attention as a potential solution to address the physical demands and risks associated with the profession. This narrative review examines the effectiveness, usability, and impact of exoskeleton technology on nurses' quality of work life. The review focuses on the reduction of physical strain and fatigue, improved posture and body mechanics, enhanced patient care, usability and acceptance factors, and the broader impact on work life. The effectiveness of exoskeletons in reducing physical strain and fatigue among nurses is supported by evidence showing decreased muscle activation and reduced forces exerted on the body. The usability and acceptance of exoskeletons are critical considerations, including device comfort and fit, ease of use and integration into workflows, user experience and training, compatibility with the work environment, and user feedback for iterative design improvements. The implementation of exoskeletons has the potential to positively impact nurses' work life by reducing work-related injuries, improving physical well-being, enhancing job satisfaction, and promoting psychological and psychosocial benefits. Additionally, the use of exoskeletons can lead to improved patient care outcomes. Challenges and future directions in the field of exoskeleton technology for nurses include cost and accessibility, adaptability to nursing specialties and tasks, long-term durability and maintenance, integration with personal protective equipment, and ethical considerations. Addressing these challenges and considering future research and development efforts are crucial for the successful integration of exoskeleton technology in nursing practice, ultimately improving nurses' quality of work life and patient care delivery.

Influence of a passive back support exoskeleton on simulated patient bed bathing: results of an exploratory study

Low-back pain is a major concern among healthcare workers. One cause is the frequent adoption of repetitive forward bent postures in their daily activities. Occupational exoskeletons have the potential to assist workers in such situations. However, their efficacy is largely task-dependent, and their biomechanical benefit in the healthcare sector has rarely been evaluated. The present study investigates the effects of a passive back support exoskeleton in a simulated patient bed bathing task. Nine participants performed the task on a medical manikin, with and without the exoskeleton. Results show that working with the exoskeleton induced a significantly larger trunk forward flexion, by 13 deg in average. Due to this postural change, using the exoskeleton did not affect substantially the muscular and cardiovascular demands nor the perceived effort. These results illustrate that postural changes induced by exoskeleton use, whether voluntary or not, should be considered carefully since they may cancel out biomechanical benefits expected from the assistance. Practitioner summary: Low-back pain is a major concern among nurses, associated with bent postures. We observed that using a passive back-support exoskeleton during the typical patient bed bathing activity results in a larger trunk flexion, without changing muscular, cardiovascular or perceived physical effort.

Critical review on applications and roles of exoskeletons in patient handling

Musculoskeletal Disorders (MSDs) remain a major concern for workers in the healthcare industry. Healthcare workers are at high risk of work-related MSDs mainly caused by overexertion from manually handling patients. Exoskeletons may be a useful tool to help reduce the risk of MSDs during patient handling. As a review study, we surveyed articles focusing on applying exoskeletons to patient handling tasks specifically. We also reviewed relevant government databases and other studies related to Safe Patient Handling and Mobility (SPHM) programs and exoskeleton applications in general. The exoskeletons specifically designed for patient handling were found to be sparse. To have a better understanding of the needs and challenges of developing and using exoskeletons for reducing risks of work-related MSDs in healthcare workers during patient handling, this critical review (1) provided an overview of the existing issues and projected future burdens related to work-related MSDs during patient handling tasks, (2) recognized current and potential roles and applications of existing exoskeletons, and (3) identified challenges and needs for future exoskeleton products. In conclusion, we do not expect exoskeletons to replace the existing SPHM programs, but rather play a complementary role to these multi-pronged programs. We expect that emerging exoskeleton products can be introduced to uncontrolled or specialized healthcare environments. There are various expectations and requirements for an exoskeleton used in different healthcare settings. Additionally, introducing certain types of exoskeletons for patients to assist them during treatment and rehabilitation may help reduce the MSD risks to the healthcare workers.

Biofeedback Physical Therapy With the Hybrid Assistive Limb (HAL) Lumbar Type for Chronic Low Back Pain: A Pilot Study

Objective

There are many treatments for chronic low back pain, including various medications, exercise therapy, orthotics, and surgery, but no treatment is definitive. We hypothesized that biofeedback therapy using the hybrid assistive limb (HAL) lumbar type would have some immediate effects on chronic low back pain. The purpose of this pilot study was to assess whether immediate changes in low back pain and hip flexibility and any other adverse events would occur following the HAL biofeedback physical therapy.

Methods

This was a single-center, pilot, prospective, single-arm study of outpatient biofeedback physical therapy using the HAL lumbar type for patients with chronic low back pain. Patients underwent a 10-minute biofeedback physical therapy (lumbar flexion-extension, sit-to-stand, and squat) with the HAL lumbar type (in one session). The visual analog scale (VAS) score of low back pain during lumbar flexion, extension, lateral bending, and rotation was evaluated. The finger-to-floor distance (FFD), straight leg raising test (SLR), and the Thomas test were measured to assess hip flexibility.

Results

All 35 participants (14 men and 21 women) (100%) conducted a biofeedback HAL therapy session using the HAL lumbar type. No participant had deterioration of low back pain. No adverse events occurred. After the biofeedback therapy using the HAL lumbar type, SLR demonstrated a significant positive change with large effect size and sufficient power. Lumbar VAS during lumbar flexion and extension and FFD showed a significant positive change with medium effect size and adequate power.

Conclusions

Biofeedback therapy using the HAL lumbar type is an option for intervention in chronic low back pain.

Early Postoperative Rehabilitation Using the Hybrid Assistive Limb (HAL) Lumbar Type in Patients With Hip Fracture: A Pilot Study

Objective: To extend life expectancy after surgery, patients with hip fractures need to improve their mobility quickly through postoperative rehabilitation. Voluntary hip joint motion supported by the hybrid assistive limb (HAL) lumbar type, an exoskeleton robot suit characterized by its ability to detect the wearer’s intentions through the bioelectrical signals and assist hip extension motions at an optimal timing, may be effective to improve mobility in patients with hip joint dysfunction after surgery. We aimed to introduce rehabilitation using the HAL lumbar type in the early period after hip fracture surgery.

Methods: Patients who underwent internal fixation for hip fracture at a single institution were prospectively enrolled. They received early postoperative rehabilitation (forward and backward bending of the lumbar spine, pelvic tilt forward and backward, standing up, and squatting) using the HAL lumbar type (six times a week for 15 min per session). Five-times-sit-to-stand (FTSS) and timed-up-and-go (TUG) tests were conducted at baseline before HAL rehabilitation (pre-HAL) and after the HAL rehabilitation (post-HAL) intervention.

Results: We enrolled 14 patients (one man, 13 women) in this study. There were no adverse events, and all patients were able to complete the entire rehabilitation program. Post-HAL FTSS showed significant improvement compared with pre-HAL and had a large effect size of 1.81 (95% CI = 0.93 to 2.66) and sufficient power.

Conclusions: Robotic rehabilitation with HAL lumbar type could be introduced without adverse events, even in the early postoperative period following surgery for hip fracture. Further study is needed to develop an appropriate rehabilitation protocol using the HAL lumbar type.

Electromyographic examination of knee training using a hybrid assistive limb after anterior cruciate ligament reconstruction: A case report

Muscle co-contraction can result in higher joint contact forces, compromising knee joint mobility for stability, thus leading to impaired lower extremity neuromuscular control, delayed return to sports, and increased incidence of secondary anterior cruciate ligament (ACL) injury post-ACL reconstruction. Hybrid assistive limb (HAL) training has the potential to correct impairment of antagonistic or synergistic muscle movement of the knee joint through bioelectric signal feedback from muscle signals with computer processing. We considered that HAL training would contribute to improve peak muscle torque through coordinating or decreasing higher levels of muscle co-contractions and reducing differences between hamstring and quadriceps muscle activity on electromyography (EMG). While playing handball, a 20-year-old female injured her ACL upon landing on one leg. Two months post-injury, she underwent arthroscopic, anatomic single-bundle ACL reconstruction with a semitendinosus tendon autograft. At a 4-month follow-up, she underwent knee HAL training, which was performed once a week for three sessions. EMG data were collected during the evaluations of pre- and post-HAL training. The average muscle amplitude was used to calculate the difference between vastus lateralis (VL) and semitendinosus (ST) muscles, and the muscle co-contraction index (CCI). The CCI reflects the simultaneous activation of antagonistic muscles, which is determined for knee extensor-flexor muscle pairs. Post-knee HAL training, the CCI of the lateral hamstring and quadriceps muscles during extension was lower than that during pre-HAL training in all sessions. However, no differences were found in the CCI for the medial hamstring and quadriceps muscles during extension and flexion pre- and post-knee HAL training. For post-knee HAL training, the difference between VL and ST EMG data during a closed-chain squat was lower than that during pre-HAL training in all sessions. Knee HAL training contributed to improved peak muscle torque through coordinating or decreasing higher levels of muscle co-contractions, and it reduced differences between hamstring and quadriceps muscle activity in the ACL reconstructed leg as depicted by EMG.

Influence of an on-body lifting aid (HAL® for Care Support) on kinematics during repetitive lifting in healthy men

Work-related lower back pain (LBP) leads to socio-economic burden and demands solutions. The hybrid assistive limb (HAL) for Care Support (Cyberdyne Inc., Ibaraki, Japan) is an active on-body lifting aid to assist joint motion according to the wearer's voluntary motor drive to reduce the lumbar load. A few studies investigated HAL and stated efficacy in terms of enhanced performance and reduced fatigue, yet the question remained if the use of HAL may result in a different execution of movement, for example by influencing the kinematics of the lower extremities. The aim of this study was to determine the influence of HAL on kinematics of the lower limbs and the spinal column during repetitive freestyle symmetrical lifting. Kinematic data was recorded by an inertial measurement unit sensor system in 11 healthy men lifting and lowering a 19.5 kg barbell under three conditions (no HAL, HAL Level 3/5, HAL Level 5/5). Outcome parameters were maximum and minimum angles as well as range of motion (ROM) of thoracic spine, lumbar spine, hip- and knee joint in sagittal plane. We found a significantly decreased ROM of the lumbar spine as well as a significantly reduced maximum and minimum thorax extension when starting lifting and in upright position after lifting, respectively, while using HAL. Influence of HAL on the kinematics of the lower limbs was not significant. Differences between both evaluated HAL conditions were not significant. This study proved limited lumbar spine ROM and reduced thorax extension without alterations of lower limbs kinematics when using HAL. This might potentially decrease the risk of work-related LBP.

Effects of Cardiac Rehabilitation With Lumbar-Type Hybrid Assistive Limb on Muscle Strength in Patients With Chronic Heart Failure - A Randomized Controlled Trial

BACKGROUND

Aiming to establish an effective tool in new cardiac rehabilitation programs, we investigated the use of a lumbar-type hybrid assistive limb (HAL) in patients with heart failure (HF) who had difficulty in walking at the usual speed of healthy subjects (≈80 m/min).Methods and Results:We randomly assigned 28 HF patients (age, 73.1±13.8 years) to perform a sit-to-stand exercise with or without HAL. The sit-to-stand exercise was repeated as many times as possible as cardiac rehabilitation therapy over a period of 6-10 days. We measured 5 parameters before and after the completion of cardiac rehabilitation: B-type natriuretic peptide, Short Physical Performance Battery (SPPB), 6-min walking distance (6MWD), 30-s chair-stand test (CS-30), and isometric knee extensor muscle strength. The SPPB and 6MWD were significantly improved, and the CS-30 score was somewhat improved, after the exercise therapy in both the HAL and non-HAL groups. The knee extensor muscle strength improved significantly in the HAL group (0.29±0.11 to 0.35±0.11 kgf/kg, P<0.01), but showed no change in the non-HAL group (0.35±0.11 to 0.35±0.13 kgf/kg, P=0.40).

CONCLUSIONS

The improved knee extensor muscle strength in the HAL group suggests that the lumbar-type HAL may be an effective tool for cardiac rehabilitation in HF patients with frailty, which is a predictor of poor prognosis in HF.

Exercise Therapy Using the Lumbar-Type Hybrid Assistive Limb Ameliorates Locomotive Function after Lumbar Fusion Surgery in an Elderly Patient

The number of elderly people who undergo lumbar fusion surgery (LFS) has been increasing. Postoperative rehabilitation for them can be problematic due to lumbar stiffness. This is the first case report describing exercise therapy using the lumbar-type hybrid assistive limb (HAL) after multiple LFS in an elderly patient. An 83-year-old man underwent LFS at L4-S1. Additional fusion surgery at L2-3 for adjacent segment disease was performed 2 years after the primary surgery. Although the patient's leg pain declined, he had severe locomotive dysfunction at 3 months after his final surgery. He started exercise therapy using the lumbar-type HAL including sit-to-stand training and squat training 4 months after his final surgery. He performed 3 sets of 20 sit-to-stand and 20 squat repetitions with adequate rests in between sets. The HAL training was safely conducted every day for 12 weeks without adverse event. Timed up and go test (TUG), 1-minute sit to stand test (1MSTS), one-leg stand test (OLST), and Berg balance scale (BBS) were assessed as locomotive function measurement. Before HAL therapy, TUG, 1MSTS, OLST, and BBS were 18.1 sec, 20 times, less than 1 sec, and 47, respectively. He could not walk without assistance. After the exercise therapy with the lumbar-type HAL, his locomotive function dramatically improved. TUG, 1MSTS, OLST, and BBS were 12.2 sec, 25 times, 3.9 sec, and 52, respectively. Moreover, the patient could walk 60 meters continuously without assistance. The unique characteristics of the lumbar-type HAL to prevent the lumbar overload and assist the voluntary hip joint motion during exercise therapy may be effective for this patient with lumbar stiffness after LFS. Sit-to-stand training and squat training using the lumbar-type HAL are promising options to improve locomotive function in elderly patients after LFS.

Classification of Care Assistive Technology Based on the Relationship Between Users and Technologies

While an aging population in Japan and other countries is resulting in an increased demand for nursing care services, there is a shortage of care workers due to a decrease in the working population. The use of care assistive technologies such as robots, artificial intelligence, and information technology is expected to compensate for this shortage, and many care assistive technologies such as power assist devices and communication robots have been developed. However, their introduction and widespread use in actual service have not progressed. The aim of this study is to address the problem on less technology introduction in nursing care by surveying the attitudes of potential users to care assistive technologies, clarify the factors affecting the use of such technologies, and propose a new design method for the technologies. We surveyed attitudes to the use of care assistive technology from the perspective of function and information utilization for three groups: active seniors, informal carers, and formal carers. The survey was conducted in Japan and Finland, which have high aging populations. Based on the survey results, we proposed, as a design method, a classification of care assistive technologies according to their interaction with users as well as the nursing care process.

Exercise training using hybrid assistive limb (HAL) lumbar type for locomotive syndrome: a pilot study

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.