Treadmill Training with HAL Exoskeleton-A Novel Approach for Symptomatic Therapy in Patients with Limb-Girdle Muscular Dystrophy-Preliminary Study

Update on Exercise in Persons With Muscle Disease

Myopathies are heterogeneous in their etiology, muscle group involvement, clinical manifestation, and progression. Deficits in myopathy may include muscle weakness, atrophy, stiffness, myalgia, and extra-muscular manifestations. Consequently, these deficits could lead to impaired musculoskeletal function, inadequate engagement in daily activities and reduced participation in social activities. Exercise has been viewed as a potentially efficacious intervention to halt the loss of muscle function and to improve secondary symptoms that result from muscle loss, such as pain and fatigue. The purpose of this review is to discuss research findings within the last 10 years that examine effects of exercise interventions in many types of myopathies in humans. In general, most studies were small scale, and they varied with respect to exercise type, intensity, and outcome measures. Despite the different pathologies, various exercise subtypes of aerobic/endurance or strength/resistance training are generally beneficial and may improve muscle strength and functional outcomes. Exercise therapies are generally safe and well tolerated. Exercise prescription should be part of routine neuromuscular care for patients with myopathy, and ideally with input from a multidisciplinary team, with a focus on providing individualized exercise regimens. Further work is needed to define the optimal intensity and type of exercise to result in the best functional outcomes for persons with myopathy, as well as the effects of combining exercise and novel disease modifying therapies.

Limb-girdle muscular dystrophies: A scoping review and overview of currently available rehabilitation strategies

Limb-girdle muscular dystrophies (LGMDs) constitute a diverse group of inherited disorders primarily affecting skeletal muscle. Despite the absence of cures, rehabilitative treatments offer potential for preventing and mitigating loss of muscle strength. However, the role of exercise training in LGMD patients remains contentious. This review aims to provide an overview of the currently available motor rehabilitation strategies for the most common subtypes of LGMD. To identify relevant articles, we performed a systematic search in PubMed, Embase, Cochrane Library, and Web of Science, focusing on muscular and respiratory interventions. The search resulted in 560 potentially relevant articles, of which 16 were included in the review. Eight studies concentrated on neuromuscular functional rehabilitation therapy programs, seven combined both neuromuscular rehabilitation and interventions to maintain or enhance respiratory functionality and one focused on respiratory intervention only. Altogether, the papers examined offered a comprehensive view on the rehabilitative strategies available and provided an indication of the most valuable practices to deal with patients' health and needs. Upon analysis, we conclude that, when tailored to individual needs, muscle training can enhance strength and functional abilities, positively impacting psychological well-being. However, generic protocols may lead to limited benefits, fatigue, pain, and compliance issues. Moreover, early management of respiratory symptoms and personalized respiratory physiotherapy can enhance patients' well-being and their capability to participate in muscle training exercises. Future studies should not only refine rehabilitation approaches but also assess their impact on patients' quality of life, including psychological factors like depression and self-esteem.

The assistive gait devices and their implementation in activities of daily living for patients with neuromuscular disease: A systematic review and meta-analysis

BACKGROUND

To date, assistive gait devices (AGDs) for people with neuromuscular diseases (NMDs) have not been systematically evaluated.

OBJECTIVE

This systematic review evaluated AGDs for people with NMDs.

METHODS

Suitable tools were used to assess the study quality and the certainty of evidence. If feasible, a descriptive and quantitative synthesis was conducted.

RESULTS

Forty studies were included on: gait-assisting exoskeletons (GAEs), orthopaedic footwear (OF), knee and/or ankle-foot-orthoses (AFOs) and non-invasive neuroprostheses that provide functional electrical stimulation (FES). Pairwise meta-analysis could not be performed due to a lack of homogenous data. The within-group pre-post meta-analysis in GAE studies showed an improvement in 2-min walk test (2MWT) (m) (standardized mean difference [SMD] = 0.36, 95%-CI: 0.17 to 0.54), but not in 10-meter walk test (10MWT) (sec) (SMD = 0.33, 95%-CI: -0.10 to 0.76) and in functional independence measure (FIM) (SMD = -0.002, 95%-CI: -0.21 to 0.21). In AFO studies, there was no improvement in 10MWT(m) (SMD = -0.11, 95%-CI: -0.76 to 0.53). A single session with AFO or OF vs no-AFO or OF post-intervention meta-analysis did not reveal an improvement in walking speed (m/s) (SMD = 0.39, 95%-CI: -0.03 to 0.83).

DISCUSSION

GAEs seem to help patients to walk longer. The meta-analyses showed no significant results to support the effect of AFOs or OF. Neuroprostheses and knee orthoses showed no evidence.

CONCLUSION

No clear conclusions can be drawn on how AGDs affect NMDs. The positive AGD effects are based on very low certainty of evidence.

A Case Report of Becker Muscular Dystrophy and Stroke Who Successfully Regained Mobility With Robot-Assisted Gait Training

ABSTRACT

A 30-yr-old patient with Becker muscular dystrophy presented with stroke. Background issues of proximal weakness, dilated cardiomyopathy, and reduced endurance challenged the usual goal-setting and formulation of a stroke rehabilitation plan. We discuss the holistic rehabilitation program that this patient underwent, with a focus on the utilization of robot-assisted gait training that eventually led him to successfully regain mobility.

Patterns of Clinical Progression Among Patients With Autosomal Recessive Limb-Girdle Muscular Dystrophy: A Systematic Review

OBJECTIVES

As the clinical course of autosomal recessive limb-girdle muscular dystrophy (LGMDR) is highly variable, this study characterized the frequency of loss of ambulation (LOA) among patients by subtype (LGMDR1, LGMDR2, LGMDR3-6, LGMDR9, LGMDR12) and progression to cardiac and respiratory involvement among those with and without LOA.

METHODS

Systematic literature review.

RESULTS

From 2929 abstracts screened, 418 patients were identified with ambulatory status data (LOA: 265 [63.4%]). Cardiac and/or respiratory function was reported for 142 patients (34.0%; all with LOA). Among these, respiratory involvement was most frequent in LGMDR3-6 (74.1%; mean [SD] age 23.9 [11.0] years) and cardiac in LGMDR9 (73.3%; mean [SD] age 23.7 [17.7] years). Involvement was less common in patients without LOA except in LGMDR9 (71.4% respiratory and 52.4% cardiac).

CONCLUSIONS

This study described the co-occurrence of LOA, cardiac, and respiratory involvement in LGMDR and provides greater understanding of the clinical progression of LGMDR.

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.

Integration of Inertial Sensors in a Lower Limb Robotic Exoskeleton

Motion assistance exoskeletons are designed to support the joint movement of people who perform repetitive tasks that cause damage to their health. To guarantee motion accompaniment, the integration between sensors and actuators should ensure a near-zero delay between the signal acquisition and the actuator response. This study presents the integration of a platform based on Imocap-GIS inertial sensors, with a motion assistance exoskeleton that generates joint movement by means of Maxon motors and Harmonic drive reducers, where a near zero-lag is required for the gait accompaniment to be correct. The Imocap-GIS sensors acquire positional data from the user's lower limbs and send the information through the UDP protocol to the CompactRio system, which constitutes a high-performance controller. These data are processed by the card and subsequently a control signal is sent to the motors that move the exoskeleton joints. Simulations of the proposed controller performance were conducted. The experimental results show that the motion accompaniment exhibits a delay of between 20 and 30 ms, and consequently, it may be stated that the integration between the exoskeleton and the sensors achieves a high efficiency. In this work, the integration between inertial sensors and an exoskeleton prototype has been proposed, where it is evident that the integration met the initial objective. In addition, the integration between the exoskeleton and IMOCAP is among the highest efficiency ranges of similar systems that are currently being developed, and the response lag that was obtained could be improved by means of the incorporation of complementary systems.

Effects of Long-term Hybrid Assistive Limb Use on Gait in Patients with Amyotrophic Lateral Sclerosis

Objective To assess the long-term effects of hybrid assistive limb (HAL) treatment on gait in patients with amyotrophic lateral sclerosis (ALS). Methods Three courses of treatment with HAL were administered to three women with ALS. Each course had a four- to five-week duration, during which the treatment was performed nine times, with a rest period of at least two months between each course. Gait ability (2-minutes-walk and 10-m-walk tests), ALS Functional Rating Scale-Revised, and respiratory function tests were performed before and after each treatment course. Patients Patients diagnosed with ALS, according to the updated Awaji criteria, by board-certified neurologists in the Department of Neurology and Department of Rehabilitation Medicine, Toho University Omori Faculty of Medicine between January and December 2019 were recruited. Results The average time from the start to the end of the 3 courses was 319.7±33.7 days. A multiple regression analysis was performed for the 2-minutes-walk and 10-m-walk tests, using the baseline value, each participant's ID, and time point as covariates. Changes after each course were considered outcomes. Following the 3 treatment courses, the 2-minutes walk distance improved by 16.61 m (95% confidence interval, -9.33-42.54) compared with the baseline value, but this improvement was not statistically significant (p=0.21). However, cadence significantly improved by 1.30 steps (95% confidence interval, 0.17-2.42; p=0.02). Conclusion Long-term, repetitive HAL treatments may help patients with ALS maintain their gait.

Progression to Loss of Ambulation Among Patients with Autosomal Recessive Limb-girdle Muscular Dystrophy: A Systematic Review

Background

The impact of age at autosomal recessive limb girdle muscular dystrophy (LGMDR) onset on progression to loss of ambulation (LOA) has not been well established, particularly by subtype.

Objectives:

To describe the characteristics of patients with adult-, late childhood-, and early childhood-onset LGMDR by subtype and characterize the frequency and timing of LOA.

Methods:

A systematic review was conducted in MEDLINE, Embase and the Cochrane library. Frequency and timing of LOA in patients with LGMDR1, LGMDR2/Miyoshi myopathy (MM), LGMDR3-6, LGMDR9, and LGMDR12 were synthesized from published data.

Results:

In 195 studies, 695 (43.4%) patients had adult-, 532 (33.2%) had late childhood-, and 376 (23.5%) had early childhood-onset of disease across subtypes among those with a reported age at onset (n = 1,603); distribution of age at onset varied between subtypes. Among patients with LOA (n = 228), adult-onset disease was uncommon in LGMDR3-6 (14%) and frequent in LGMDR2/MM (42%); LGMDR3-6 cases with LOA primarily had early childhood-onset (74%). Mean (standard deviation [SD]) time to LOA varied between subtypes and was shortest for patients with early childhood-onset LGMDR9 (12.0 [4.9] years, n = 19) and LGMDR3-6 (12.3 [10.7], n = 56) and longest for those with late childhood-onset LGMDR2/MM (21.4 [11.5], n = 36).

Conclusions:

This review illustrated that patients with early childhood-onset disease tend to have faster progression to LOA than those with late childhood- or adult-onset disease, particularly in LGMDR9. These findings provide a greater understanding of progression to LOA by LGMDR subtype, which may help inform clinical trial design and provide a basis for natural history studies.

Robot-assisted training using hybrid assistive limb ameliorates gait ability in patients with amyotrophic lateral sclerosis

OBJECTIVE

The Hybrid Assistive Limb (HAL; CYBERDYNE, Inc., Japan) is a wearable robot device that provides effective gait assistance according to voluntary intention by detecting weak bioelectrical signals of neuromuscular activity on the surface of the skin. We used HAL for patients with amyotrophic lateral sclerosis (ALS) to determine whether HAL training had an effect on their gait ability.

METHODS

We conducted a single-center, single-arm, observational study. Patients with ALS underwent HAL training once per day (20-40 min per session) for 9-10 days for at least 4 weeks. Gait ability was evaluated using the 2-minute walk test, the 10-meter walk test without the assistance of HAL, and activities of daily living (ADL) using the Barthel Index and Functional Independence Measures before and after a full course of HAL training.

RESULTS

There were no dropouts or adverse events during the observation period. Gait function improved after HAL training. The 2-minute walk test revealed a mean gait distance of 73.87 m (36.65) at baseline and 89.9m (36.70) after HAL training (p = 0.004). The 10-meter walk test showed significantly improved cadence, although gait speed, step length on the 10-m walk, or ADL measurements did not change significantly.

CONCLUSIONS

Although HAL is not a curative treatment for ALS, our data suggest that HAL may be effective in ameliorating and preserving gait ability in patients with ALS.

A Survey on Design and Control of Lower Extremity Exoskeletons for Bipedal Walking

Exoskeleton robots are electrically, pneumatically, or hydraulically actuated devices that externally support the bones and cartilage of the human body while trying to mimic the human movement capabilities and augment muscle power. The lower extremity exoskeleton device may support specific human joints such as hip, knee, and ankle, or provide support to carry and balance the weight of the full upper body. Their assistive functionality for physically-abled and disabled humans is demanded in medical, industrial, military, safety applications, and other related fields. The vision of humans walking with an exoskeleton without external support is the prospect of the robotics and artificial intelligence working groups. This paper presents a survey on the design and control of lower extremity exoskeletons for bipedal walking. First, a historical view on the development of walking exoskeletons is presented and various lower body exoskeleton designs are categorized in different application areas. Then, these designs are studied from design, modeling, and control viewpoints. Finally, a discussion on future research directions is provided.

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.

Gait Evaluation with Bioelectrical Signal Patterns during Cybernic Treatment. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021;2021:6728-6733. [PMID: 34892652 DOI: 10.1109/embc46164.2021.9630152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Cybernic treatment with a wearable cyborg Hybrid Assistive Limb for medical use (Medical HAL) improves ambulatory function in patients with progressive neuromuscular diseases. The progress of cybernic treatment is evaluated based on the change in the patient's walking distance and walking speed over a certain treatment period. However, evaluation methods to capture temporal changes in gait functions during each therapy are required for more effective evaluation in clinical practice. Because the patients' muscular activities are measured with each trial of cybernic treatment, bioelectrical signals (BES) of lower limb muscles measured by Medical HAL may aid in evaluating the wearers' gait functions. Thus, this study proposed a method to quantify the BES patterns of patients during cybernic treatment and compared them with the BES patterns of healthy personnel for evaluation, which confirmed the correlation between the BES pattern and the patients' gait abilities. First, we obtained a reference BES pattern from the BES of three healthy personnel during walking using Medical HAL. Second, we calculated the similarity between the reference BES pattern of the healthy personnel and the patient's BES pattern using derivative dynamic time warping (DDTW), which quantified the patients' BES patterns based on their shape. Third, we investigated the correlation between patients' DDTW of BES patterns during cybernic treatment and 2-minute walking distances. The correlation coefficient between the patients was -0.83 (p < 0.01) and that within patients was -0.38 (p < 0.05), indicating a significant BES pattern relationship between walking with Medical HAL and gait abilities. Conclusively, the similarity between the BES patterns of healthy personnel and patients calculated using DDTW might be applied to the evaluation of patients' gait functions. The ability to assess the gait function with data measured during cybernic treatment would provide understandings of the patient's functional changes over time.

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.

Improved Physiological Gait in Acute and Chronic SCI Patients After Training With Wearable Cyborg Hybrid Assistive Limb

In recent years robotic devices became part of rehabilitation offers for patients suffering from Spinal Cord Injury (SCI) and other diseases. Most scientific publications about such devices focus on functional outcome. The aim of this study was to verify whether an improvement in physiological gait can be demonstrated in addition to the functional parameters after treatment with neurological controlled HAL® Robot Suit. Fifteen subjects with acute (<12 months since injury, n = 5) or chronic (>12 months since injury, n = 10) incomplete paraplegia (AIS B, n = 0/AIS C, n = 2/AIS D, n = 8) or complete paraplegia (AIS A, n = 5) with zones of partial preservation participated. Subjects underwent a body weight supported treadmill training for five times a week over 12 weeks using HAL®. At baseline and at the end of the study a gait analysis was performed and additional functional parameters such as 10-Meter-Walk-Test, Timed-Up-and-Go-Test, 6-Minutes-Walk-Test, and WISCI II score were collected. Results were evaluated for whole group and individually for acute and chronic subgroups. All functional parameters improved. Differences were also found in physiological parameters such as phases of gait cycle and accompanied by significant improvement in all spatiotemporal and gait phase parameters. The presented study shows signs that an improvement in physiological gait can be achieved in addition to improved functional parameters in patients with SCI after completing 12-week training with HAL®.

Trial Registration: DRKS, DRKS00020805. Registered 12 February 2020—Retrospectively registered, https://www.drks.de/DRKS00020805.

Long term treadmill exercise affects age-related oxidative stress in the spinal cord of rats

Age-induced apoptosis is believed to be caused by the imbalance between production of reactive oxygen species (ROS) and human body antioxidant defence. Regular aerobic treadmill-exercise has been suggested to enhance the antioxidant defence. This study aimed to investigate the effects of long-term treadmill exercise on age-related oxidative stress and the apoptosis of oligodendrocytes in the spinal cord of the rat. Sixty male rats were divided into six groups: three exercised groups, which underwent 6, 9 and 12 months of mild-to-moderate treadmill exercise and three non-exercised control groups. Spinal cord white or grey matter tissue sampling was done through mid-thoracic laminectomy. The malondialdehyde (MDA; indicator of oxidative stress) levels, the number of apoptotic oligodendrocytes and ultrastructural alterations were also evaluated. Our data showed that treadmill exercise resulted in decreased lipid peroxidation and the number of apoptotic oligodendrocytes in the spinal cord of rats, as compared to non-exercised animals. These results were confirmed by TUNEL (terminal deoxynucleotidyl transferase dUTP nick end labelling) staining and electron microscope. This study suggests that the long-term treadmill exercise can affect oxidative stress and oligodendrocytes apoptosis in the spinal cord of aged rats and further studies are needed to validate these findings in humans.

Management of motor rehabilitation in individuals with muscular dystrophies. 1st Consensus Conference report from UILDM - Italian Muscular Dystrophy Association (Rome, January 25-26, 2019)

Muscular dystrophy (MD) is a group of neuromuscular diseases characterized by progressive muscle weakness due to various mutations in several genes involved in muscle structure and function. The age at onset, evolution and severity of the different forms of MD can vary and there is often impairment of motor function and activities of daily living. Although there have been important scientific advances with regard to pharmacological therapies for many forms of MD, rehabilitation management remains central to ensuring the patient's psychophysical well-being. Here we report the results of an Italian consensus conference promoted by UILDM (Unione Italiana Lotta alla Distrofia Muscolare, the Italian Muscular Dystrophy Association) in order to establish general indications and agreed protocols for motor rehabilitation of the different forms of MD.

[A case study of a patient with myotonic dystrophy type 1 whose gait disturbance was improved by gait training with hybrid assistive limbs]

A Japanese woman first noticed dysarthria at the age of 23. She visited a hospital at the age of 32 and was diagnosed as having myotonic dystrophy clinically. She was diagnosed genetically as having myotonic dystrophy type 1 at 47 years old with 160-270 CTG repeats on the DMPK gene. At the age of 48, she needed non-invasive positive pressure ventilation because of hypoxia at night. Her gait function also deteriorated. She could not stand up from the supine position by herself. However, when she stood, she could walk without a cane for a short distance. She was admitted to our hospital to receive rehabilitation against progressive gait disturbance at the age of 53. She received gait training with hybrid assistive limb^® (HAL^®). We evaluated some parameters such as walking distance of 2-minute walk test (2MWT), gait speed /cadence/stride length of 10-meter walk test (10MWT), before and just after the course. The first course was performed in September 2017 and the second was done in May 2018 so the interval was about six months. After two courses of HAL^® gait training, the distance on the 2-minute walk test increased from 111 m to 154 m, the average speed and the cadence of 10MWT improved from 2.01 m/s to 2.78 m/s and from 2.21 steps/s to 3.05 steps/s respectively. The score of the muscular disability quality of life (QOL) rating scale was also improved. The factors including "defecation," "breathing," and "ADL" suggest that the patient's physical abilities improved and she could move easily. Other factors such as "hope", "activity" and "human relationship" suggest that patient's mood improved after the HAL^® training.It was suggested that HAL^® gait training could improve QOL as well as gait function in patients with progressive neuromuscular disorder.

Rehabilitation Challenges in Limb-Girdle Muscular Dystrophies

Limb-girdle muscular dystrophy (LGMD) is a burdensome progressive neuromuscular disease, with a great impact upon quality of life. Unlike other types of neuromuscular dystrophies, which have onset in early childhood and severely limit the life expectancy, LGMD is usually diagnosed at young adulthood age. Since no etiological treatment is currently available, physiotherapy and generally, rehabilitation therapy, are mandatory for preserving the functional capabilities of the muscles for as long as possible. Exercise therapy, electrical stimulation or novel therapies such as exoskeleton devices aim towards alleviating the impact of disability. It is ideal that muscular dystrophy should be assessed in interdisciplinary clinics (physical therapy, neurology, cardiology, pneumology, surgery and orthopedics) for proper long-term care. Keywords: LGMD, muscle strength, rehabilitation, quality of life,

Wearable rehabilitation exoskeletons of the lower limb: analysis of versatility and adaptability

PURPOSE

To analyse the versatility and adaptability of commercially available exoskeletons for mobility assistance and their adaptation to diverse pathologies through a review of clinical trials in robotic lower limb training.

DATA SOURCES

A computer-aided search in bibliographic databases (PubMed and Web of Science) of clinical trials published up to September 2020 was done.

METHODS

To be selected for detailed review, clinical trials had to meet the following criteria: (1) a protocol was designed and approved, (2) participants were people with pathologies, and (3) the trials were not a single case study. Clinical trial data were collected, extracted, and analysed, considering: objectives, trial participants, number of sessions, pathologies involved, and conclusions.

RESULTS

The search resulted in 312 potentially relevant studies of seven commercial exoskeletons, of which 135 passed the preliminary screening; and 69 studies were finally selected. Of the 69 clinical trials included in the review about 50% involved Spinal Cord Injury participants, while roughly 25% focussed on stroke and two trials corresponded to patients with both disorders. The rest were composed of neurological diseases and trauma disorders.

CONCLUSIONS

The use of a single wearable robot for different medical conditions in various diseases is a challenge. Based on this comparative, the properties of the exoskeletons that improve the working ability with different pathologies and patient conditions have been evaluated. Suggestions were made for developing a new lower-limb exoskeleton based on various modules with a distributed control system to improve versatility in wearable technology for different gait pattern progression.Implications for rehabilitationWearable robotic exoskeletons for gait assistance have been analysed from the perspective of adaptation to different diseases.This paper emphasizes the importance of personalized therapies and adaptive assistive technology.Suggestions were made for a new modular exoskeleton capable of addressing the issue of low versatility characterizing currently wearable assistive technology.

Occurrence and Type of Adverse Events During the Use of Stationary Gait Robots-A Systematic Literature Review

Robot-assisted gait training (RAGT) devices are used in rehabilitation to improve patients' walking function. While there are some reports on the adverse events (AEs) and associated risks in overground exoskeletons, the risks of stationary gait trainers cannot be accurately assessed. We therefore aimed to collect information on AEs occurring during the use of stationary gait robots and identify associated risks, as well as gaps and needs, for safe use of these devices. We searched both bibliographic and full-text literature databases for peer-reviewed articles describing the outcomes of stationary RAGT and specifically mentioning AEs. We then compiled information on the occurrence and types of AEs and on the quality of AE reporting. Based on this, we analyzed the risks of RAGT in stationary gait robots. We included 50 studies involving 985 subjects and found reports of AEs in 18 of those studies. Many of the AE reports were incomplete or did not include sufficient detail on different aspects, such as severity or patient characteristics, which hinders the precise counts of AE-related information. Over 169 device-related AEs experienced by between 79 and 124 patients were reported. Soft tissue-related AEs occurred most frequently and were mostly reported in end-effector-type devices. Musculoskeletal AEs had the second highest prevalence and occurred mainly in exoskeleton-type devices. We further identified physiological AEs including blood pressure changes that occurred in both exoskeleton-type and end-effector-type devices. Training in stationary gait robots can cause injuries or discomfort to the skin, underlying tissue, and musculoskeletal system, as well as unwanted blood pressure changes. The underlying risks for the most prevalent injury types include excessive pressure and shear at the interface between robot and human (cuffs/harness), as well as increased moments and forces applied to the musculoskeletal system likely caused by misalignments (between joint axes of robot and human). There is a need for more structured and complete recording and dissemination of AEs related to robotic gait training to increase knowledge on risks. With this information, appropriate mitigation strategies can and should be developed and implemented in RAGT devices to increase their safety.

Frizzled related protein deficiency impairs muscle strength, gait and calpain 3 levels

Background

Limb-girdle muscular dystrophy recessive 1 calpain3-related (LGMDR1), previously known as LGMD2A, is a disease caused by mutations in the CAPN3 gene. It is characterized by progressive weakness and muscle degeneration. Frizzled related protein (FRZB), upregulated in LGMDR1, was identified as a key regulator of the crosstalk between Wnt and integrin signalling pathways. FRZB gene silencing showed a recovery in the expression of some of the costamere protein levels in myotubes.

Results

Here, we performed a comprehensive characterization of Frzb^−/− mice muscles to study the absence of Frzb in skeletal muscle and eventual links with the molecular characteristics of LGMDR1 patient muscles. Frzb^−/− mice showed reduced muscle size and strength. Gait analysis showed that Frzb^−/− mice moved more slowly but no impaired regeneration capacity was observed after muscle injury. Additionally, Frzb^−/− mice muscle showed an increased number of mesoangioblasts. Lack of Frzb gene in Frzb^−/− mice and its increased expression in LGMDR1 patients, showed contrary regulation of Rora, Slc16a1, Tfrc and Capn3 genes. The reciprocal regulation of Frzb and Capn3 genes further supports this axis as a potential target for LGMDR1 patients.

Conclusions

Our data confirm a role for Frzb in the regulation of Rora, Slc16a1, Tfrc, and Capn3 genes in muscle cells. In vivo, reduced muscle strength and gait in the Frzb^−/− mice are intriguing features. The reciprocal relationship between FRZB and CAPN3 further supports a key role for this axis in patients with LGMDR1.

Effects of Gait Treatment With a Single-Leg Hybrid Assistive Limb System After Acute Stroke: A Non-randomized Clinical Trial

We hypothesized that a single-leg version of the Hybrid Assistive Limb (HAL) system could improve the gait and physical function of patients with hemiparesis following a stroke. In this pilot study, we therefore compared the efficacy of HAL-based gait training with that of conventional gait training (CGT) in patients with acute stroke. Patients admitted to the participating university hospital were assigned to the HAL group, whereas those admitted to outside teaching hospitals under the same rehabilitation program who did not use the HAL were assigned to the control group. Over 3 weeks, all participants completed nine 20 min sessions of gait training, using either HAL (i.e., the single-leg version of HAL on the paretic side) or conventional methods (i.e., walking aids and gait orthoses). Outcome measures were evaluated before and after the nine training sessions. The Functional Ambulation Category (FAC) was the primary outcome measure, but the following secondary outcome measures were also assessed: National Institutes of Health Stroke Scale, Fugl-Meyer Assessment (Lower Extremity), comfortable walking speed, step length, cadence, 6-min walk distance, Barthel Index, and Functional Independence Measure. In total, 22 post-stroke participants completed the clinical trial: 12 in the HAL group and 10 in the CGT group. No serious adverse events occurred in either group. The HAL group showed significant improvement in FAC after nine sessions when compared with the CGT group (P = 0.014). However, secondary outcomes did not differ significantly between the groups. Our results demonstrate that HAL-based gait therapy may improve independent walking in patients with acute stroke hemiplegia who are dependent on ambulatory assistance. A larger-scale randomized controlled trial is needed to clarify the effectiveness of single-leg HAL therapy. Clinical Trial Registration: UMIN Clinical Trials Registry, identifier UMIN000022410.

Exercise therapy for muscle and lower motor neuron diseases

Muscle and lower motor neuron diseases share a common denominator of perturbed muscle function, most often related to wasting and weakness of muscles. This leads to a number of challenges, such as restricted mobility and respiratory difficulties. Currently there is no cure for these diseases. The purpose of this review is to present research that examines the effects of exercise in muscle and lower motor neuron diseases. Evidence indicates that moderate intensity aerobic- and strength exercise is advantageous for patients with muscle diseases, without causing harmful exercise-induced muscle damage. On the contrary, motor neuron diseases show a rather blunted response from exercise training. High-intensity training is a modality that seems safe and a promising exercise method, which may circumvent neural fatigue and provide effect to patients with motor neuron disease. Although we have come far in changing the view on exercise therapy in neuromuscular diseases to a positive one, much knowledge is still needed on what dose of time, intensity and duration should be implemented for different disease and how we should provide exercise therapy to very weak, non-ambulatory and wheelchair bound patients.

Calcium Mechanisms in Limb-Girdle Muscular Dystrophy with CAPN3 Mutations

Limb-girdle muscular dystrophy recessive 1 (LGMDR1), previously known as LGMD2A, is a rare disease caused by mutations in the CAPN3 gene. It is characterized by progressive weakness of shoulder, pelvic, and proximal limb muscles that usually appears in children and young adults and results in loss of ambulation within 20 years after disease onset in most patients. The pathophysiological mechanisms involved in LGMDR1 remain mostly unknown, and to date, there is no effective treatment for this disease. Here, we review clinical and experimental evidence suggesting that dysregulation of Ca2+ homeostasis in the skeletal muscle is a significant underlying event in this muscular dystrophy. We also review and discuss specific clinical features of LGMDR1, CAPN3 functions, novel putative targets for therapeutic strategies, and current approaches aiming to treat LGMDR1. These novel approaches may be clinically relevant not only for LGMDR1 but also for other muscular dystrophies with secondary calpainopathy or with abnormal Ca2+ homeostasis, such as LGMD2B/LGMDR2 or sporadic inclusion body myositis.

Efficacy of Cardiac Rehabilitation with Assistance from Hybrid Assistive Limb in Patients with Chronic Heart Failure: Protocol for a Randomized Controlled Study

The hybrid assistive limb (HAL) provides motion assistance based on bioelectrical signals detected on the skin surface when muscle forces are generated. The lumbar-type HAL is expected to expand the therapeutic options for severe cardiac patients who have difficulty in moving on their own legs. We aim to compare the efficacy of exercise therapy performed with assistance from a lumbar-type HAL versus conventional training (sit-to-stand exercise without HAL) in patients with chronic heart failure. This investigation will be a randomized, nonblinded, controlled study. Sixty patients who satisfy the criteria to receive cardiac rehabilitation therapy under the Japanese national insurance system will be enrolled at the University of Tsukuba Hospital. Participants randomly assigned to 2 groups (HAL group and conventional group) at a 1:1 allocation ratio will perform exercise therapy either with HAL or without HAL for 5-30 min once a day for 6-10 days. Outcome parameters will be measured just before and after the completion of the exercise therapy and at 1 year after hospital discharge. The primary outcomes will be the heart rate, blood pressure, subjective ratings of exercise intensity during exercise (Borg scale), number of days from the start of exercise therapy to independent walking and to discharge, and prognosis (mortality and cardiovascular events) over the 1-year period after discharge. The secondary outcomes will be the assessment of heart failure severity, brain natriuretic peptide, grip strength, thigh muscle thickness, isometric knee extensor strength, standing ability, 10-meter walking speed, 6-min walking distance, short physical performance battery, and adverse events. Unpaired t tests will be used for baseline assessments and outcome measures. This is the first randomized controlled study to examine the efficacy and feasibility of lumbar-type HAL in patients with chronic heart failure. If the results confirm beneficial effects in the outcomes of patients with heart failure, this study will add more evidence in support of the use of the lumbar-type HAL as an effective tool in new cardiac rehabilitation programs.

Effects of a lumbar-type hybrid assistive limb on cardiopulmonary burden during squat exercise in healthy subjects

The lumbar-type Hybrid Assistive Limb (HAL) is expected to expand the possibilities of exercise therapy for severe cardiac patients who have difficulty in moving on their own legs. We investigated whether motion assistance from HAL during squat exercise could effectively reduce the cardiopulmonary burden in healthy subjects. Twelve healthy subjects (33 ± 11 years) performed squat exercise for 3 consecutive minutes at a repetition rate of 20 squats per minute with and without assistance from a lumbar-type HAL. The oxygen uptake (VO2), carbon dioxide output (VCO2), minute ventilation (VE), and the Borg Scale were monitored during exercise. VO2 (930 ± 207 vs 992 ± 169 mL/min, p < 0.05) and the Borg Scale rating (12.8 ± 1.1 vs 13.7 ± 0.8, p < 0.05) at the end of exercise were significantly lower when HAL was used. When 2 subjects who regularly perform high-intensity exercise for more than 10 h per week were excluded from the analyses, VO2, VCO2, VE, and the Borg Scale were significantly lower when HAL was used. Our results demonstrate that the lumbar-type HAL significantly reduces cardiopulmonary burden during squat exercise in healthy subjects. The effects were especially striking in sedentary subjects. Further studies on cardiac patients are expected to establish a new cardiac rehabilitation program using HAL.

Exercise in muscle disorders: what is our current state?

PURPOSE OF REVIEW

Regular exercise improves muscle and cardiovascular function, which is why exercise is used as an adjuvant treatment in myopathies. In this review, we provide an update on recent exercise studies (from 2016) performed in humans with inherited myopathy.

RECENT FINDINGS

Several studies provide new and interesting insight in the field of exercise in myopathies. A retrospective cohort study suggests that exercise may actually increase rate of disease progression in dysferlinopathy, and high intensity exercise, which is normally discouraged in muscle disorders because of the risk of muscle damage, is demonstrated to be an efficient time saving mode of exercise to train patients with facioscapulohumeral muscular dystrophy. Exoskeletons and antigravity trainers are examples of new devices, which provide an opportunity for very weak patients to train. Finally, several studies, including two randomized controlled trials, support the beneficial role of exercise as treatment of myopathy.

SUMMARY

The reviewed studies extend previous knowledge about exercise, indicating that exercise is generally safe and well tolerated, and improves functional outcomes in patients with inherited muscle disease. However, recent studies also highlight the fact that the effect of exercise differs with mode of exercise and exercise prescriptions should be disease specific.

Prevalence, pathological mechanisms, and genetic basis of limb-girdle muscular dystrophies: A review

Limb-girdle muscular dystrophies (LGMDs) are a highly heterogeneous group of neuromuscular disorders that are associated with weakness and wasting of muscles in legs and arms. Signs and symptoms may begin at any age and usually worsen by time. LGMDs are autosomal disorders with different types and their prevalence is not the same in different areas. New technologies such as next-generation sequencing can accelerate their diagnosis. Several important pathological mechanisms that are involved in the pathology of the LGMD include abnormalities in dystrophin-glycoprotein complex, the sarcomere, glycosylation of dystroglycan, vesicle and molecular trafficking, signal transduction pathways, and nuclear functions. Here, we provide a comprehensive review that integrates LGMD clinical manifestations, prevalence, and some pathological mechanisms involved in LGMDs.

Effects of a cyborg-type robot suit HAL on cardiopulmonary burden during exercise in normal subjects

BACKGROUND

The hybrid assistive limb (HAL) is the world's first cyborg-type robot suit that provides motion assistance to physically challenged patients. HAL is expected to expand the possibilities of exercise therapy for severe cardiac patients who have difficulty in moving on their own legs. As a first step, we examined whether or not the motion assistance provided by HAL during exercise could effectively reduce the cardiopulmonary burden in healthy subjects.

METHODS

A total of ten healthy male adults (35 ± 12 years) underwent cardiopulmonary exercise testing (CPX) on a cycle ergometer with or without assistance from HAL. The CPX protocol consisted of four 3-min stages performed in a continuous sequence: rest, 0 W, 40 W, and 80 W. The heart rate (HR), blood pressure, oxygen uptake (VO₂), minute ventilation (VE), and gas exchange ratio (R) were monitored during the CPX.

RESULTS

At 0 W, the HR, VO₂, and VE were significantly higher when HAL was used. At 80 W, however, the HR (107 ± 14 vs 114 ± 14 beats/min, p < 0.01), systolic blood pressure (141 ± 15 vs 155 ± 20 mmHg, p < 0.01), VO₂ (17.6 ± 2.4 vs 19.0 ± 2.5 mL/min/kg, p < 0.05), and R (0.88 ± 0.04 vs 0.95 ± 0.09, p < 0.05) were significantly lower when HAL was used.

CONCLUSIONS

HAL has the potential to reduce cardiopulmonary burden during moderate-intensity exercise and can, therefore, be used as a support for exercise therapy. Further studies on cardiac patients are expected to contribute to the establishment of a new exercise therapy program using HAL.

Reshaping of Gait Coordination by Robotic Intervention in Myelopathy Patients After Surgery

The Ossification of the Posterior Longitudinal Ligament (OPLL) is an idiopathic degenerative spinal disease which may cause motor deficit. For patients presenting myelopathy or severe stenosis, surgical decompression is the treatment of choice; however, despite adequate decompression residual motor impairment is found in some cases. After surgery, there is no therapeutic approach available for this population. The Hybrid Assistive Limb® (HAL) robot suit is a unique powered exoskeleton designed to predict, support, and enhance the lower extremities performance of patients using their own bioelectric signals. This approach has been used for spinal cord injury and stroke patients where the walking performance improved. However, there is no available data about gait kinematics evaluation after HAL therapy. Here we analyze the effect of HAL therapy in OPLL patients in acute and chronic stages after decompression surgery. We found that HAL therapy improved the walking performance for both groups. Interestingly, kinematics evaluation by the analysis of the elevation angles of the thigh, shank, and foot by using a principal component analysis showed that planar covariation, plane orientation, and movement range evaluation improved for acute patients suggesting an improvement in gait coordination. Being the first study performing kinematics analysis after HAL therapy, our results suggest that HAL improved the gait coordination of acute patients by supporting the relearning process and therefore reshaping their gait pattern.

Voluntary Ambulation by Upper Limb-Triggered HAL® in Patients with Complete Quadri/Paraplegia Due to Chronic Spinal Cord Injury

Patients with complete paraplegia after spinal cord injury (SCI) are unable to stand or walk on their own. Standing exercise decreases the risk of decubitus ulcers, osteoporosis, and joint deformities in patients with SCI. Conventional gait training for complete paraplegia requires excessive upper limb usage for weight bearing and is difficult in cases of complete quadriplegia. The purpose of this study was to describe voluntary ambulation triggered by upper limb activity using the Hybrid Assistive Limb® (HAL) in patients with complete quadri/paraplegia after chronic SCI. Four patients (3 men, 1 woman) were enrolled in this study. The mean patient age ± standard deviation was 37.2 ± 17.8 (range, 20–67) years. Clinical evaluation before intervention revealed the following findings: case 1, neurological level C6, American Spinal Cord Injury Association impairment scale (AIS) grade B; case 2, T6, AIS A; case 3, T10 AIS A; and case 4, T11, AIS A. The HAL intervention consisted of 10 sessions. Each HAL session lasted 60–90 min. The HAL electrodes for hip and knee flexion-extension were placed on the anterior and posterior sides of the upper limbs contralaterally corresponding to each of the lower limbs. Surface electromyography (EMG) was used to evaluate muscle activity of the tensor fascia lata and quadriceps femoris (Quad) in synchronization with a Vicon motion capture system. The modified Ashworth scale (mAs) score was also evaluated before and after each session. All participants completed all 10 sessions. Cases 1, 2, and 3 demonstrated significant decreases in mAs score after the sessions compared to pre-session measurements. In all cases, EMG before the intervention showed no apparent activation in either Quad. However, gait phase dependent activity of the lower limb muscles was seen during voluntarily triggered ambulation driven by upper limb muscle activities. In cases 3 and 4, active contraction in both Quads was observed after intervention. These findings suggest that upper-limb-triggered HAL ambulation is a safe and feasible option for rehabilitation in patients with complete quadri/paraplegia caused by chronic SCI.