Clinical application of the Hybrid Assistive Limb (HAL) for gait training-a systematic review

This completely and totally exemplifies the stupidity in the stroke medical world for not having a database of all stroke research and protocols where these reviews would never be needed because the database would be up-to-date all the time.  And survivors could then use it to train their doctors and therapists in the appropriate 100% recovery rehab.  I know pie in the sky but with survivors in charge it would get accomplished. 

These later ones shouldn't have been needed? Or didn't you and your mentors know about this 2015 one?

Clinical application of the Hybrid Assistive Limb (HAL) for gait training-a systematic review February 2020

 

Gait training early after stroke with a new exoskeleton--the hybrid assistive limb: a study of safety and feasibility January 2020

A Randomized and Controlled Crossover Study Investigating the Improvement of Walking and Posture Functions in Chronic Stroke Patients Using HAL Exoskeleton – The HALESTRO Study (HAL-Exoskeleton STROke Study) April 2019

The earliest  here(2015):

Clinical application of the Hybrid Assistive Limb (HAL) for gait training-a systematic review

Anneli Wall1,2*, Jörgen Borg1,2 and Susanne Palmcrantz1,2
1Department of Rehabilitation Medicine, Danderyd University Hospital, Stockholm, Sweden
2Department of Clinical Sciences, Karolinska Institute, Stockholm, Sweden

Objective: 
The aim of this study was to review the literature on clinical applications of the Hybrid Assistive Limb system for gait training.
Methods: 
A systematic literature search was conducted using Web of Science, PubMed, CINAHL and clinicaltrials.gov and additional search was made using reference lists in identified reports. Abstracts were screened, relevant articles were reviewed and subject to quality assessment.
Results:
Out of 37 studies, 7 studies fulfilled inclusion criteria. Six studies were single group studies and 1 was an explorative randomized controlled trial. In total, these studies involved 140 participants of whom 118 completed the interventions and 107 used HAL for gait training. Five studies concerned gait training after stroke, 1 after spinal cord injury (SCI) and 1 study after stroke, SCI or other diseases affecting walking ability. Minor and transient side effects occurred but no serious adverse events were reported in the studies. Beneficial effects on gait function variables and independence in walking were observed.
Conclusions: 
The accumulated findings demonstrate that the HAL system is feasible when used for gait training of patients with lower extremity paresis in a professional setting. Beneficial effects on gait function and independence in walking were observed but data do not allow conclusions. Further controlled studies are recommended.

Background

Normal gait depends on the functional integrity and interactions in sensory-motor neural networks at spinal and supraspinal levels (Bowden et al., 2013). This complex system may be disturbed in many neurological conditions such as stroke or spinal cord injury (SCI) resulting in limited mobility and impaired gait function, which are major challenges in neuro rehabilitation. Intensive, repetitive task specific training may drive beneficial neuroplasticity, enhance functional restitution and improve final outcome (Kwakkel et al., 2004; Langhorne et al., 2009, 2011; Peurala et al., 2014). However, there is a need for further development of training methods in response to an increasing understanding of the individual capacity for regaining functioning (Krakauer et al., 2012; Bowden et al., 2013).
Approaches to improve gait function after stroke and SCI include treadmill training with or without use of partial body weight support (BWS), yet the evidence to support this is inconclusive (Schwartz and Meiner, 2013; Dobkin et al., 2014). Gait machines (GM) may allow more reproducible gait movements compared to conventional training and reduce the burden on the therapist. GM work according to the end-effector principle (foot plates move the feet in a controlled gait pattern) or as exoskeletons, which have joints matching the limb joints and motors that drive movements over these joints to assist, e.g., leg movements (Hesse et al., 2010). A recent Cochrane review concluded that electromechanically assisted gait training in combination with physiotherapy after stroke increases the odds of achieving independent walking and most so when applied for severely impaired patients in the first 3 months after stroke (Mehrholz et al., 2013) but less clear after SCI (Mehrholz et al., 2012).
The importance of incorporating more active participation than allowed by gait machines to enhance training effects and the need for new concepts and devices are recognized (Dobkin, 2009; Pennycott et al., 2012). One new approach is represented by the Hybrid Assistive Limb system (HAL). HAL is an exoskeleton with a hybrid system allowing both a voluntary and an autonomous mode of action to support training of gait. HAL comprises a control algorithm and supporting devices, where each knee and hip joint can be controlled separately. Key features of the HAL system have been reported in detail (Kawamoto, 2002; Suzuki et al., 2007; Kawamoto et al., 2010). Movements are triggered by use of either the “Cybernic Voluntary Control” (CVC), which is based on the users voluntary activation of gait muscles as recorded by surface electromyography (EMG), or by the “Cybernic Autonomous Control” (CAC), which is based on the users weight shifting and input from force pressure sensors in the shoes. The CVC mode allows the operator to adjust the degree of support for each joint and reduce the support as training progress and to adjust settings to achieve a gait pattern that is as close as possible to normal gait. In case of complete loss of voluntary activation of gait muscles the CAC mode may be used. Gait is then initiated and sustained by input from force-pressure sensors in the shoes. HAL is manufactured in single-leg and double-leg versions and training with HAL may be performed with or without BWS.
A number of clinical studies with HAL have been conducted and there is a need for an evaluation of available data to guide further trials. The aim of this report was to provide a systematic review in order to evaluate current evidence with regard to feasibility (i.e., usability and safety) and effects and to make recommendations for further studies.