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Hybrid Assistive Limb (HAL) is a wearable human assistant cyborg-type robot that helps lower-leg movement based on bioelectrical signals detected from the voluntary movement of the person wearing it. In this study, we developed a novel staged HAL treatment protocol for patients with acute stroke. The Regain Program for Gait with HAL (RPG-HAL) was formulated in four steps, based on the severity of limb paralysis. Twenty-one patients with acute stroke received a combination treatment of RPG-HAL and conventional rehabilitation. The feasibility and safety of RPG-HAL were evaluated based on changes in physical function and activities of daily living (ADL). RPG-HAL yielded improvement in gait speed, cadence, step length, and functional ambulation category (FAC). The effect size was >0.8 in all measurements. FAC (1.90) and Barthel Index (BI) (1.92) exhibited the highest scores. Twelve out of 14 patients with FAC 0 before RPG-HAL reached the upper FAC. Thus, earlier intervention using RPG-HAL as improving physical function, ADL, and gait ability in patients with stroke.

Context: We sought to describe our experience with the Hybrid Assistive Limb® (HAL®) for active knee extension and voluntary ambulation with remaining muscle activity in a patient with complete paraplegia after spinal cord injury. Findings: A 30-year-old man with complete paraplegia used the HAL® for 1 month (10 sessions) using his remaining muscle activity, including hip flexor and upper limb activity. Electromyography was used to evaluate muscle activity of the gluteus maximus, tensor fascia lata, quadriceps femoris, and hamstring muscles in synchronization with the Vicon motion capture system. A HAL® session included a knee extension session with the hip flexor and voluntary gait with upper limb activity. After using the HAL® for one month, the patient's manual muscle hip flexor scores improved from 1/5 to 2/5 for the right and from 2/5 to 3/5 for the left knee, and from 0/5 to 1/5 for the extension of both knees. Conclusion/clinical relevance: Knee extension sessions with HAL®, and hip flexor and upper-limb-triggered HAL® ambulation seem a safe and feasible option in a patient with complete paraplegia due to spinal cord injury.

Context/Objective: The hybrid assistive limb (HAL) is a wearable exoskeleton robot that assists walking and lower limb movements via real-time actuator control. Our aim was to clarify the safety and feasibility of using the HAL robotic suit for rehabilitation in patients with severe thoracic myelopathy due to ossification of the posterior longitudinal ligament (T-OPLL). Design: Uncontrolled case series; pre- and post-intervention measurement. Setting: In-patient rehabilitation unit. Intervention: HAL training was provided in 60-minuts session, 2-3 sessions per week, for a total of 10 sessions. HAL training was initiated on average 27.5 days post-surgery. Patients: Eight patients (four males and four females; mean age, 60.9 ± 10.2 years) with severe myelopathy, who had undergone posterior decompression with instrumented fusion, were enrolled. Outcome Measures: Gait speed, step length and cadence were measured along a 10-m walkway every session. The American Spinal Injury Association (ASIA) motor score (lower extremities) and Walking Index for Spinal Cord Injury (WISCI) II were also evaluated at baseline and after 10 sessions. The Japanese Orthopaedic Association (JOA) score was calculated over time after surgery. Results: All participants completed the 10 training sessions, with no serious adverse effect noted. Gait speed, step length and cadence improved over time. Both the WISCI-II and ASIA motor (lower extremities) scores improved from baseline after 10 sessions. The JOA score improved over time post-surgery. Conclusion: HAL training can be feasibly initiated in the early postoperative period, without severe adverse events in patients, with T-OPLL-related severe gait disturbance.

Context: Spinal cord infarction (SCI) causes gait disturbance because of paresis, spasticity, and sensory disturbance of the lower limbs. There is no effective medical treatment for SCI, and conventional rehabilitation alone is the main approach to helping individuals work toward independent walking. The aim of this study was to evaluate the effect of gait treatment using the Hybrid Assistive Limb (HAL) on acute SCI., Findings: A 61-year-old female and a 62-year-old male with incomplete paraplegia participated in this study. Our study participants received gait treatment with HAL 3-4 times per week, with a total of 7-8 sessions (20 min), in addition to conventional physical therapy. The American Spinal Injury Association Impairment Scale, Lower Extremity Motor Score (LEMS), Modified Ashworth Scale (MAS), the Walking Index for Spinal Cord Injury (WISCI II), comfortable gait speed (CGS), stride, cadence, Barthel Index (BI), Functional Independence Measure (FIM), modified Rankin Scale (mRS), joint angles, and adverse effects were assessed prior to HAL treatment and post-HAL treatment. HAL facilitated intensive gait treatment in people during the acute phase after SCI. Improvements in LEMS, WISCI II, CGS, stride, cadence, BI, FIM, mRS, and joint angles were observed in both study participants. Furthermore, decreased spasticity in the gastrocnemius muscle was found in one participant as assessed by MAS., Conclusion: Gait treatment using HAL may be beneficial for paraplegic, non-ambulatory individuals with acute SCI. HAL may be useful for intensive gait treatment without increasing spasticity.

Context: The hybrid assistive limb (HAL) (the wearable robot) can assist kinesis during voluntary control of hip and knee joint motion by detecting the wearer's bioelectric signals on the surface of their skin. The purpose of this study was to report on walking ability following the wearable robot treatment in a patient with chronic myelopathy after surgery for cervical ossification of the posterior longitudinal ligament (OPLL)., Findings: The patient was a 66-year-old woman with cervical OPLL who was able to ambulate independently with the aid of bilateral crutches. The wearable robot treatment was received once every 2 weeks for ten sessions beginning approximately 14 years after surgery. Improvements were observed in gait speed (BL 22.5; post 46.7 m/min), step length (BL 0.36; post 0.57 m), and cadence (BL 61.9; post 81.6 m/min) based on a 10-m walk test and a 2-minute walk test (BL 63.4; post 103.7 m) assessing total walking distance. The improvements in walking ability were maintained after the wearable robot treatment for 6 months., Conclusion: We report the functional recovery in the walking ability of a patient with chronic cervical myelopathy following the wearable robot treatment, suggesting that as a rehabilitation tool, the wearable robot has the potential to effectively improve functional ambulation in chronic cervical myelopathy patients whose walking ability has plateaued, even many years after surgery.

Context: The purpose of this report was to describe the improvement in walking ability using the Hybrid Assistive Limb® (HAL®) intervention in the case of a patient with paraplegia after spinal cord injury whose condition deteriorated because of a spinal dural arteriovenous fistula (SDAVF)., Findings: A 48-year-old man started the HAL® intervention twice per week (total 10 sessions), after his neurologic improvement had plateaued from 3 to 6 months postoperatively for an SDAVF. During the HAL® intervention, the 10-m walk test (10MWT) without HAL® was performed before and after each session. An electromyography system was used to evaluate muscle activity of both the gluteus maximus (Gmax) and quadriceps femoris (Quad) muscles in synchronization with the Vicon motion capture system. The International Standards for Neurological and Functional Classification of Spinal Cord Injury (ISNCSCI) motor scores of the lower extremities and the Walking Index for Spinal Cord Injury II (WISCI II) score were also assessed to evaluate motor function. The HAL® intervention improved gait speed and cadence during the 10MWT. Before the intervention, both the Gmax and left Quad muscles were not activated. After the intervention, the right Gmax and both Quad muscles were activated in stance phase rhythmically according to the gait cycle. The ISNCSCI motor score also improved from 14 to 16, and the WISCI II scored improved from 7 to 12., Conclusion/clinical Relevance: Our experience with this patient suggests that the HAL® can be an effective tool for improving functional ambulation in patients with chronic spinal cord injury.

Context: Recently, locomotor training with robotic assistance has been found effective in treating spinal cord injury (SCI). Our case report examined locomotor training using the robotic suit hybrid assistive limb (HAL) in a patient with complete C4 quadriplegia due to chronic SCI. This is the first report examining HAL in complete C4 quadriplegia., Findings: The patient was a 19-year-old man who dislocated C3/4 during judo 4 years previously. Following the injury, he underwent C3/4 posterior spinal fusion but remained paralyzed despite rehabilitation. There was muscle atrophy under C5 level and no sensation around the anus, but partial sensation of pressure remained in the limbs. The American Spinal Injury Association impairment scale was Grade A (complete motor C4 lesion). HAL training was administered in 10 sessions (twice per week). The training sessions consisted of treadmill walking with HAL. For safety, 2 physicians and 1 therapist supported the subject for balance and weight-bearing. The device's cybernic autonomous control mode provides autonomic physical support based on predefined walking patterns. We evaluated the adverse events, walking time and distance, and the difference in muscle spasticity before and after HAL-training using a modified Ashworth scale (mAs). No adverse events were observed that required discontinuation of rehabilitation. Walking distance and time increased from 25.2 meters/7.6 minutes to 148.3 meter/15 minutes. The mAs score decreased after HAL training., Conclusion: Our case report indicates that HAL training is feasible and effective for complete C4 quadriplegia in chronic SCI.

Context: Patients with complete quadriplegia after high cervical spinal cord injury are fully dependent with activities of daily living. Assistive technology can improve their quality of life. We examined the use of a hybrid assistive limb for single joints (HAL-SJ) in a 19-year-old man with complete C4 quadriplegia due to chronic spinal cord injury to restore function of active elbow flexion. This is the first report on the use of the HAL-SJ in a patient with spinal cord injury., Findings: The HAL-SJ intervention for each elbow was administered in 10 sessions. Clinical assessment using surface EMG was conducted to evaluate muscle activity of the trapezius, biceps brachii, infraspinatus, and triceps brachii muscle before, and during the 2nd, 3rd, 6th, and 9th interventions. Surface electromyography (EMG) before intervention showed no contraction in the upper arms, but in the bilateral trapezius. The HAL-SJ used motion intention from the right trapezius for activation. After the 6th and 7th session, respectively, biceps EMG showed that voluntary contraction and right elbow flexion could be performed by motion intention from the right biceps. After the 10th session, voluntary bicep contraction was possible. HAL-SJ treatment on the left elbow was performed using the same protocol with a similar outcome. After completing treatment on both upper extremities, both biceps contracted voluntarily, and he could operate a standard wheelchair for a short distance independently., Conclusion: HAL-SJ intervention is feasible and effective in restoring elbow flexor function in a patient with C4 chronic spinal cord injury and complete quadriplegia.

Context: The hybrid assistive limb (HAL) is a wearable robot suit that assists in voluntary control of knee and hip joint motion by detecting bioelectric signals on the surface of the skin with high sensitivity. HAL has been reported to be effective for functional recovery in motor impairments. However, few reports have revealed the utility of HAL for patients who have undergone surgery for thoracic ossification of the posterior longitudinal ligament (thoracic OPLL). Herein, we present a postoperative thoracic OPLL patient who showed remarkable functional recovery after training with HAL., Findings: A 63-year-old woman, who could not walk due to muscle weakness before surgery, underwent posterior decompression and fusion. Paralysis was re-aggravated after the initial postoperative rising. We diagnosed that paralysis was due to residual compression from the anterior lesion and microinstability after posterior fixation, and prescribed bed rest for a further 3 weeks. The incomplete paralysis gradually recovered, and walking training with HAL was started on postoperative day 44 in addition to standard physical therapy. The patient underwent 10 sessions of HAL training until discharge on postoperative day 73. Results of a 10-m walk test were assessed after every session, and the patient's speed and cadence markedly improved. At discharge, the patient could walk with 2 crutches and no assistance. Furthermore, no adverse events associated with HAL training occurred., Conclusion: HAL training for postoperative thoracic OPLL patients may enhance improvement in walking ability, even if severe impairment of ambulation and muscle weakness exist preoperatively.