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


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          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.

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          Clinical and laboratory measures of postural balance in an elderly population.

          The objective of this cross-sectional study was to compare scores on the Balance Scale with laboratory measures of postural sway and other clinical measures of balance and mobility. Thirty-one elderly subjects were assessed on the clinical measures and the laboratory tests of postural sway while standing still and in response to pseudorandom movements of the platform. The average correlation between the Balance Scale and the spontaneous sway measures was -.55. It was slightly lower (r = -.38) for the same parameters measured during the pseudorandom tests. There were high correlations between the Balance Scale and the Balance Sub-Scale developed by Tinetti (r = .91), Barthel Mobility sub-scale (r = .67), and timed "Up and Go" (r = -.76). The Balance Scale was the most efficient measure (effect size > 1) to statistically discriminate between subjects according to their use of each type of mobility aide (walker, cane, no aids). These data contribute to existing information on the performance of the Balance Scale and supports the validity of the Balance Scale in this geriatric population.
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            Improvements in speed-based gait classifications are meaningful.

            Gait velocity is a powerful indicator of function and prognosis after stroke. Gait velocity can be stratified into clinically meaningful functional ambulation classes, such as household ambulation ( 0.8 m/s). The purpose of the current study was to determine whether changes in velocity-based community ambulation classification were related to clinically meaningful changes in stroke-related function and quality of life. In subacute stroke survivors with mild to moderate deficits who participated in a randomized clinical trial of stroke rehabilitation and had a baseline gait velocity of 0.8 m/s or less, we assessed the effect of success versus failure to achieve a transition to the next class on function and quality of life according to domains of the Stroke Impact Scale (SIS). Of 64 eligible participants, 19 were initially household ambulators, and 12 of them (68%) transitioned to limited community ambulation, whereas of 45 initially limited community ambulators, 17 (38%) became full community ambulators. Function and quality-of-life SIS scores after treatment were significantly higher among survivors who achieved a favorable transition compared with those who did not. Among household ambulators, those who transitioned to limited or full community ambulation had significantly better SIS scores in mobility (P=0.0299) and participation (P=0.0277). Among limited community ambulators, those who achieved the transition to full community ambulatory status had significantly better scores in SIS participation (P=0.0085). A gait velocity gain that results in a transition to a higher class of ambulation results in better function and quality of life, especially for household ambulators. Household ambulators possibly had more severe stroke deficits, reducing the risk of "ceiling" effects in SIS-measured activities of daily living and instrumental activities of daily living. Outcome assessment based on transitions within a mobility classification scheme that is rooted in gait velocity yields potentially meaningful indicators of clinical benefit. Outcomes should be selected that are clinically meaningful for all levels of severity.
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              Classification of walking handicap in the stroke population.

              The limited walking ability that follows a stroke restricts the patient's independent mobility about the home and community, a significant social handicap. To improve the in-hospital prediction of functional outcome, the relationships between impairment, disability, and handicap were assessed with clinical measures in 147 stroke patients. The patients' level of functional walking ability at home and in the community was assigned by expert clinicians to one of the six categories of a modified Hoffer Functional Ambulation scale at least 3 months after discharge. A 19-item questionnaire was further used to assess current customary mobility of the subjects. Functional muscle strength and proprioception were tested, and walking velocity was measured. The significant indicators of impairment, upright motor control knee flexion and extension strength, differentiated household from community ambulators. The addition of velocity improved the functional prediction. Proprioception was clinically normal in all walkers. The validity of the criteria for the six levels of walking handicap was confirmed statistically. Stepwise discriminant analysis reduced the ambulation activities on the questionnaire from 19 to 7. Redefinition of the criteria for patient classification using the coefficients and constants of the seven critical functions improved the prediction of patient walking ability to 84%. The results of this study offer a quantitative method of relating the social disadvantage of stroke patients to the impairment and disability sustained. The measurement of therapeutic outcome in relation to the social advantage for the patient would allow more efficient standardization of treatment and services.

                Author and article information

                Front Syst Neurosci
                Front Syst Neurosci
                Front. Syst. Neurosci.
                Frontiers in Systems Neuroscience
                Frontiers Media S.A.
                25 March 2015
                : 9
                : 48
                [1] 1Department of Rehabilitation Medicine, Danderyd University Hospital Stockholm, Sweden
                [2] 2Department of Clinical Sciences, Karolinska Institute Stockholm, Sweden
                Author notes

                Edited by: Mikhail Lebedev, Duke University, USA

                Reviewed by: Jun Morimoto, ATR Computational Neuroscience Labs, Japan; Mukul Talaty, Moss, USA; Antoinette Domingo, San Diego State University, USA

                *Correspondence: Anneli Wall, Department of Rehabilitation Medicine, Danderyd University Hospital, Danderyds Sjukhus, Rehabiliteringsmedicinska Universitetskliniken, Hus 39, plan 3, Stockholm 18288, Sweden anneli.wall@ 123456ds.se
                Copyright © 2015 Wall, Borg and Palmcrantz.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                : 23 December 2014
                : 10 March 2015
                Page count
                Figures: 1, Tables: 1, Equations: 0, References: 45, Pages: 10, Words: 7378
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                rehabilitation,robotics,gait,walking,locomotion,paresis,review,gait machine
                rehabilitation, robotics, gait, walking, locomotion, paresis, review, gait machine


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