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      HAL® exoskeleton training improves walking parameters and normalizes cortical excitability in primary somatosensory cortex in spinal cord injury patients


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          Reorganization in the sensorimotor cortex accompanied by increased excitability and enlarged body representations is a consequence of spinal cord injury (SCI). Robotic-assisted bodyweight supported treadmill training (BWSTT) was hypothesized to induce reorganization and improve walking function.


          To assess whether BWSTT with hybrid assistive limb® (HAL®) exoskeleton affects cortical excitability in the primary somatosensory cortex (S1) in SCI patients, as measured by paired-pulse somatosensory evoked potentials (ppSEP) stimulated above the level of injury.


          Eleven SCI patients took part in HAL® assisted BWSTT for 3 months. PpSEP were conducted before and after this training period, where the amplitude ratios (SEP amplitude following double pulses - SEP amplitude following single pulses) were assessed and compared to eleven healthy control subjects. To assess improvement in walking function, we used the 10-m walk test, timed-up-and-go test, the 6-min walk test, and the lower extremity motor score.


          PpSEPs were significantly increased in SCI patients as compared to controls at baseline. Following training, ppSEPs were increased from baseline and no longer significantly differed from controls. Walking parameters also showed significant improvements, yet there was no significant correlation between ppSEP measures and walking parameters.


          The findings suggest that robotic-assisted BWSTT with HAL® in SCI patients is capable of inducing cortical plasticity following highly repetitive, active locomotive use of paretic legs. While there was no significant correlation of excitability with walking parameters, brain areas other than S1 might reflect improvement of walking functions. EEG and neuroimaging studies may provide further information about supraspinal plastic processes and foci in SCI rehabilitation.

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          Most cited references56

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          Mobility-related function in older adults: assessment with a 6-minute walk test.

          To determine the usefulness of the 6-minute walk test as an integrated measure of mobility in older adults. Observational study. Community centers and retirement homes in the Los Angeles area. Eighty-six older adults without significant disease. None. Assessments included the 6-minute walk, chair stands, standing balance, gait speed, body mass index, and self-reported physical functioning and general health perceptions. One-week test-retest reliability of the 6-minute walk was .95. As hypothesized, the 6-minute walk distance was significantly greater for active than for inactive older adults (p < .0001), moderately correlated with chair stands (r = .67), standing balance (r = .52), and gait speed (r = -.73). It had a low correlation with body mass index (r = -.07). The correlation of the 6-minute walk with self-reported physical functioning was .55, and its correlation with general health perceptions was .39. Self-report and performance measures explained 69% of the variance in 6-minute walk scores. The 6-minute walk test is reliable and is valid in relation to the performance and self-reported indicators of physical functioning tested in this study. It could serve as a useful integrated measure of mobility.
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            Massive cortical reorganization after sensory deafferentation in adult macaques.

            After limited sensory deafferentations in adult primates, somatosensory cortical maps reorganize over a distance of 1 to 2 millimeters mediolaterally, that is, in the dimension along which different body parts are represented. This amount of reorganization was considered to be an upper limit imposed by the size of the projection zones of individual thalamocortical axons, which typically also extend a mediolateral distance of 1 to 2 millimeters. However, after extensive long-term deafferentations in adult primates, changes in cortical maps were found to be an order of magnitude greater than those previously described. These results show the need for a reevaluation of both the upper limit of cortical reorganization in adult primates and the mechanisms responsible for it.
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              Voluntary driven exoskeleton as a new tool for rehabilitation in chronic spinal cord injury: a pilot study.

              Treadmill training after traumatic spinal cord injury (SCI) has become an established therapy to improve walking capabilities. The hybrid assistive limb (HAL) exoskeleton has been developed to support motor function and is tailored to the patients' voluntary drive.

                Author and article information

                +492343023258 , matthias.sczesny-kaiser@rub.de
                J Neuroeng Rehabil
                J Neuroeng Rehabil
                Journal of NeuroEngineering and Rehabilitation
                BioMed Central (London )
                20 August 2015
                20 August 2015
                : 12
                : 68
                [ ]Department of Neurology, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
                [ ]Department of Spinal Cord Injuries, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
                [ ]Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
                © Sczesny-Kaiser et al. 2015

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                : 9 April 2015
                : 3 August 2015
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