Hybrid Assistive Limb

The Hybrid Assistive Limb is a powered exoskeleton suit developed by Japan's Tsukuba University and the robotics company Cyberdyne. It is designed to support and expand the physical capabilities of its users, particularly people with physical disabilities.

Watanabe et al. investigated the long-term effects of a lumbar-type hybrid assistive limb for patients with chronic heart failure. [Participants and Methods] A total of 28 hospitalized patients with chronic heart failure (mean age, 73.1 ± 13.8 years) were randomly assigned to two groups: the hybrid assistive limb group or the control group, in which they performed a sit-to-stand exercise with or without the hybrid assistive limb, respectively. The cardiac rehabilitation therapy included this intervention, which was performed as many times as possible for 5-30 minutes per day for 6-10 days. Clinical assessments like lower-limb muscle strength, walking ability, etc., were measured before and after the intervention. Cardiac events were followed up for up to a year after discharge. [Results] No adverse events occurred during the study period in either group. In terms of long-term effects, the incidence of cardiac events was 23% and 45% in the hybrid assistive limb and the control groups, respectively. [Conclusion] Hybrid assistive limb-assisted exercise therapy may be a safe and feasible cardiac rehabilitation tool in patients with chronic heart failure. The lumbar-type wearable cyborg hybrid assistive limb may have a positive effect on heart failure prognosis by adding long-term exercise therapy ¹⁾.

A robotic arm (not robotic hand) is a type of mechanical arm, usually programmable, with similar functions to a human arm; the arm may be the sum total of the mechanism or may be part of a more complex robot. The links of such a manipulator are connected by joints allowing either rotational motion (such as in an articulated robot) or translational (linear) displacement.

The links of the manipulator can be considered to form a kinematic chain. The terminus of the kinematic chain of the manipulator is called the end effector and it is analogous to the human hand.

To determine how differences in frequency of the single-joint hybrid assistive limb (HAL-SJ) use affect the improvement of upper limb motor function and activities of daily living (ADL) in stroke patients.

Subacute stroke patients were divided into the high or low frequency of HAL-SJ use groups. The two groups were matched by propensity score, and the degree of changes 30 days after initiating HAL-SJ use was compared. A logistic regression analysis was performed to examine whether frequent use would increase the number of subjects experiencing the efficacy of more than the minimal clinically important difference (MCID) of Fugl-Meyer assessment (FMA).

Twenty-five stroke patients were matched by propensity score, and nine pairs were matched. The high-frequency group showed a significantly superior increase to total FMA shoulder, elbow, forearm, and Barthel index compared with the low-frequency group. Logistic regression analysis revealed no significant associations between frequent use and MCID.

The frequency of HAL-SJ use may affect the improvement of motor function and ADL ability of the upper limb with exception of the fingers and wrist. However, the frequency of intervention was not effective enough to further increase the number of subjects with clinically meaningful changes in upper limb motor function.IMPLICATIONS FOR REHABILITATIONThe current study aimed to clarify how differences in the frequency of single-joint hybrid assistive limb (HAL-SJ) use can affect the improvement of upper-limb motor functions and ADL in subacute stroke patients.Our results implied that the frequency of HAL-SJ use may influence the recovery of upper limb function.However, even if HAL-SJ is used frequently, it does not mean that more patients will achieve clinically meaningful recovery ²⁾.

The Hybrid Assistive Limb (HAL) was developed as an exoskeleton robot that supports gait training. The purpose of a study of Setoguchi et al. was to assess the usefulness of training using the HAL after total hip arthroplasty (THA). They targeted 16 consecutive patients who underwent THA via the posterior approach. They randomized patients to the HAL group (8 hips), in which the HAL was used as part of physical therapy, or the control group (8 hips), in which only typical physical therapy was performed. Gait analysis was performed before and after surgery, and comparisons were made between the two groups. They evaluated the single support time (%), double support time (%), cadence (steps/min), velocity (cm/s), stride length (cm), and anteroposterior and lateral variability, and assessed the hip and knee joint range of motion in the sagittal plane. The results showed improvements in the hip extension angle and other gait parameters in the HAL group. Among gait-related problems after THA, a decreased peak hip extension angle is reported to be a significant factor that affects gait disability. This study revealed that HAL usage after THA seems to be a useful method to obtain sufficient extension angle ³⁾.

Use of the Hybrid Assistive Limb (HAL) that is effective for improvement of gait ability in chronic stroke patients has been reported. However, how long the effects are maintained remains unknown. The purpose of the present study was to investigate whether the effect of gait training using the HAL on gait ability was maintained for 3 months after the intervention.

A longitudinal, observational study with an intervention for a single group that adhered to the STROBE guidelines was performed. Nine chronic stroke patients were enrolled in this study. The patients performed gait training sessions using the HAL, 2-5 sessions/week for 3 weeks. Gait speed, stride length, cadence, and 2-minute walk distance (2MWD) were measured before and after intervention and at 3-month follow-up. The clinical trial registration number of this study is UMIN000012764 R000014756. Results: Compared to the initial status, gait speed (p = .02), stride length (p = .03), cadence (p = .01), and 2MWD (p < .05) were significantly increased immediately after the intervention. Moreover, gait speed (p < .01), cadence (p = .03), and 2MWD (p = .02) remained significantly higher 3 months after the intervention. There were no significant changes in all outcome measures between after intervention and at 3-month follow-up. Conclusions: This study showed that gait training using the HAL resulted in significant improvement of gait ability after the intervention and the effect was maintained for 3 months after the training ⁴⁾.

2: Watanabe H, Koike A, Wu L, Kato H, Konno H, Sato A, Kawamoto H, Matsumura A, Aonuma K, Sankai Y, Ieda M. Efficacy of Cardiac Rehabilitation with Assistance from Hybrid Assistive Limb in Patients with Chronic Heart Failure: Protocol for a Randomized Controlled Study. Cardiology. 2019 Jun 25:1-7. doi: 10.1159/000500263. [Epub ahead of print] PubMed PMID: 31238304.

3: Watanabe H, Koike A, Pak YJ, Wu L, Kubota H, Konno H, Sato A, Kawamoto H, Matsumura A, Aonuma K, Sankai Y, Ieda M. Effects of a lumbar-type hybrid assistive limb on cardiopulmonary burden during squat exercise in healthy subjects. J Clin Neurosci. 2019 Aug;66:226-230. doi: 10.1016/j.jocn.2019.05.026. Epub 2019 May 31. PubMed PMID: 31160202.

4: Tanaka H, Nankaku M, Nishikawa T, Hosoe T, Yonezawa H, Mori H, Kikuchi T, Nishi H, Takagi Y, Miyamoto S, Ikeguchi R, Matsuda S. Spatiotemporal gait characteristic changes with gait training using the hybrid assistive limb for chronic stroke patients. Gait Posture. 2019 Jun;71:205-210. doi: 10.1016/j.gaitpost.2019.05.003. Epub 2019 May 3. PubMed PMID: 31078010.

5: Iwamoto Y, Imura T, Suzukawa T, Fukuyama H, Ishii T, Taki S, Imada N, Shibukawa M, Inagawa T, Araki H, Araki O. Combination of Exoskeletal Upper Limb Robot and Occupational Therapy Improve Activities of Daily Living Function in Acute Stroke Patients. J Stroke Cerebrovasc Dis. 2019 Jul;28(7):2018-2025. doi: 10.1016/j.jstrokecerebrovasdis.2019.03.006. Epub 2019 Apr 30. PubMed PMID: 31047819.

6: Hyakutake K, Morishita T, Saita K, Fukuda H, Shiota E, Higaki Y, Inoue T, Uehara Y. Effects of Home-Based Robotic Therapy Involving the Single-Joint Hybrid Assistive Limb Robotic Suit in the Chronic Phase of Stroke: A Pilot Study. Biomed Res Int. 2019 Mar 18;2019:5462694. doi: 10.1155/2019/5462694. eCollection 2019. PubMed PMID: 31011576; PubMed Central PMCID: PMC6442446.

7: Puentes S, Kadone H, Watanabe H, Ueno T, Yamazaki M, Sankai Y, Marushima A, Suzuki K. Reshaping of Bilateral Gait Coordination in Hemiparetic Stroke Patients After Early Robotic Intervention. Front Neurosci. 2018 Oct 9;12:719. doi: 10.3389/fnins.2018.00719. eCollection 2018. PubMed PMID: 30356738; PubMed Central PMCID: PMC6189332.

8: Kubota S, Abe T, Kadone H, Shimizu Y, Funayama T, Watanabe H, Marushima A, Koda M, Hada Y, Sankai Y, Yamazaki M. Hybrid assistive limb (HAL) treatment for patients with severe thoracic myelopathy due to ossification of the posterior longitudinal ligament (OPLL) in the postoperative acute/subacute phase: A clinical trial. J Spinal Cord Med. 2019 Jul;42(4):517-525. doi: 10.1080/10790268.2018.1525975. Epub 2018 Oct 18. PubMed PMID: 30335588.

9: Abe H, Morishita T, Samura K, Yagi K, Nonaka M, Inoue T. Potential of Hybrid Assistive Limb Treatment for Ataxic Gait Due to Cerebellar Disorders Including Hemorrhage, Infarction, and Tumor. Acta Neurochir Suppl. 2018;129:135-140. doi: 10.1007/978-3-319-73739-3_20. Review. PubMed PMID: 30171326.

10: Tan CK, Kadone H, Watanabe H, Marushima A, Yamazaki M, Sankai Y, Suzuki K. Lateral Symmetry of Synergies in Lower Limb Muscles of Acute Post-stroke Patients After Robotic Intervention. Front Neurosci. 2018 Apr 25;12:276. doi: 10.3389/fnins.2018.00276. eCollection 2018. PubMed PMID: 29922121; PubMed Central PMCID: PMC5996914.

11: Kubota S, Kadone H, Shimizu Y, Hara Y, Kubo T, Watanabe H, Hada Y, Ochiai N, Sankai Y, Yamazaki M. Robotic rehabilitation training with a newly developed upper limb single-joint Hybrid Assistive Limb (HAL-SJ) for elbow flexor reconstruction after brachial plexus injury: A report of two cases. J Orthop Surg (Hong Kong). 2018 May-Aug;26(2):2309499018777887. doi: 10.1177/2309499018777887. PubMed PMID: 29874971.

12: Taketomi M, Shimizu Y, Kadone H, Kubota S, Abe T, Marushima A, Ueno T, Endo A, Kawamoto H, Matsumura A, Sankai Y, Hada Y, Yamazaki M. Hybrid Assistive Limb Intervention in a Patient with Late Neurological Deterioration after Thoracic Myelopathy Surgery due to Ossification of the Ligamentum Flavum. Case Rep Orthop. 2018 Feb 8;2018:6171760. doi: 10.1155/2018/6171760. eCollection 2018. PubMed PMID: 29593925; PubMed Central PMCID: PMC5822893.

13: Puentes S, Kadone H, Kubota S, Abe T, Shimizu Y, Marushima A, Sankai Y, Yamazaki M, Suzuki K. Reshaping of Gait Coordination by Robotic Intervention in Myelopathy Patients After Surgery. Front Neurosci. 2018 Mar 2;12:99. doi: 10.3389/fnins.2018.00099. eCollection 2018. PubMed PMID: 29551960; PubMed Central PMCID: PMC5840280.

14: Kubota S, Abe T, Koda M, Kadone H, Shimizu Y, Mataki Y, Noguchi H, Fujii K, Marushima A, Funayama T, Kawamoto H, Hada Y, Sankai Y, Yamazaki M. Application of a newly developed upper limb single-joint hybrid assistive limb for postoperative C5 paralysis: An initial case report indicating its safety and feasibility. J Clin Neurosci. 2018 Apr;50:268-271. doi: 10.1016/j.jocn.2018.01.038. PubMed PMID: 29402566.

15: Shimizu Y, Kadone H, Kubota S, Suzuki K, Saotome K, Ueno T, Abe T, Marushima A, Watanabe H, Endo A, Tsurumi K, Ishimoto R, Matsushita A, Koda M, Matsumura A, Sankai Y, Hada Y, Yamazaki M. Voluntary ambulation using voluntary upper limb muscle activity and Hybrid Assistive Limb® (HAL®) in a patient with complete paraplegia due to chronic spinal cord injury: A case report. J Spinal Cord Med. 2019 Jul;42(4):460-468. doi: 10.1080/10790268.2017.1423267. Epub 2018 Jan 19. PubMed PMID: 29351051.

16: Saita K, Morishita T, Arima H, Hyakutake K, Ogata T, Yagi K, Shiota E, Inoue T. Biofeedback effect of hybrid assistive limb in stroke rehabilitation: A proof of concept study using functional near infrared spectroscopy. PLoS One. 2018 Jan 16;13(1):e0191361. doi: 10.1371/journal.pone.0191361. eCollection 2018. PubMed PMID: 29338060; PubMed Central PMCID: PMC5770063.

17: Nishimura M, Kobayashi S, Kinjo Y, Hokama Y, Sugawara K, Tsuchida Y, Tominaga D, Ishiuchi S. Factors Leading to Improved Gait Function in Patients with Subacute or Chronic Central Nervous System Impairments Who Receive Functional Training with the Robot Suit Hybrid Assistive Limb. Neurol Med Chir (Tokyo). 2018 Jan 15;58(1):39-48. doi: 10.2176/nmc.oa.2017-0082. Epub 2017 Dec 1. PubMed PMID: 29199246; PubMed Central PMCID: PMC5785696.

18: Watanabe H, Marushima A, Kawamoto H, Kadone H, Ueno T, Shimizu Y, Endo A, Hada Y, Saotome K, Abe T, Yamazaki M, Sankai Y, Ishikawa E, Matsumura A. Intensive Gait Treatment Using a Robot Suit Hybrid Assistive Limb in Acute Spinal Cord Infarction: Report of Two Cases. J Spinal Cord Med. 2019 May;42(3):395-401. doi: 10.1080/10790268.2017.1372059. Epub 2017 Oct 9. PubMed PMID: 28990874; PubMed Central PMCID: PMC6522957.

19: Shimizu Y, Nakai K, Kadone H, Yamauchi S, Kubota S, Ueno T, Marushima A, Hiruta K, Endo A, Kawamoto H, Matsumura A, Sankai Y, Hada Y, Yamazaki M. The Hybrid Assistive Limb® intervention for a postoperative patient with spinal dural arteriovenous fistula and chronic spinal cord injury: A case study. J Spinal Cord Med. 2018 Nov;41(6):710-717. doi: 10.1080/10790268.2017.1329916. Epub 2017 May 29. PubMed PMID: 28552031; PubMed Central PMCID: PMC6217463.

20: Kubota S, Abe T, Kadone H, Fujii K, Shimizu Y, Marushima A, Ueno T, Kawamoto H, Hada Y, Matsumura A, Sankai Y, Yamazaki M. Walking ability following hybrid assistive limb treatment for a patient with chronic myelopathy after surgery for cervical ossification of the posterior longitudinal ligament. J Spinal Cord Med. 2019 Jan;42(1):128-136. doi: 10.1080/10790268.2017.1313932. Epub 2017 Apr 20. PubMed PMID: 28424026; PubMed Central PMCID: PMC6340273.

21: Shimizu Y, Kadone H, Kubota S, Ikumi A, Abe T, Marushima A, Ueno T, Endo A, Kawamoto H, Saotome K, Matsushita A, Matsumura A, Sankai Y, Hada Y, Yamazaki M. Active elbow flexion is possible in C4 quadriplegia using hybrid assistive limb (HAL®) technology: A case study. J Spinal Cord Med. 2017 Jul;40(4):456-462. doi: 10.1080/10790268.2017.1305036. Epub 2017 Mar 29. PubMed PMID: 28355990; PubMed Central PMCID: PMC5537963.

22: Watanabe H, Goto R, Tanaka N, Matsumura A, Yanagi H. Effects of gait training using the Hybrid Assistive Limb® in recovery-phase stroke patients: A 2-month follow-up, randomized, controlled study. NeuroRehabilitation. 2017;40(3):363-367. doi: 10.3233/NRE-161424. PubMed PMID: 28222558.

23: Saita K, Morishita T, Hyakutake K, Fukuda H, Shiota E, Sankai Y, Inoue T. Combined therapy using botulinum toxin A and single-joint hybrid assistive limb for upper-limb disability due to spastic hemiplegia. J Neurol Sci. 2017 Feb 15;373:182-187. doi: 10.1016/j.jns.2016.12.056. Epub 2016 Dec 28. PubMed PMID: 28131185.

24: Ikumi A, Kubota S, Shimizu Y, Kadone H, Marushima A, Ueno T, Kawamoto H, Hada Y, Matsumura A, Sankai Y, Yamazaki M. Decrease of spasticity after hybrid assistive limb(®) training for a patient with C4 quadriplegia due to chronic SCI. J Spinal Cord Med. 2017 Sep;40(5):573-578. doi: 10.1080/10790268.2016.1225913. Epub 2016 Oct 20. PubMed PMID: 27762171; PubMed Central PMCID: PMC5815155.

25: Goto K, Morishita T, Kamada S, Saita K, Fukuda H, Shiota E, Sankai Y, Inoue T. Feasibility of rehabilitation using the single-joint hybrid assistive limb to facilitate early recovery following total knee arthroplasty: A pilot study. Assist Technol. 2017 Winter;29(4):197-201. doi: 10.1080/10400435.2016.1219883. Epub 2016 Aug 10. PubMed PMID: 27689789.

26: Morishita T, Inoue T. Interactive Bio-feedback Therapy Using Hybrid Assistive Limbs for Motor Recovery after Stroke: Current Practice and Future Perspectives. Neurol Med Chir (Tokyo). 2016 Oct 15;56(10):605-612. Epub 2016 Sep 8. Review. PubMed PMID: 27616320; PubMed Central PMCID: PMC5066081.

27: Fujii K, Abe T, Kubota S, Marushima A, Kawamoto H, Ueno T, Matsushita A, Nakai K, Saotome K, Kadone H, Endo A, Haginoya A, Hada Y, Matsumura A, Sankai Y, Yamazaki M. The voluntary driven exoskeleton Hybrid Assistive Limb (HAL) for postoperative training of thoracic ossification of the posterior longitudinal ligament: a case report. J Spinal Cord Med. 2017 May;40(3):361-367. doi: 10.1080/10790268.2016.1142056. Epub 2016 Feb 9. PubMed PMID: 26856189; PubMed Central PMCID: PMC5472024.

28: Chihara H, Takagi Y, Nishino K, Yoshida K, Arakawa Y, Kikuchi T, Takenobu Y, Miyamoto S. Factors Predicting the Effects of Hybrid Assistive Limb Robot Suit during the Acute Phase of Central Nervous System Injury. Neurol Med Chir (Tokyo). 2016;56(1):33-7. doi: 10.2176/nmc.oa.2015-0178. Epub 2015 Nov 5. PubMed PMID: 26538291; PubMed Central PMCID: PMC4728147.

29: Ogata T, Abe H, Samura K, Hamada O, Nonaka M, Iwaasa M, Higashi T, Fukuda H, Shiota E, Tsuboi Y, Inoue T. Hybrid Assistive Limb (HAL) Rehabilitation in Patients with Acute Hemorrhagic Stroke. Neurol Med Chir (Tokyo). 2015;55(12):901-6. doi: 10.2176/nmc.oa.2015-0209. Epub 2015 Oct 28. PubMed PMID: 26511112; PubMed Central PMCID: PMC4686453.

30: Fukuda H, Morishita T, Ogata T, Saita K, Hyakutake K, Watanabe J, Shiota E, Inoue T. Tailor-made rehabilitation approach using multiple types of hybrid assistive limb robots for acute stroke patients: A pilot study. Assist Technol. 2016 Spring;28(1):53-6. doi: 10.1080/10400435.2015.1080768. PubMed PMID: 26478988.

31: Ueba T, Hamada O, Ogata T, Inoue T, Shiota E, Sankai Y. Feasibility and safety of acute phase rehabilitation after stroke using the hybrid assistive limb robot suit. Neurol Med Chir (Tokyo). 2013;53(5):287-90. PubMed PMID: 23708218.