Locomotion Improvement Using a Hybrid Assistive Limb in Recovery Phase Stroke Patients: A Randomized Controlled Pilot Study



      To compare the efficacy of gait training using a single-leg version of the Hybrid Assistive Limb (HAL) on the paretic side with conventional gait training in individuals with subacute stroke.


      Randomized open controlled pilot trial.


      Hospitalized care.


      Convenience sample of 44 patients who met the criteria; 12 patients refused. After randomization (N=32), 10 patients withdrew and a total of 22 poststroke participants (HAL group: n=11; conventional group: n=11) completed the randomized controlled trial.


      All participants received twelve 20-minute sessions in 4 weeks of either HAL (wearing the single-leg version of the HAL on their paretic side) or conventional (performed by skilled and experienced physical therapists) gait training.

      Main Outcome Measures

      Outcome measures were evaluated prior to training and after 12 sessions. Functional Ambulation Category (FAC) was the primary outcome measure, whereas secondary outcome measures included maximum walking speed, timed Up and Go test, 6-minute walk distance, Short Physical Performance Battery, Fugl-Meyer Assessment of Lower Extremity, and isometric muscle strength (hip flexion and extension, knee flexion and extension).


      No participants withdrew because of adverse effects. Participants who received gait training with the HAL showed significantly more improvement in the FAC than those who received conventional gait training (95% confidence interval, .02–.88; P=.04). Secondary measures did not differ between the 2 groups.


      The results obtained in this randomized controlled trial suggest that a gait training program with the HAL could improve independent walking more efficiently than conventional gait training.


      List of abbreviations:

      CGT (conventional gait training), FAC (Functional Ambulation Category), HAL (Hybrid Assistive Limb)
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        • Dobkin B.H.
        Clinical practice. Rehabilitation after stroke.
        N Engl J Med. 2005; 352: 1677-1684
        • Jørgensen H.S.
        • Nakayama H.
        • Raaschou H.O.
        • Olsen T.S.
        Recovery of walking function in stroke patients: the Copenhagen Stroke Study.
        Arch Phys Med Rehabil. 1995; 76: 27-32
        • Bohannon R.W.
        • Horton M.G.
        • Wikholm J.B.
        Importance of four variables of walking to patients with stroke.
        Int J Rehabil Res. 1991; 14: 246-250
        • Beckerman H.
        • Becher J.
        • Lankhorst G.J.
        • Verbeek A.L.
        Walking ability of stroke patients: efficacy of tibial nerve blocking and a polypropylene ankle-foot orthosis.
        Arch Phys Med Rehabil. 1996; 77: 1144-1151
        • Dickstein R.
        • Hocherman S.
        • Pillar T.
        • Shaham R.
        Stroke rehabilitation. Three exercise therapy approaches.
        Phys Ther. 1986; 66: 1233-1238
        • Bayona N.A.
        • Bitensky J.
        • Salter K.
        • Teasell R.
        The role of task-specific training in rehabilitation therapies.
        Top Stroke Rehabil. 2005; 12: 58-65
        • Finch L.
        • Barbeau H.
        • Arsenault B.
        Influence of body weight support on normal human gait: development of a gait retraining strategy.
        Phys Ther. 1991; 71: 842-855
        • Colombo G.
        • Wirz M.
        • Dietz V.
        Driven gait orthosis for improvement of locomotor training in paraplegic patients.
        Spinal Cord. 2001; 39: 252-255
        • Iwata H.
        • Yano H.
        • Nakaizumi F.
        GaitMaster: a versatile locomotion interface for uneven virtual terrain.
        Proc IEEE Virtual Real Conf. 2001; : 131-137
        • Tanaka N.
        • Saitou H.
        • Takao T.
        • et al.
        Effects of gait rehabilitation with a footpad-type locomotion interface in patients with chronic post-stroke hemiparesis: a pilot study.
        Clin Rehabil. 2012; 26: 686-695
        • Hesse S.
        • Uhlenbrock D.
        • Werner C.
        • Bardeleben A.
        A mechanized gait trainer for restoring gait in nonambulatory subjects.
        Arch Phys Med Rehabil. 2000; 81: 1158-1161
        • Mehrholz J.
        • Elsner B.
        • Werner C.
        • Kugler J.
        • Pohl M.
        Electromechanical-assisted training for walking after stroke.
        Cochrane Database Syst Rev. 2013; : CD006185
        • Kasaoka K.
        • Sankai Y.
        Predictive control estimating operator's intention for stepping-up motion by exo-skeleton type power assist system HAL..
        Proceedings of the IEEE International Conference on Intelligent Robots and Systems. Maui, Hawaii,. 2001; : 1578-1583
      1. Lee S, Sankai Y. Power assist control for leg with HAL-3 based on virtual trque and impedance adjustment. In Proceedings of IEEE International Conference on Systems, Man and Cybernetics (SMC), Hammamet, Tunisia, TP1B3 (CD-ROM); 2002.

        • Kawamoto H.
        • Hayashi T.
        • Sakurai T.
        • Eguchi K.
        • Sankai Y.
        Development of single leg version of HAL for hemiplegia.
        Conf Proc IEEE Eng Med Biol Soc. 2009; 2009: 5038-5043
      2. Kawamoto H, Sankai Y. power assist system HAL-3 for gait disorder person. Proceedings of the 2002 International Conference on Computers Helping People with Special Needs (IC-CHP 2002), Linz, Austria, 2002;196-203.

        • Lee S.
        • Sankai Y.
        Virtual impedance adjustment in unconstrained motion for exoskeletal robot assisting lower limb.
        Adv Robot. 2005; 19: 773-795
        • Suzuki K.
        • Mito G.
        • Kawamoto H.
        • Hasegawa Y.
        • Sankai Y.
        Intention-based walking support for paraplegia patients with Robot Suit HAL.
        Adv Robot. 2007; 21: 1441-1469
        • Kawamoto H.
        • Sankai Y.
        Power assist method based on phase sequence and muscle force condition for HAL.
        Adv Robot. 2005; 19: 717-734
      3. Sankai Y. Leading edge of cybernics: robot suit HAL. SICE-ICASE International Joint Conference; Bexco, Busan, Korea, 2006;18-21.

        • Kubota S.
        • Nakata Y.
        • Eguchi K.
        • et al.
        Feasibility of rehabilitation training with a newly developed wearable robot for patients with limited mobility.
        Arch Phys Med Rehabil. 2013; 94: 1080-1087
        • Nilsson A.
        • Vreede K.S.
        • Häglund V.
        • et al.
        Gait training early after stroke with a new exoskeleton-the hybrid assistive limb: a study of safety and feasibility.
        J Neuroeng Rehabil. 2014; 11: 92
        • Kawamoto H.
        • Kamibayashi K.
        • Nakata Y.
        • et al.
        Pilot study of locomotion improvement using hybrid assistive limb in chronic stroke patients.
        BMC Neurol. 2013; 13: 141
        • Holden M.K.
        • Gill K.M.
        • Magliozzi M.R.
        Gait assessment for neurologically impaired patients. Standards for outcome assessment.
        Phys Ther. 1986; 66: 1530-1539
        • Raphael C.
        • Briscoe C.
        • Davies J.
        • et al.
        Limitations of the New York Heart Association functional classification system and self-reported walking distances in chronic heart failure.
        Heart. 2007; 93: 476-482
        • Ohta T.
        • Waga S.
        • Handa W.
        • Saito I.
        • Takeuchi K.
        [New grading of level of disordered consiousness].
        No Shinkei Geka. 1974; 2 ([Japanese]): 623-627
        • Suzuki K.
        • Imada G.
        • Iwaya T.
        • Handa T.
        • Kurogo H.
        Determinants and predictors of the maximum walking speed during computer-assisted gait training in hemiparetic stroke patients.
        Arch Phys Med Rehabil. 1999; 80: 179-182
        • Shumway-Cook A.
        • Brauer S.
        • Woollacott M.
        Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test.
        Phys Ther. 2000; 80: 896-903
        • ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories
        ATS statement: guidelines for the six-minute walk test.
        Am J Respir Crit Care Med. 2002; 166: 111-117
        • Guralnik J.M.
        • Simonsick E.M.
        • Ferrucci L.
        • et al.
        A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission.
        J Gerontol. 1994; 49: 85-94
        • Freire A.N.
        • Guerra R.O.
        • Alvarado B.
        • Guralnik J.M.
        • Zunzunegui M.V.
        Validity and reliability of the short physical performance battery in two diverse older adult populations in Quebec and Brazil.
        J Aging Health. 2012; 24: 863-878
        • Fugl-Meyer A.R.
        • Jaasko L.
        • Leyman I.
        • Olsson S.
        • Steglind S.
        The post-stroke hemiplegic patient. 1. A method for evaluation of physical performance.
        Scand J Rehabil Med. 1975; 7: 13-31
        • Hong S.J.
        • Goh E.Y.
        • Chua S.Y.
        • Ng S.S.
        Reliability and validity of step test scores in subjects with chronic stroke.
        Arch Phys Med Rehabil. 2012; 93: 1065-1071
        • Cohen J.
        A power primer.
        Psychol Bull. 1992; 112: 155-159
        • Cohen J.
        Statistical power analysis for the behavioral sciences.
        2nd ed. Lawrence Erlbaum, Hillsdale1988
        • Morone G.
        • Bragoni M.
        • Iosa M.
        • et al.
        Who may benefit from robotic-assisted gait training? A randomized clinical trial in patients with subacute stroke.
        Neurorehabil Neural Repair. 2011; 25: 636-644
        • Chang W.H.
        • Kim M.S.
        • Huh J.P.
        • Lee P.K.
        • Kim Y.H.
        Effects of robot-assisted gait training on cardiopulmonary fitness in subacute stroke patients: a randomized controlled study.
        Neurorehabil Neural Repair. 2012; 26: 318-324
        • Schwartz I.
        • Sajin A.
        • Fisher I.
        • et al.
        The effectiveness of locomotor therapy using robotic-assisted gait training in subacute stroke patients: a randomized controlled trial.
        PM R. 2009; 1: 516-523
        • Pohl M.
        • Werner C.
        • Holzgraefe M.
        • et al.
        Repetitive locomotor training and physiotherapy improve walking and basic activities of daily living after stroke: a single-blind, randomized multicentre trial (DEutsche GAngtrainerStudie, DEGAS).
        Clin Rehabil. 2007; 21: 17-27
        • Ada L.
        • Dean C.M.
        • Vargas J.
        • Ennis S.
        Mechanically assisted walking with body weight support results in more independent walking than assisted overground walking in non-ambulatory patients early after stroke: a systematic review.
        J Physiother. 2010; 56: 153-161
        • Katz N.
        • Hartman-Maeir A.
        • Ring H.
        • Soroker N.
        Functional disability and rehabilitation outcome in right hemisphere damaged patients with and without unilateral spatial neglect.
        Arch Phys Med Rehabil. 1999; 80: 379-384
        • Karnath H.O.
        • Broetz D.
        Understanding and treating “pusher syndrome”.
        Phys Ther. 2003; 83: 1119-1125