Publications by authors named "Mirko Aach"

34 Publications

Rehabilitation during early postoperative period following total knee arthroplasty using single-joint hybrid assistive limb as new therapy device: a randomized, controlled clinical pilot study.

Arch Orthop Trauma Surg 2021 Nov 16. Epub 2021 Nov 16.

Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany.

Introduction: The first weeks after total knee arthroplasty (TKA) are crucial for the functional outcome. To improve knee mobility, a continuous passive motion (CPM) motor rail is commonly used during in-hospital rehabilitation. The single-joint hybrid assistive limb (HAL-SJ) is a new therapy device. The aim of the study was to improve patients' range of motion (ROM), mobility, and satisfaction using the active-assistive support of the HAL-SJ.

Materials And Methods: Between 09/2017 and 10/2020, 34 patients, who underwent TKA and matched the inclusion criteria, were randomized into study (HAL-SJ) and control (CPM) group. Treatment began after drain removal and was carried out until discharge. Primary outcome parameters were raised pre- and postoperatively and included the Oxford knee score (OKS), visual analog scale (VAS), and acquired range of motion. Furthermore complications caused by the device were recorded.

Results: OKS increased in both groups postoperatively, but only significantly in the HAL-SJ group. Postoperative pain improved in both groups without significant differences. Flexion improvement was significant in both groups between days 3/7 and 8 weeks postoperatively. We did not encounter any complications related to HAL-SJ.

Conclusions: In conclusion, use of the HAL-SJ during rehabilitation in the early postoperative period after TKA was safe without disadvantages compared to the control group and seems to have advantages in terms of daily life impairment.
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http://dx.doi.org/10.1007/s00402-021-04245-9DOI Listing
November 2021

Rehabilitation of Acute Vs. Chronic Patients With Spinal Cord Injury With a Neurologically Controlled Hybrid Assistive Limb Exoskeleton: Is There a Difference in Outcome?

Front Neurorobot 2021 27;15:728327. Epub 2021 Oct 27.

Department of Spinal Cord Injuries, BG University Hospital Bergmannsheil, Bochum, Germany.

This study aimed to assess the outcome of acute and chronic participants with spinal cord injury (SCI) after 12 weeks of bodyweight supported treadmill training (BWSTT) with a hybrid assistive limb exoskeleton (HAL). Acute participants were defined as ≤12 months between SCI and training, chronic participants >12 months between SCI and training. We assessed whether HAL-assisted BWSTT is advantageous for acute and chronic participants and if length of time post injury impacts the outcome of HAL-assisted BWSTT. As the primary outcome, we assessed the time needed for the 10 meter walk test (10MWT). Hundred and twenty-one individuals participated in a 12-week HAL-assisted BWSTT five times a week. We regularly conducted a 10MWT, a 6 minute walk test (6MWT), and assessed the walking index for spinal cord injury (WISCI II) and lower extremity motor score (LEMS) to evaluate the gait performance without the exoskeleton. Distance and time were recorded by the treadmill while the participant was walking with the exoskeleton. All participants benefit from the 12-week HAL-assisted BWSTT. A significant difference between acute and chronic participants' outcomes was found in 6MWT, LEMS, and WISCI II, though not in 10MWT. Although chronic participants improved significantly lesser than acute participants, they did improve their outcome significantly compared to the beginning. Hybrid assistive limb-assisted BWSTT in the rehabilitation of patients with SCI is advantageous for both acute and chronic patients. We could not define a time related cut-off threshold following SCI for effectiveness of HAL-assisted BWSTT.
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http://dx.doi.org/10.3389/fnbot.2021.728327DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8578862PMC
October 2021

[Germany-wide, Web-based ParaReg Registry for Lifelong Monitoring of People with Spinal Cord Injury: Data Model, Ethico-legal Prerequisites and Technical Implementation].

Gesundheitswesen 2021 Nov 3;83(S 01):S18-S26. Epub 2021 Nov 3.

Zentrum für Tetra-/Paraplegie, Orthopädische Klinik Hessisch Lichtenau, Hessisch Lichtenau, Deutschland.

Objective: In Germany, treatment paths for patients with acute spinal cord injury (SCI) differ considerably depending on intrinsic, disease-specific and extrinsic factors. Which of these factors are associated with improved outcome with fewer subsequent complications and inpatient re-admissions is not clear. The German-wide, patient-centered, web-based ParaReg registry will be implemented to improve the long-term quality of patient care and the planning of treatment paths with increased cost-effectiveness.

Methods: In the 2017-18 conceptualization phase, the data model of the registry was developed in an iterative process of the ParaReg steering committee together with the extended DMGP board and patient representatives. In ParaReg, routine social and medical data as well as internationally established neurological, functional and participation scores will be documented. The assignment of a unique patient ID allows a lifelong, cross-center documentation of inpatient stays in one of the 27 SCI centers organized in the German-speaking Medical Society for SCI (DMGP). The ParaReg data protection concept and patient information/consent are based on the Open Source Registry for Rare Diseases (OSSE) which were extended by GDPR-relevant aspects.

Results: In the realization phase, which started in 2019, the information technology infrastructure was implemented according to the clinical ID management module of the Technology and Methods Platform for Networked Medical Research (TMF). In parallel, the legal and ethical prerequisites for registry operation under the patronage of the DMGP were created. Recommendations of the working group data protection of the TMF were integrated into ParaReg's data protection concept. Based on the feedback from the alpha test phase with documentation of the hospitalization data of 40 patients, the ergonomics of the electronic case report forms were improved in particular for data entry on mobile devices.

Conclusion: After completion of the monocentric alpha test phase, the multicenter data acquisition was started in 5 DMGP-SCI centers. The sustainability of ParaReg is ensured by the structural and financial support of the DMGP after expiry of the funding by the German Federal Ministry of Education and Research (BMBF).
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http://dx.doi.org/10.1055/a-1538-6537DOI Listing
November 2021

Fecal diversion does not support healing of anus-near pressure ulcers in patients with spinal cord injury-results of a retrospective cohort study.

Spinal Cord 2021 Oct 7. Epub 2021 Oct 7.

Gastroenterology and Hepatology, Berufsgenossenschaftliche Universitätsklinik Bergmannsheil Bochum gGmbH, Bochum, Germany.

Study Design: Retrospective cohort study including spinal cord injured patients with anus-near pressure ulcers.

Objective: The primary objective was to evaluate the impact of stool diversion via stoma on the decubital wound healing. Secondary objectives included the risk of complications and ulcer recurrence. Associations between the wound healing and potentially interfering parameters were determined.

Setting: University hospital with a spinal cord injury unit.

Methods: A total of 463 consecutive patients who presented with a decubitus were retrospectively included. Patients with and without a stoma were compared using descriptive and explorative statistics including multiple regression analysis.

Results: The severity of the pressure ulcers was determined as stage 3 in two-thirds and stage 4 in one-third of all cases. The wound healing lasted longer in the 71 stoma-presenting patients than in the 392 patients with undeviated defecation (77 vs. 59 days, p = 0.02). The age (regression coefficient b = 0.41, p = 0.02), the ASA classification (b = 16.04, p = 0.001) and the stage of the ulcers (b = 19.65, p = 0.001) were associated with prolonged ulcer treatment in the univariate analysis. The multiple regression analysis revealed that the fecal diversion (b = -18.19, p = 0.03) and the stage of the ulcers (b = 21.62, p = 0.001) were the only predictors of delayed wound healing.

Conclusion: The presence of a stoma is not related to improved wound healing of ulcers near the anus. On the contrary, stoma patients needed more time until complete wound healing, conceivably related to selection bias. Nonetheless, we currently do not recommend fecal diversion to be the standard concept for decubitus treatment.
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http://dx.doi.org/10.1038/s41393-021-00717-2DOI Listing
October 2021

Improved Physiological Gait in Acute and Chronic SCI Patients After Training With Wearable Cyborg Hybrid Assistive Limb.

Front Neurorobot 2021 26;15:723206. Epub 2021 Aug 26.

Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany.

In recent years robotic devices became part of rehabilitation offers for patients suffering from Spinal Cord Injury (SCI) and other diseases. Most scientific publications about such devices focus on functional outcome. The aim of this study was to verify whether an improvement in physiological gait can be demonstrated in addition to the functional parameters after treatment with neurological controlled HAL® Robot Suit. Fifteen subjects with acute (<12 months since injury, = 5) or chronic (>12 months since injury, = 10) incomplete paraplegia (AIS B, = 0/AIS C, = 2/AIS D, = 8) or complete paraplegia (AIS A, = 5) with zones of partial preservation participated. Subjects underwent a body weight supported treadmill training for five times a week over 12 weeks using HAL®. At baseline and at the end of the study a gait analysis was performed and additional functional parameters such as 10-Meter-Walk-Test, Timed-Up-and-Go-Test, 6-Minutes-Walk-Test, and WISCI II score were collected. Results were evaluated for whole group and individually for acute and chronic subgroups. All functional parameters improved. Differences were also found in physiological parameters such as phases of gait cycle and accompanied by significant improvement in all spatiotemporal and gait phase parameters. The presented study shows signs that an improvement in physiological gait can be achieved in addition to improved functional parameters in patients with SCI after completing 12-week training with HAL®. DRKS, DRKS00020805. Registered 12 February 2020-Retrospectively registered, https://www.drks.de/DRKS00020805.
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http://dx.doi.org/10.3389/fnbot.2021.723206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8426634PMC
August 2021

Influence of Locomotion Therapy With the Wearable Cyborg HAL on Bladder and Bowel Function in Acute and Chronic SCI Patients.

Global Spine J 2021 Apr 16:21925682211003851. Epub 2021 Apr 16.

Department of Spinal Cord Injuries, BG University Hospital Bergmannsheil, Bochum, Germany.

Study Design: Retrospective survey.

Objectives: Purpose of this study was to explore whether bowel and bladder management can be influenced by locomotion therapy with HAL Robot Suit.

Methods: 35 subjects with acute (< one year since injury, n = 13) or chronic (> one year since injury, n = 22) incomplete paraplegia (American Spinal Injury Association Impairment Scale (AIS) B, n = 1 / AIS C, n = 22 / AIS D, n = 7) or complete paraplegia (AIS A, n = 5) with zones of partial preservation (ZPP) participated. A retrospective survey was carried out asking for bowel incontinence (Wexner Score), constipation (Cleveland Clinic Constipation Scoring System (CCCS)) and bladder function (self-developed questionnaire) before and after completing a training period of 12 weeks with HAL.

Results: Wexner Score over all patients and for group of chronic patients decreased significantly. For group of acute patients Wexner Score decreased insignificantly. Patients from both groups with higher baseline scores could decrease significantly. CCCS was insignificantly reduced for all patients, group of acute and group of chronic patients. For subgroup of chronic patients with higher baseline scores, CCCS decreased at end of training period missing out significance. The self-developed questionnaire showed an improvement in bladder function in 28.24% of all patients, 31.43% of chronic patients, and 23.08% of acute patients.

Conclusions: Our findings show trends of enhanced bladder and bowel function following exoskeleton training. Patients with higher baseline scores in Wexner Score and CCCS seem to benefit more than those with mild to moderate scores.
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http://dx.doi.org/10.1177/21925682211003851DOI Listing
April 2021

Factors Associated With Major Complications and Mortality During Hospitalization in Patients With Ankylosing Spondylitis Undergoing Surgical Management for a Spine Fracture.

Global Spine J 2021 Jan 12:2192568220980702. Epub 2021 Jan 12.

Department of General and Trauma Surgery, 39060BG University Hospital Bergmannsheil, Bochum, Germany.

Study Design: Retrospective study.

Objectives: To analyze factors associated with major complications (MC) in patients with ankylosing spondylitis (AS) undergoing surgical management for a spine fracture.

Methods: Included were all persons with spine fractures and AS in a teriary health care center between 2003 and 2019. Clinical data and MC were characterized with descriptive characteristics. Multivariable analyses were used to find factors associated with MC.

Results: In total, 174 traumatic fracture incidents in 166 patients with AS were included, with a mean patient age of 70.7 ± 13.1 years. The main reason for spine fracture was minor trauma (79.9%). Spinal cord injuries (SCI) were described in 36.7% of cases. The majority of patients (54.6%) showed more than one fracture of the spine, with cervical fractures being the most common (50.5%). Overall, the incidences of surgical site infection, implant failure, nosocomial pneumonia (NP), and mortality were 17.2%, 9.2%, 31%, and 14.9%, respectively. ICU stay > 48 hours was associated with MC (including death). Posterior approach for spondylodesis, ICU stay > 48 hours and cervical SCI were related to MC (excluding death). Age > 70 years, NP and Charlson comorbidity index > 5 points were associated with in-hospital mortality.

Conclusions: Patients with AS and surgical treatment of spine fractures are at high risk for MC. Therefore, our results might give physicians better insight into the incidence and sequelae of major complications and therefore might improve patient and family expectations.
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http://dx.doi.org/10.1177/2192568220980702DOI Listing
January 2021

Spinal Cord Injury With Tetraplegia in Young Persons After Diving Into Shallow Water: What Has Changed in the Past 10 to 15 Years?

Global Spine J 2021 Oct 10;11(8):1238-1247. Epub 2020 Sep 10.

Department of General and Trauma Surgery, 39060BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany.

Study Design: Retrospective, monocentric, observational study in a tertiary health care center.

Objectives: To analyze prehospital and clinical findings, complications, neurological improvement and follow-up in a young person cohort with spinal cord injury (SCI) and tetraplegia according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS) A to D after diving into shallow water.

Methods: Included were all persons younger than 50 years with SCI after head-first diving into shallow water between June 2001 and June 2019. All persons with SCI were divided into complete tetraplegia (AIS A) and incomplete tetraplegia (AIS B, C, and D) to test differences.

Results: A total of 59 males (98.7%) and 1 female with a mean age of 27.7 years suffered an SCI. Alcohol use was documented in 25 cases (41.7%). At the time of admission, 33 people (55%) showed a complete tetraplegia (AIS A) and 27 showed an incomplete tetraplegia with 8 AIS B (13.3%), 15 AIS C (25%), and 4 AIS D (6.7%). At the time of discharge, people with initially complete tetraplegia showed a significant improvement from admission to discharge ( ≤ .004). Persons with incomplete tetraplegia were more likely to improve their neurological status compared with complete tetraplegia patients ( ≤ .001). Especially persons with complete tetraplegia suffered from typical SCI-related problems and complications.

Conclusions: People with SCI and tetraplegia at the time admission show neurological improvement in 50% of the cases with an overall better outcome in persons with incomplete tetraplegia. The surgical treatment of SCI within 24 hours seems to be associated with a better neurological outcome and a lower level of tetraplegia. The incidence of SCI caused by diving into shallow water remains stable without a significant change, especially in high-risk groups. More education and prevention programs are necessary to avoid these injuries.
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http://dx.doi.org/10.1177/2192568220944124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8453686PMC
October 2021

Clinical and Radiological Outcomes After Surgical Treatment of Lower Limb Fractures in Patients With Spinal Cord Injury.

Global Spine J 2020 Sep 19;10(6):715-719. Epub 2019 Aug 19.

BG-University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany.

Study Design: Retrospective observational study.

Objectives: To analyze the clinical and radiological outcomes of lower limb fractures following surgical treatment in patients with chronic spinal cord injury (SCI).

Methods: Between January 2003 and December 2015, 102 chronic SCI patients with a lower limb fracture were surgically treated at our hospital. A total of 58 patients met the inclusion criteria and were recruited for final analysis. Patients with 2-stage procedure or incomplete clinical records with lost-to-follow-up were excluded from the study. Patients were divided into 2 groups (group 1= internal fixation; group 2 = external fixation). Primary outcome measures were to identify the number of nonunions via Kaplan-Meier analysis and the time to bone consolidation. The diagnosis of a pseudarthrosis was made after more than 180 days of consolidation time. Considering the Kaplan-Meier analysis, pseudarthrosis was interpreted as treatment failure. Secondary outcome measure was to evaluate the complication rate with special focus on heterotopic ossification.

Results: A total of 58 chronic SCI patients with closed bone fractures were included in this study. Fifty-two fractures (88%) were simple and 7 (12%) were complex (type C) fractures according to AO classification. The majority of patients (34 cases, 59%) developed femur fractures followed by 24 tibial fractures (41%). Seventeen patients received an external (29%) and 41 an internal fixation (71%). Bone consolidation was reported in 31 patients (53%) with a mean time interval of bone consolidation after 97 days (range from 45 to 160 days; SD = 30). The reported nonunion (pseudarthrosis) rate was 47%. Comparing the internal group (n = 15 patients) versus the external group (n = 14), we could not find any significant difference ( = .939) concerning the bone consolidation time. The Kaplan-Meier analysis showed a 75% cumulative survivorship at 120 days (internal group) versus 111 days (external group). Most common postoperative complications occurred in the internal fixation group with Wound infections being predominantly observed (10%), followed by heterotopic ossifications (8%).

Conclusions: Our results show that surgical treatment of lower limb fractures in chronic SCI patients is a challenging treatment with a high pseudarthrosis rate in both groups. The complication rate seems to be lower in the patients treated with external fixation. As a clinical recommendation, longer implants should be used for a stable osteosynthesis since SCI patients seem to have a higher load on the osteosynthesis material due to missing sensomotoric feedback.
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http://dx.doi.org/10.1177/2192568219871019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383793PMC
September 2020

Similar Adenoma Detection Rates in Colonoscopic Procedures of Patients with Spinal Cord Injury Compared to Controls.

Dig Dis Sci 2020 04 29;65(4):1197-1205. Epub 2019 Aug 29.

Department of Gastroenterology and Hepatology, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany.

Background: Cancer is a major cause of death in patients with spinal cord injury (SCI). Preventive strategies, such as colonoscopy, deal with higher burdens that may lead to lower quality.

Aims: The primary objective was to evaluate the adenoma detection rate. Secondary objectives were to investigate other quality indicators regarding bowel preparation, sedation, and endoscopy.

Methods: Consecutive SCI patients who had undergone colonoscopy from 2003 to 2014 were assigned to a control group matched for age, gender, and year of procedure and reviewed retrospectively.

Results: Bowel preparation lasted longer (3.6 ± 1.5 vs. 1.2 ± 0.6 days, p = 0.001), achieved unsatisfactory cleansing results more often (23.7 vs. 3.6%) and caused more adverse events in 236 SCI compared to 414 control patients. Colonoscopy needed a longer time (36.9 vs. 25.0 min) and remained incomplete more often (24.6 vs. 4.6%), resulting in more re-colonoscopies (14.8 vs. 4.3%). Endoscopy- and sedation-related adverse events were equal. However, neither overall nor size-dependent polyp (30.9 vs. 34.8%), adenoma (21.2 vs. 21.0%), advanced adenoma (6.8 vs. 7.2%), or cancer (1.7 vs. 2.0%) detection rates differed.

Conclusion: Despite intensified protocols, bowel preparation shows inferior results in SCI patients; colonoscopy needs more effort to succeed but achieves a comparable quality.
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http://dx.doi.org/10.1007/s10620-019-05814-0DOI Listing
April 2020

Incidence and complications of cannula changes in long-term tracheotomized patients: a prospective observational study.

Spinal Cord 2020 Jan 16;58(1):11-17. Epub 2019 Jul 16.

Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany.

Study Design: Prospective, monocentric observational study.

Objective: Investigation of incidence and complication rate of cannula changes in long-term tracheotomized patients suffering spinal cord injury.

Setting: University hospital in Bochum, Germany.

Methods: Prospective data collection of all cannula changes between September 2016 and September 2017. Physicians recorded mechanical complications and techniques to solve them, and/or complications resulting in patient-threatening condition.

Results: There were 149 cannula changes during 3191 observation days. Overall, urgent cannula changes occurred 2.1 times per 100 observation days. Within the first 8 weeks after tracheostomy, urgent cannula changes were necessary four times per 100 observation days, and were mandatory less than two times per 100 observation days thereafter. Overall, mechanical complications occurred in 12% of cannula changes, and 8% of cannula changes were accompanied by patient-threatening complications. Accidental decannulation (AD) occurred in 0.97 of 100 observation days. Recannulation after AD was accompanied by 29% of mechanical complications during reinsertion, and 16% led to patient-threatening complications. The major risk factors for mechanical complications were the time lag between cannula change and tracheostomy, and the urgency of the procedure while the thyroid cartilage-jugular distance was significantly associated with patient-threatening complications.

Conclusion: AD and the requirement for urgent cannula changes are common and often related with mechanical and patient-threatening complications. Even weeks after tracheostomy, caregivers need to be aware of serious events, and therefore provide monitoring, knowledge, and appropriate resources to handle these events.
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http://dx.doi.org/10.1038/s41393-019-0329-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223970PMC
January 2020

A Randomized and Controlled Crossover Study Investigating the Improvement of Walking and Posture Functions in Chronic Stroke Patients Using HAL Exoskeleton - The HALESTRO Study (HAL-Exoskeleton STROke Study).

Front Neurosci 2019 29;13:259. Epub 2019 Mar 29.

Department of Neurology, BG University Hospital Bergmannsheil Bochum, Bochum, Germany.

The exoskeleton HAL (hybrid assistive limb) has proven to improve walking functions in spinal cord injury and chronic stroke patients when using it for body-weight supported treadmill training (BWSTT). Compared with other robotic devices, it offers the possibility to initiate movements actively. Previous studies on stroke patients did not compare HAL-BWSTT with conventional physiotherapy (CPT). Therefore, we performed a crossover clinical trial comparing CPT and HAL-BWSTT in chronic stroke patients with hemiparesis, the HALESTRO study. Our hypothesis was that HAL-training would have greater effects on walking and posture functions compared to a mixed-approach CPT. A total of 18 chronic stroke patients participated in this study. Treatment consisted of 30 CPT sessions and of 30 sessions of BWSTT with a double leg type HAL exoskeleton successively in a randomized, crossover study design. Primary outcome parameters were walking time and speed in 10-meter walk test (10MWT), time in timed-up-and-go test (TUG) and distance in 6-min walk test (6MWT). Secondary outcome parameters were the functional ambulatory categories (FAC) and the Berg-Balance Scale (BBS). Data were assessed at baseline, at crossover and at the end of the study, all without using and wearing HAL. Our study demonstrate neither a significant difference in walking parameters nor in functional and balance parameters. When HAL-BWSTT was applied to naïve patients, it led to an improvement in walking parameters and in balance abilities. Pooling all data, we could show a significant effect in 10MWT, 6MWT, FAC and BBS, both therapies sequentially applied over 12 weeks. Thereby, FAC improve from dependent to independent category (3 to 4). One patient dropped out of the study due to intensive fatigue after each training session. HAL-BWSTT and mixed-approach CPT were effective therapies in chronic stroke patients. However, compared with CPT, HAL training with 30 sessions over 6 weeks was not more effective. The combination of both therapies led to an improvement of walking and balance functions. Robotic rehabilitation of walking disorders alone still lacks the proof of superiority in chronic stroke. Robotic treatment therapies and classical CPT rehabilitation concepts should be applied in an individualized therapy program.
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http://dx.doi.org/10.3389/fnins.2019.00259DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6450263PMC
March 2019

Outcome of subtrochanteric femur resection in patients with spinal cord injuries.

J Wound Care 2018 11;27(11):774-778

Department of Spinal Cord Injury, BG-University Hospital Bergmannsheil, Ruhr-University, Bochum, Bochum, Germany.

Objective: To analyse the clinical outcome of subtrochanteric femur resection in patients with infected hip joints caused by pressure ulcers (PUs) in patients following spinal cord injury (SCI).

Method: A retrospective cohort study, carried out between January 2004 and December 2015. Only patients receiving a subtrochanteric femur resection were included. SCI patients were treated for a hip joint infection caused by a PU. Primary outcome measures were to work out the revision rates and the rate of heterotopic ossification occurrence.

Results: At the time of admission, 37 out of the 56 participating patients (66.1%) showed a category IV PU with the ischium being most commonly affected (n=25, 44.6%). The subtrochanteric femur resection was combined either with a direct wound closure (n=29; 51.8%) or a myocutaneous flap (n=27; 48.2%). The mean number of surgeries was 2.6 (1-4; SD=1.6) and 21 patients were successfully treated by a single surgery. Of the patients, 28 had wound healing disorders (50%) and required a revision surgery, and 24 (42.9%) developed a postoperative heterotopic ossification.

Conclusion: Hip joint infection caused by PUs can be treated with subtrochanteric femur resection. However, the number of postoperative complications is still high
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http://dx.doi.org/10.12968/jowc.2018.27.11.774DOI Listing
November 2018

Successful non-surgical management of pleuroparenchymal fistula following cervical intraspinal empyema.

Monaldi Arch Chest Dis 2018 01 29;88(1):889. Epub 2018 Jan 29.

BG University Hospital Bergmannsheil, Department of General and Trauma Surgery.

Pulmonary infections are life-threatening complications in patients with spinal cord injuries. In particular, paraplegic patients are at risk if they are ventilator-dependent. This case history refers to a spinal cord injury with a complete sensorimotor tetraplegia below C2 caused by a septic scattering of an intraspinal empyema at C2-C5 and T3-T4. A right-sided purulent pneumonia led to a complex lung infection with the formation of a pleuroparenchymal fistula. The manuscript describes successful, considerate, non-surgical management with shortterm separate lung ventilation. Treatment aimed to achieve the best possible result without additional harm. A variety of surgical and conservative strategies for the treatment of pleuroparenchymal fistula (PPF) have been described with different degrees of success. We detail the non-surgical management of a persistent PPF with temporary separate lung ventilation (SLV) via a double-lumen tube (DLT) in combination with talc pleurodesis as an approach in patients who are unable to undergo surgical treatment.
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http://dx.doi.org/10.4081/monaldi.2018.889DOI Listing
January 2018

Functional Outcome of Neurologic-Controlled HAL-Exoskeletal Neurorehabilitation in Chronic Spinal Cord Injury: A Pilot With One Year Treatment and Variable Treatment Frequency.

Global Spine J 2017 Dec 7;7(8):735-743. Epub 2017 Jul 7.

BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany.

Study Design: Longitudinal prospective study.

Objectives: Whether 1-year HAL-BWSTT of chronic spinal cord injured patients can improve independent ambulated mobility further as a function of training frequency, after an initial 3-month training period.

Methods: Eight patients with chronic SCI were enrolled. They initially received full standard physical therapy and neurorehabilitation in the acute/subacute posttrauma phase. During this trial, all patients first underwent a daily (5 per week) HAL-BWSTT for 12 weeks. Subsequently, these patients performed a 40-week HAL-BWSTT with a training session frequency of either 1 or 3 to 5 sessions per week. The patients' functional status including HAL-associated treadmill-walking time, -distance, and -speed with additional analysis of gait pattern, and their independent (without wearing the robot suit) functional mobility improvements, were assessed using the 10-Meter-Walk Test (10MWT), Timed-Up-and-Go Test (TUG) and 6-Minute-Walk Test (6MinWT) on admission, at 6 weeks, 12 weeks, and 1 year after enrollment. The data were analyzed separately for the 2 training frequency subgroups after the initial 12-week training period, which was identical in both groups.

Results: During the 1-year follow-up, HAL-associated walking parameters and independent functional improvements were maintained in all the patients. This result held irrespective of the training frequency.

Conclusions: Long-term 1-year maintenance of HAL-associated treadmill walking parameters and of improved independent walking abilities after initial 12 weeks of daily HAL-BWSTT is possible and depends mainly on the patients' ambulatory status accomplished after initial training period. Subsequent regular weekly training, but not higher frequency training, seems to be sufficient to preserve the improvements accomplished.
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http://dx.doi.org/10.1177/2192568217713754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5722001PMC
December 2017

Hybrid Assistive Limb Exoskeleton HAL in the Rehabilitation of Chronic Spinal Cord Injury: Proof of Concept; the Results in 21 Patients.

World Neurosurg 2018 Feb 15;110:e73-e78. Epub 2017 Dec 15.

Department of Spinal Cord Injuries, BG University Hospital Bergmannsheil, Bochum, Germany.

Introduction: The use of mobile exoskeletons is becoming more and more common in the field of spinal cord injury (SCI) rehabilitation. The hybrid assistive limb (HAL) exoskeleton provides a tailored support depending on the patient's voluntary drive.

Materials And Methods: After a pilot study in 2014 that included 8 patients with chronic SCI, this study of 21 patients with chronic SCI serves as a proof of concept. It was conducted to provide further evidence regarding the efficacy of exoskeletal-based rehabilitation. Functional assessment included walking speed, distance, and time on a treadmill, with additional analysis of functional mobility using the following tests: 10-meter walk test (10MWT), timed up and go (TUG) test, 6-minute walk test (6MWT), and the walking index for SCI II (WISCI-II) score.

Results: After a training period of 90 days, all 21 patients significantly improved their functional and ambulatory mobility without the exoskeleton. Patients were assessed by the 6MWT, the TUG test, and the 10MWT, which also indicated an increase in the WISCI-II score along with significant improvements in HAL-associated walking speed, distance, and time.

Conclusion: Although, exoskeletons are not yet an established treatment in the rehabilitation of spinal cord injuries, the devices will play a more important role in the future. The HAL exoskeleton training enables effective, body weight-supported treadmill training and is capable of improving ambulatory mobility. Future controlled studies are required to enable a comparison of the new advances in the field of SCI rehabilitation with traditional over-ground training.
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http://dx.doi.org/10.1016/j.wneu.2017.10.080DOI Listing
February 2018

Treadmill Training with HAL Exoskeleton-A Novel Approach for Symptomatic Therapy in Patients with Limb-Girdle Muscular Dystrophy-Preliminary Study.

Front Neurosci 2017 8;11:449. Epub 2017 Aug 8.

Department of Neurology, BG-University Hospital Bergmannsheil Bochum, Ruhr University BochumBochum, Germany.

Exoskeletons have been developed for rehabilitation of patients with walking impairment due to neurological disorders. Recent studies have shown that the voluntary-driven exoskeleton HAL® (hybrid assistive limb) can improve walking functions in spinal cord injury and stroke. The aim of this study was to assess safety and effects on walking function of HAL® supported treadmill therapy in patients with limb-girdle muscular dystrophy (LGMD). Three LGMD patients received 8 weeks of treadmill training with HAL® 3 times a week. Outcome parameters were 10-meter walk test (10 MWT), 6-minute walk test, and timed-up-and-go test (TUG). Parameters were assessed pre and post training and 6 weeks later (follow-up). All patients completed the therapy without adverse reactions and reported about improvement in endurance. Improvements in outcome parameters after 8 weeks could be demonstrated. Persisting effects were observed after 6 weeks for the 10 MWT and TUG test (follow-up). HAL® treadmill training in LGMD patients can be performed safely and enables an intensive highly repetitive locomotor training. All patients benefitted from this innovative method. Upcoming controlled studies with larger cohorts should prove its effects in different types of LGMD and other myopathies.
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http://dx.doi.org/10.3389/fnins.2017.00449DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5550721PMC
August 2017

Against the odds: what to expect in rehabilitation of chronic spinal cord injury with a neurologically controlled Hybrid Assistive Limb exoskeleton. A subgroup analysis of 55 patients according to age and lesion level.

Neurosurg Focus 2017 May;42(5):E15

Spinal Cord Injuries Unit.

Objective Age and lesion level are believed to represent outcome predictors in rehabilitation of patients with chronic spinal cord injury (SCI). The Hybrid Assistive Limb (HAL) exoskeleton enables patients to perform a voluntary controlled gait pattern via an electromyography-triggered neuromuscular feedback system, and has been introduced as a temporary gait training tool in patients with SCI. The aim of this prospective pre- and postintervention study was to examine functional outcomes as a function of age and lesion level in patients with chronic incomplete SCI (iSCI) or chronic complete SCI (cSCI) with zones of partial preservation (ZPP) by using the HAL as a temporary training tool. Methods Fifty-five participants with chronic iSCI or cSCI (mean time since injury 6.85 ± 5.12 years) were classified according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS) and divided by age (< 50 or ≥ 50 years), independent of lesion level, and also into 4 homogeneous groups according to lesion level. The subgroups were as follows: Subgroup 1, tetraplegic iSCI (n = 13) (C2-8, AIS C [n = 8] and AIS D [n = 5]); Subgroup 2, paraplegic iSCI with spastic motor behavior (n = 15) (T2-12, AIS C [n = 8] and AIS D [n = 7]); Subgroup 3, paraplegic cSCI with complete motor paraplegia and absence of spastic motor behavior (n = 18) (T11-L4 [AIS A], and ZPP from L-3 to S-1); and Subgroup 4, paraplegic iSCI with absence of spastic motor behavior (n = 9) (T12-L3, AIS C [n = 8] and AIS D [n = 1]). The training paradigm consisted of 12 weeks of HAL-assisted treadmill training (5 times/week). Baseline status was documented prior to intervention by using the AIS grade, Walking Index for SCI II (WISCI II) score, the 10-meter walk test (10MWT), and the 6-minute walk test (6MinWT). Training effects were assessed after 6 and 12 weeks of therapy, without HAL assistance. Results Overall, a time reduction of 47% in the 10MWT, self-selected speed (10MWTsss) (< 50 years = 56% vs ≥ 50 years = 37%) and an increase of 50% in the 6MinWT were documented. The WISCI II scores showed a mean gain of 1.69 levels. At the end of the study, 24 of 55 patients (43.6%) were less dependent on walking aids. Age had a nonsignificant negative influence on the 10MWTsss. Despite a few nonsignificant subgroup differences, participants improved across all tests. Namely, patients with iSCI who had spastic motor behavior improved to a nonsignificant, lesser extent in the 6MinWT. Conclusions The HAL-assisted treadmill training leads to functional improvements in chronic iSCI or cSCI, both in and out of the exoskeleton. An improvement of approximately 50% in the 10MWTsss and in gait endurance (6MinWT) can be expected from such training. The influences of SCI lesion level and age on functional outcome were nonsignificant in the present study. Older age (≥ 50 years) may be associated with smaller improvements in the 10MWTsss. An iSCI in paraplegic patients with spastic motor behavior may be a nonsignificant negative predictor in gait endurance improvements. Clinical trial registration no.: DRKS00010250 ( https://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_DE.do ).
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http://dx.doi.org/10.3171/2017.2.FOCUS171DOI Listing
May 2017

Muscle localization of heterotopic ossification following spinal cord injury.

Spine J 2017 10 27;17(10):1519-1522. Epub 2017 Apr 27.

BG-University Hospital, Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany.

Background Context: Heterotopic ossification (HO) is a known complication especially in people with traumatic spinal cord injury (SCI). Although some risk factors have already been described, the pathophysiology of HO is still unknown. The pelvis is the most common region for HO occurrence. However, the prevalence of HO by muscle groups about the hip is not well described.

Purpose: To analyze the prevalence of early HO in muscle groups about the hip in 267 patients with SCI.

Patient Sample: 267 patients with traumatic SCI and pelvic HO.

Methods: Between January 2001 and December 2014, 267 patients with SCI were treated in our university hospital and were included in the study. Patients were routinely screened for HO using ultrasound. The diagnosis of HO was validated using magnetic resonance imaging (MRI) or computed tomography (CT). The primary outcome measure was the prevalence of HO by muscle groups around the hip. The following muscle groups around the hip were defined: (1) gluteal group, (2) adductor group, (3) iliopsoas group, and (4) deep muscle group. Additionally, the prevalence of concomitant trochanteric bursitis was recorded in all cases.

Results: The gluteal group showed the highest HO prevalence with 55.8%, followed by the deep muscle group with 31.1%. Concomitant trochanteric bursitis was found in 62 patients (23.2%). No association between pelvic trauma and HO development was observed (n=16, 11%).

Conclusions: The most common muscular location for the occurrence of HO about the hip was the gluteal muscle group. Considering that no laboratory parameters are currently available for screening for HO, highly sensitive ultrasound screening examinations should be routinely performed, with particular attention paid to the gluteal muscles. Additionally, routine range of motion examination for extension and external rotation of the hip joint is warranted.
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http://dx.doi.org/10.1016/j.spinee.2017.04.021DOI Listing
October 2017

Early percutaneous dilational tracheostomy does not lead to an increased risk of surgical site infection following anterior spinal surgery.

J Trauma Acute Care Surg 2017 02;82(2):383-386

From the Chirurgische Universitätsklinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bochum, Germany (C.K., M.F.H., E.Y., T.A.S., U.H.); and the Abteilung für Rückenmarksverletzte, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bochum, Germany (M.A.).

Background: Most patients with cervical spinal cord injuries require tracheostomy. The optimal timing is still a matter of debate. Previous studies showed that patients receiving early tracheostomy had fewer ventilator days and decreased rates of pneumonia and were mobilized earlier. Because of the proximity of the anterior approach to the tracheostoma, there is concern about an increased risk of surgical site infection (SSI) related to tracheostomy.

Methods: This was a retrospective analysis at a Level I trauma center of patient records from 2008 to 2014, identifying all patients with spinal cord injury who received anterior cervical spinal surgery and had early percutaneous dilational tracheostomy (PDT). Follow-up for SSI was performed throughout hospital stay (mean, 110 days; median, 96 days, with lower quartile 89 days and upper quartile 119 days) and at 6 weeks and 3 months (clinical examination and computed tomography scans).

Results: Fifty-one patients underwent anterior spinal surgery with PDT performed within a median of 5 days (range, 1-18 days). Seventy-eight percent (n = 40) of patients had anterior spinal surgery, whereas 22% (n = 11) had a combined anterior-posterior repair. All percutaneous dilational tracheostomies were performed using the Ciaglia single-step dilation technique. Despite an SSI of one patient's cannulation site, no SSI of the anterior approach was observed.

Conclusion: Performing a PDT in a timely fashion after anterior spinal surgery does not increase the risk of SSI.

Level Of Evidence: Therapeutic study, level V.
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http://dx.doi.org/10.1097/TA.0000000000001320DOI Listing
February 2017

The Effectiveness and Safety of Exoskeletons as Assistive and Rehabilitation Devices in the Treatment of Neurologic Gait Disorders in Patients with Spinal Cord Injury: A Systematic Review.

Global Spine J 2016 Dec 3;6(8):822-841. Epub 2016 Nov 3.

Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany.

 Systematic review.  (1) When used as an assistive device, do wearable exoskeletons improve lower extremity function or gait compared with knee-ankle-foot orthoses (KAFOs) in patients with complete or incomplete spinal cord injury? (2) When used as a rehabilitation device, do wearable exoskeletons improve lower extremity function or gait compared with other rehabilitation strategies in patients with complete or incomplete spinal cord injury? (3) When used as an assistive or rehabilitation device, are wearable exoskeletons safe compared with KAFO for assistance or other rehabilitation strategies for rehabilitation in patients with complete or incomplete spinal cord injury?  PubMed, Cochrane, and Embase databases and reference lists of key articles were searched from database inception to May 2, 2016, to identify studies evaluating the effectiveness of wearable exoskeletons used as assistive or rehabilitative devices in patients with incomplete or complete spinal cord injury.  No comparison studies were found evaluating exoskeletons as an assistive device. Nine comparison studies (11 publications) evaluated the use of exoskeletons as a rehabilitative device. The 10-meter walk test velocity and Spinal Cord Independence Measure scores showed no difference in change from baseline among patients undergoing exoskeleton training compared with various comparator therapies. The remaining primary outcome measures of 6-minute walk test distance and Walking Index for Spinal Cord Injury I and II and Functional Independence Measure-Locomotor scores showed mixed results, with some studies indicating no difference in change from baseline between exoskeleton training and comparator therapies, some indicating benefit of exoskeleton over comparator therapies, and some indicating benefit of comparator therapies over exoskeleton.  There is no data to compare locomotion assistance with exoskeleton versus conventional KAFOs. There is no consistent benefit from rehabilitation using an exoskeleton versus a variety of conventional methods in patients with chronic spinal cord injury. Trials comparing later-generation exoskeletons are needed.
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http://dx.doi.org/10.1055/s-0036-1593805DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5110426PMC
December 2016

Percutaneous Dilatational Tracheostomy in Ankylosing Spondylitis (Bechterew Disease) Is Feasible and Not Associated With Higher Complication Rates.

J Intensive Care Med 2018 Jul 16;33(7):420-423. Epub 2016 Nov 16.

1 Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany.

Background: Ankylosing spondylitis (AS) is a common disease with an incidence of approximately 0.5% in Europe, causing severe limitations of axial spine mobility and cervical kyphosis. Deformities of the cervical spine and the temporomandibular joints could increase the risk of complications while performing an intubation or tracheostomy. The percutaneous dilatational tracheostomy (PDT) is a standard procedure in intensive care medicine. However, the combination of cervical kyphosis and osteoporosis makes patient positioning challenging. Therefore, one could conclude that patients with AS are not candidates for PDT, but neither studies nor case reports yet reported about feasibility of this procedure in AS.

Methods: Retrospective analysis at a level 1 trauma center of patient records from 2002 to 2016, assessing all patients with AS and PDT.

Results: A total of 31 patients with AS have been subjected to PDT. All PDTs were performed using the modified Ciaglia single-step dilatational technique. Neither cardiopulmonary nor surgical complications occurred during the procedure. One patient received a change of the existing airway prior to the procedure; a small nasal tube was changed for a laryngeal mask.

Conclusion: Although head positioning may be challenging, PDT should be taken into consideration for patients with AS. In the hands of an experienced doctor, it is safe and feasible.
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http://dx.doi.org/10.1177/0885066616677959DOI Listing
July 2018

Extracorporeal lung support in patients with spinal cord injury: Single center experience.

J Spinal Cord Med 2017 03 9;40(2):188-192. Epub 2016 Mar 9.

a Department of Surgery.

Objective: Trauma-related spinal cord injury (SCI) leads to a loss of motor, sensory and vegetative functions and is disproportionately associated with respiratory complications. SCI has a significant impact on respiratory muscle function and can lead to respiratory dysfunction or severe lung failure.

Participants: Between 2008 and 2014, 7 patients with severe lung failure following SCI received veno-venous extracorporeal membrane oxygenation (ECMO) n = 5 and interventional lung assist (iLA) n = 2.

Results: The median duration of extracorporeal lung support was 8 (5.7-17.6) days. All 5 of the ECMO-supported patients were successfully weaned, and one of the two patients treated with iLA was weaned from the device. The median intensive care unit (ICU) stay was 35 (8.5-44.5) days. The mean hospital stay was 81 (8.5-120.7) days, and the average ventilation time was 817 (206-1,225) hours. Five (71.4%) of the 7 patients were discharged from the ICU and hospital.

Conclusions: In patients with SCI, serious complications include microatelectasis, infection, ventilation-perfusion mismatching and aspiration (special case: salt-water aspiration after jumping into shallow water). In patients with SCI with post-traumatic lung failure, ECMO is a feasible and life-saving procedure. After surviving spinal shock, a long rehabilitation period with intensive follow-up in specialized centers is required.
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http://dx.doi.org/10.1080/10790268.2016.1153859DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5430476PMC
March 2017

Heterotopic ossification mimicking infection in patients with traumatic spinal cord injury.

Technol Health Care 2016 ;24(1):87-91

Department of General and Trauma Surgery, Division of Spinal Cord Injury, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Bochum, Germany.

Background: Heterotopic ossification (HO) is a common concominant condition in patients with traumatic spinal cord injury (SCI). In this context, we report on patients with heterotopic ossification causing infection like symptoms as a first manifestation of HO subsequent to traumatic SCI.

Objective: The objective of the study was to analyse possible ``early-indicator symptoms'' in patients suffering from heterotopic ossification following SCI with special focus on elevated serum CRP, serum CK and body temperature.

Methods: All eligible patients treated between January 2004 and December 2013 because of a SCI and heterotopic ossification have been enrolled in this retrospective study. An age below 18 years and the absence of the combination of elevated serum CRP, CK and elevated body temperature (> 38.5 °C) were defined as exclusion criteria. The presence of another infection, led to exclusion. Fifteen out of 235 patients (6.4%) met the inclusion criteria and were included in the final data analysis.

Results: The patient cohort consists of 13 male and two female patients with a mean age of 30.6 years (range from 18 to 56 years; SD = 13.5). The mean time interval between HO development and the injury was 49.4 days (range from 16 to 131 days; SD = 34.3). Focussing on laboratory parameters, mean serum CRP level was 10.2 mg/dl (range from 1.3 to 24.4 mg/dl; SD = 9.6). Mean serum CK was 1365 U/l (range from 255 to 4729 U/l; SD = 1491). Worth mentioning, in 9 cases (60%) serum CK was higher than 500 U/l. Mean body temperature was 38.7 °C (range from 38.0 to 39.4; SD = 0.4). CT scans of the thorax, abdomen and pelvis revealed no further pathologies besides the heterotopic ossification. Urinary tract infections were ruled out, using urine tests as a standard procedure in all cases.

Conclusions: Elevated levels of serum CRP, serum CK and high body temperature in acute SCI may be considered as indicators for a concominant HO diagnosis.
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http://dx.doi.org/10.3233/THC-151070DOI Listing
January 2017

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

J Neuroeng Rehabil 2015 Aug 20;12:68. Epub 2015 Aug 20.

Department of Neurology, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany.

Background: 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.

Objective: 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.

Methods: 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.

Results: 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.

Conclusions: 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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http://dx.doi.org/10.1186/s12984-015-0058-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4545929PMC
August 2015

Patients with thoracic trauma and concomitant spinal cord injury have a markedly decreased mortality rate compared to patients without spinal cord injury.

Int Orthop 2016 Jan 23;40(1):155-9. Epub 2015 May 23.

Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany.

Introduction: The present study was performed to compare the clinical outcome, with special focus on the mortality rate of thoracic injuries, in patients with and without spinal cord injury.

Materials And Methods: Patients who were treated for thoracic trauma at our institution between January 1998 and December 2007 were included in this retrospective cohort study. Patients were divided into two groups according to whether they had suffered a concomitant spinal cord injury (SCI) (N = 54) or not (N = 61). Survival analysis was performed using the Kaplan-Meier function and the Cox proportional hazards model. Age, sex, injury severity score (ISS), Charlson comorbidity index (CCI), and infection with pneumonia were included as covariates in the final model.

Results: Patients with SCI have a 65 % reduction in the chance of dying compared to patients without SCI following thoracic trauma (HR = 0.35; 95%CI = 0.13-0.96; p = 0.041). Sex (HR = 0.67; 95 % CI: 0.26-1.71, P = 0.141), ISS > =25 (HR = 2.08 95 % CI: 0.58-7.49, P = 2.63) and a Charlson Comorbidity Index of 2 (HR = 1.82; 95 % CI: 0.58-7.22, P = 0.393) had no effect in the risk of dying. However, patients older than 60 years had four times the chance of dying than patients younger than 30 years (HR = 4.39; 95 % CI: 1.02-19, P = 0.048). Patients with pneumonia had a nonsignificant twofold increase in the risk of dying (HR = 2.28; 95 % CI: 0.97-5.34, P = 0.059).

Conclusions: Our results demonstrate that patients with thoracic trauma and concomitant SCI had markedly decreased mortality compared to patients without SCI, even after adjusting for age, sex, injury severity, comorbidities and pneumonia infection.
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http://dx.doi.org/10.1007/s00264-015-2798-3DOI Listing
January 2016

Complicated fecal microbiota transplantation in a tetraplegic patient with severe Clostridium difficile infection.

World J Gastroenterol 2015 Mar;21(12):3736-40

Thorsten Brechmann, Wolff Schmiegel, Jörg Willert, Department of Gastroenterology and Hepatology, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil GmbH, Ruhr-University Bochum, 44789 Bochum, Germany.

A 65-year-old male suffering from acute spinal cord injury leading to incomplete tetraplegia presented with severe recurrent Clostridium difficile (C. difficile) infection subsequent to antibiotic treatment for pneumonia. After a history of ineffective antimicrobial therapies, including metronidazole, vancomycin, fidaxomicin, rifaximin and tigecycline, leading to several relapses, the patient underwent colonoscopic fecal microbiota transplantation from his healthy son. Four days subsequent to the procedure, the patient showed a systemic inflammation response syndrome. Without detecting an infectious cause, the patient received antimicrobial treatment, including tigecycline, metronidazole, vancomycin via polyethylene glycol and an additional enema for a period of seven days, leading to a prompt recovery and no reported C. difficile infection relapse during a 12 wk follow up.
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http://dx.doi.org/10.3748/wjg.v21.i12.3736DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4375600PMC
March 2015

Impact of locomotion training with a neurologic controlled hybrid assistive limb (HAL) exoskeleton on neuropathic pain and health related quality of life (HRQoL) in chronic SCI: a case study (.).

Disabil Rehabil Assist Technol 2016 08 10;11(6):529-34. Epub 2014 Nov 10.

a Department of Spinal Cord Injuries .

Chronic neuropathic pain (CNP) is a common condition associated with spinal cord injury (SCI) and has been reported to be severe, disabling and often treatment-resistant and therefore remains a clinical challenge for the attending physicians. The treatment usually includes pharmacological and/or nonpharmacological approaches. Body weight supported treadmill training (BWSTT) and locomotion training with driven gait orthosis (DGO) have evolved over the last decades and are now considered to be an established part in the rehabilitation of SCI patients. Conventional locomotion training goes along with improvements of the patients' walking abilities in particular speed and gait pattern. The neurologic controlled hybrid assistive limb (HAL®, Cyberdyne Inc., Ibraki, Japan) exoskeleton, however, is a new tailored approach to support motor functions synchronously to the patient's voluntary drive. This report presents two cases of severe chronic and therapy resistant neuropathic pain due to chronic SCI and demonstrates the beneficial effects of neurologic controlled exoskeletal intervention on pain severity and health-related quality of life (HRQoL). Both of these patients were engaged in a 12 weeks period of daily HAL®-supported locomotion training. In addition to improvements in motor functions and walking abilities, both show significant reduction in pain severity and improvements in all HRQoL domains. Although various causal factors likely contribute to abatement of CNP, the reported results occurred due to a new approach in the rehabilitation of chronic spinal cord injury patients. These findings suggest not only the feasibility of this new approach but in conclusion, demonstrate the effectiveness of neurologic controlled locomotion training in the long-term management of refractory neuropathic pain. Implications for Rehabilitation CNP remains a challenge in the rehabilitation of chronic SCI patients. Locomotion training with the HAL exoskeleton seems to improve CNP in chronic SCI. HAL locomotion training is feasible and safe in the rehabilitation of chronic SCI patients.
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http://dx.doi.org/10.3109/17483107.2014.981875DOI Listing
August 2016

Locomotion training using voluntary driven exoskeleton (HAL) in acute incomplete SCI.

Neurology 2014 Jul;83(5):474

From the Departments of Spinal Cord Injuries (O.C., M.A.), Neurology (M.T., P.S.), and General and Trauma Surgery (T.A.S.), BG University Hospital Bergmannsheil, Bochum, Germany.

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http://dx.doi.org/10.1212/WNL.0000000000000645DOI Listing
July 2014

Voluntary driven exoskeleton as a new tool for rehabilitation in chronic spinal cord injury: a pilot study.

Spine J 2014 Dec 4;14(12):2847-53. Epub 2014 Apr 4.

Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44797, Bochum, Germany.

Background Context: 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.

Purpose: To determine whether locomotor training with the exoskeleton HAL is safe and can increase functional mobility in chronic paraplegic patients after SCI.

Design: A single case experimental A-B (pre-post) design study by repeated assessments of the same patients. The subjects performed 90 days (five times per week) of HAL exoskeleton body weight supported treadmill training with variable gait speed and body weight support.

Patient Sample: Eight patients with chronic SCI classified by the American Spinal Injury Association (ASIA) Impairment Scale (AIS) consisting of ASIA A (zones of partial preservation [ZPP] L3-S1), n=4; ASIA B (with motor ZPP L3-S1), n=1; and ASIA C/D, n=3, who received full rehabilitation in the acute and subacute phases of SCI.

Outcome Measures: Functional measures included treadmill-associated walking distance, speed, and time, with additional analysis of functional improvements using the 10-m walk test (10MWT), timed-up and go test (TUG test), 6-minute walk test (6MWT), and the walking index for SCI II (WISCI II) score. Secondary physiologic measures including the AIS with the lower extremity motor score (LEMS), the spinal spasticity (Ashworth scale), and the lower extremity circumferences.

Methods: Subjects performed standardized functional testing before and after the 90 days of intervention.

Results: Highly significant improvements of HAL-associated walking time, distance, and speed were noticed. Furthermore, significant improvements have been especially shown in the functional abilities without the exoskeleton for over-ground walking obtained in the 6MWT, TUG test, and the 10MWT, including an increase in the WISCI II score of three patients. Muscle strength (LEMS) increased in all patients accompanied by a gain of the lower limb circumferences. A conversion in the AIS was ascertained in one patient (ASIA B to ASIA C). One patient reported a decrease of spinal spasticity.

Conclusions: Hybrid assistive limb exoskeleton training results in improved over-ground walking and leads to the assumption of a beneficial effect on ambulatory mobility. However, evaluation in larger clinical trials is required.
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http://dx.doi.org/10.1016/j.spinee.2014.03.042DOI Listing
December 2014
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