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

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

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)

Background: 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.Methods: 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.Results: 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.Conclusion: 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

Learning to control a BMI-driven wheelchair for people with severe tetraplegia

Mind-controlled wheelchairs are an intriguing assistive mobility solution applicable in complete paralysis. Despite technical progress in brain-machine interface (BMI) technology, its translation remains elusive. The primary objective of this study is to probe the hypothesis that BMI skill acquisition by end-users is fundamental to control a non-invasive brain-actuated intelligent wheelchair in real-world settings. Here, we show that three tetraplegic spinal cord injury users could be trained to operate a non-invasive, self-paced thought-controlled wheelchair and execute complex navigation tasks. However, only the two users exhibiting increasing decoding performance and feature discriminancy, as well as significant neuroplasticity changes and improved BMI command latency, achieved high navigation performance. Additionally, we show that dexterous, continuous control of robots is possible through low-degree of freedom, discrete and uncertain control channels like a motor imagery BMI, by blending human and artificial intelligence through shared-control methodologies. We posit that subject learning and shared-control are the key-components paving the way for translational non-invasive BMI

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

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 \textgreater12 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

Water exchange technique improves colonoscopy in patients with spinal cord injury – results of a matched cohort study.

Background and study aims Colonoscopies in patients with spinal cord injury (SCI) frequently remain incomplete. The study aimed to evaluate the feasibility and impact of water exchange colonoscopy (WE) in SCI patients. Methods Three matched groups, each of 31 patients (WE in SCI patients (WE-SCI) and in the general population (WE-GP), carbon dioxide-based colonoscopy in SCI patients (CO2-SCI)) were analysed retrospectively. Results The intubation of the caecum and the terminal ileum was achieved in every case in both WE groups; the intubations among the CO2-SCI succeeded in 29 (93.5 %, ns) and 20 cases (64.5 %, p < .001), respectively. The caecal insertion time (23:17 ± 10:17 min vs. 22:12 ± 16:48 min) and the bowel preparation during caecal insertion did not differ between both SCI groups; the insertion in the general population was faster (13:38 ± 07:00 min, p < .01) and the cleanliness was better. Both WE groups equally showed significantly better cleansing results during drawback; the improvement of cleanliness was highest in the WE-SCI (based on the five-step scale 1.4 ± 0.8 vs. 0.8 ± 0.8, p = .001). Conclusion The WE in SCI patients is feasible and safe and has the potential to improve the quality of colonoscopies substantially

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

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

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

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

Fecal diversion does not support healing of anus-near pressure ulcers in patients with spinal cord injury

$\textbf {Study Design:}$ Retrospective cohort study including spinal cord injured patients with anus-near pressure ulcers. $\bf Objective:$ 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. $\bf Setting:$ University hospital with a spinal cord injury unit. $\bf Methods:$ 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. $\bf Results:$ 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, $\it p$ = 0.02). The age (regression coefficient $\it b$ = 0.41, $\it p$ = 0.02), the ASA classification ($\it b$ = 16.04, $\it p$ = 0.001) and the stage of the ulcers ($\it b$ = 19.65, $\it p$ = 0.001) were associated with prolonged ulcer treatment in the univariate analysis. The multiple regression analysis revealed that the fecal diversion ($\it b$ = −18.19, $\it p$ = 0.03) and the stage of the ulcers ($\it b$ = 21.62, $\it p$ = 0.001) were the only predictors of delayed wound healing. $\bf Conclusion:$ 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

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

Purpose: 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).Materials and Methods: 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).Results: 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).Conclusions: 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