# HAL Training in Spinal Cord Injured Patients: A Narrative Review of 10 Years Experience
## 3 Results
### Single-Case or Two-Case Reports
The authors note that this is probably due to the very high expectations for the novel therapy, which is an extremely interesting point that has not been mentioned in previous studies. In the other patients of the collective, there was no noteworthy improvement in QOL despite good mobility improvements, which suggests that QOL is determined by more diverse factors [25]. This result contrasts with that of [PERSON] et al. [21], whose two patients improved in health related QOL, but is confirmed by the study of [PERSON] et al. [19]. HAL training was completed as a contiguous training phase in most studies. [PERSON] et al. [2], however, chose an alternating design of conventional gait training (A) and HAL training (B) in their single-case study of a patient with chronic thoracic SCI. A similar protocol has already been practiced in stroke patients. The patient completed a total 25-week program with a switch from conventional gait training to HAL training every 5 weeks. In total, 15 weeks of conventional gait training and 10 weeks of HAL (A1-B1-A2-B2-A3) were performed, with three sessions per week. Accompanying physiotherapy took place permanently. Global parameters such as 2-min-walk-test, WISCI II, and BBS improved from the beginning to 25 weeks while spasticity did not. Walking speed, stride length, and cadence improved after phase A but not B [2]. During phase B a decrease in speed was seen, which could, according to the authors, reflect fatigue and changes in lower limb spasticity after using HAL. However, the alternating training program is considered potentially successful, although it remains unclear which phases have which share in the overall result. As in [PERSON] et al. [25] a two-case study by [PERSON] et al. [26] included patients after spinal cord infarction. Both patients were in a very early acute phase (14 and 7 days after infarction) at the start of training. In addition to conventional physical therapy, they received 7-8 HAL sessions 3-4 times per week. Improvements in LEMS, WISCI II, comfortable gait speed, stride, cadence, BI, FIM, and further assessments were observed in both study participants [26]. Therefore, the authors state that gait treatment using HAL in people with acute spinal cord infarction is possible and may be beneficial. [PERSON] et al. [27] presents in their study a severely affected case with a patient who was diagnosed with cervical spondylic myelopathy, underwent surgery, and was rediagnosed with traumatic cervical SCI (incomplete tetraplegic, AIS C) after a fall. He received HAL training 2-3 times per week for 13 sessions and additional physical therapy. Improvements were observed in gait speed, step length, and cadence based on a 10 MWT, ISNCSCI motor score, and WISCI II score [27]. The authors state, as [PERSON] et al. [15] did before, that in other studies, such as that of [PERSON] et al. [9], only patients who were already able to perform high-performance testing at baseline, such as the 6 MWT, participated and it can be seen from their results that even severely affected patients benefit from HAL training. However, it must be noted that also in the mentioned [PERSON] et al. [9] study only three out of eight patients were able to perform the 6 MWT at baseline. After the training, all eight were able to do so. Regardless of this, a notable improvement of a severely affected patient is reported here, who, beyond the functional tests, also showed kinematic improvements, e.g., in hip extension, which is consistent with the results of [PERSON] et al. [17]. Table 2 summarizes single-case or two-case reports studies details and results.