Morris et al.

Journal of NeuroEngineering
Journal of NeuroEngineering and Rehabilitation (2023) 20:18
https://doi.org/10.1186/s12984-022-01122-3 and Rehabilitation

REVIEW Open Access

The‑state‑of‑the‑art of soft robotics

to assist mobility: a review of physiotherapist
and patient identified limitations of current
lower‑limb exoskeletons and the potential
soft‑robotic solutions
Leah Morris1,2* , Richard S. Diteesawat2,3, Nahian Rahman2,3, Ailie Turton1, Mary Cramp1 and
Jonathan Rossiter2,3

Abstract
Background Soft, wearable, powered exoskeletons are novel devices that may assist rehabilitation, allowing users to
walk further or carry out activities of daily living. However, soft robotic exoskeletons, and the more commonly used
rigid exoskeletons, are not widely adopted clinically. The available evidence highlights a disconnect between the
needs of exoskeleton users and the engineers designing devices. This review aimed to explore the literature on physi-
otherapist and patient perspectives of the longer-standing, and therefore greater evidenced, rigid exoskeleton limita-
tions. It then offered potential solutions to these limitations, including soft robotics, from an engineering standpoint.
Methods A state-of-the-art review was carried out which included both qualitative and quantitative research papers
regarding patient and/or physiotherapist perspectives of rigid exoskeletons. Papers were themed and themes formed
the review’s framework.
Results Six main themes regarding the limitations of soft exoskeletons were important to physiotherapists and
patients: safety; a one-size-fits approach; ease of device use; weight and placement of device; cost of device; and,
specific to patients only, appearance of the device. Potential soft-robotics solutions to address these limitations
were offered, including compliant actuators, sensors, suit attachments fitting to user’s body, and the use of control
algorithms.
Conclusions It is evident that current exoskeletons are not meeting the needs of their users. Solutions to the limita-
tions offered may inform device development. However, the solutions are not infallible and thus further research and
development is required.
Keywords Mobility, Rehabilitation, Patient, Therapist, Exoskeleton, Assistive device, Soft robotics

*Correspondence: Introduction
Leah Morris In the UK, 6.8 million people live with mobility-related
[email protected]
1
Centre for Health and Clinical Research, University of the West disabilities; the leading causes of which are muscu-
of England, Bristol, UK loskeletal conditions and stroke [1, 2]. Persons with
2
Bristol Robotics Laboratory, Bristol, UK stroke are living longer due to reductions in risk factors
3
Department of Engineering Mathematics, University of Bristol, Bristol, UK
and improvements of treatments [2]. The population

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Morris et al. Journal of NeuroEngineering and Rehabilitation (2023) 20:18 Page 2 of 15

overall is also aging; the number of people living over development [12, 25]. Although not identical, their prin-
85 is expected to increase from 1.8 million in 2018 to 3 ciples and designs are similar, consisting of an external
million by 2043 [3]. Musculoskeletal impairments are actuator(s) fitted in parallel with weak or paralysed lower
associated with older age, therefore both those with mus- limbs to assist with mobilising and activities of daily liv-
culoskeletal impairments and stroke survivors are living ing [26].
longer with disabilities that require assistance [2, 4]. Many of these existing rigid exoskeletons were ini-
Impaired mobility can have widespread effects on an tially developed to provide maximal assistance to those
individual’s quality of life as participation challenges with complete paralysis resulting from spinal cord injury.
impact their work, social life and activities of daily liv- Interest has increased in the exoskeletons that can pro-
ing (ADLs) [5]. Mobility impairments are also a risk fac- vide sensory-guided motorised lower limb assistance for
tor for falls which reduce an individual’s confidence and person’s with stroke [27, 28]. These devices provide par-
self-belief in their own mobility, and can lead to activity tial assistance during mobility tasks, allowing persons
avoidance, social isolation and depression, which in turn with stroke to actively participate through practising pos-
increases frailty and the ‘fear of falling’ cycle [6–8]. Thus, tural control and locomotion patterns [12]. A systematic
the paramount goal for physiotherapy rehabilitation is review with a meta-analysis demonstrated that rigid exo-
to ensure the continued mobility of individuals, with skeletons are safe, with no reported adverse events, with
evidence demonstrating that, for neurological patients, falls only reported in a study using an early prototype [26,
repetitive movements are crucial to re-learn motor func- 29]. Further, rigid exoskeletons have widespread benefits
tions [9]. This is not without its challenges; in the UK, including increased walking time, number of steps and
persons with stroke typically receive only 35 minutes of improved strength and postural control in stroke survi-
inpatient physiotherapy per day, despite the guidance of vors [30]. Studies have only recently explored patients
45 minutes minimum [10, 11]. Increasing rehabilitation and physiotherapists’ perspectives of the use of exoskel-
time may not be achievable as traditional rehabilitation etons [18, 25, 31]. A key advantage of existing rigid exo-
frequently requires body weight support of the patient, skeletons was their ability to reduce the physical strain
which can be physically demanding for the physiothera- on therapists, therefore fewer members of staff would be
pist who may require assistance from others [12, 13]. needed to assist a patient, increasing the service’s capac-
Consequently, therapist fatigue and staffing capacity ity [18, 31]. The ways in which exoskeletons may have
limits what a patient is able to achieve in a session [13]. psychosocial benefit to individuals was also highlighted,
Assistive devices such as walkers are commonly provided including the potential improvement to a patient’s confi-
to patients with mobility impairments [14]. These devices dence and feeling of independence [18, 31].
fall under the umbrella of ’assistive technology’, which Despite these proposed advantages, rigid exoskeletons
describes products or systems that assist individuals with have not been widely adopted clinically [32]. Although a
disabilities, restricted mobility or other impairments to systematic literature review on user perspective of rigid
perform functions that might otherwise be impossible or exoskeletons has been undertaken previously by Hill
challenging [15]. Although assistive devices can improve et al. [33], the review only included three papers which
rehabilitation of muscle and neural processing, they have had limited reporting of qualitative data and their meth-
limitations that prevent individuals from carrying out ods were predominantly quantitative components [29,
their ADLs as normal [14]. Reported challenges include 34, 35]. The review was inconclusive on user perspectives
opening of doors or getting on to public transport when of rigid exoskeletons due to the minimal amount of evi-
using four-wheeled walkers, and issues carrying items, dence that has been undertaken; nevertheless, they con-
food and drink when using a walking stick [14, 16, 17]. cluded that users are able to offer their opinions, which
Development in wearable powered exoskeletons offers may facilitate the design process. Since the publication of
a potential solution to traditional rehabilitation chal- the Hill et al. [33] review, there has been further research
lenges [18, 19]. An exoskeleton, also known as a wear- into patient and physiotherapists’ perspectives; papers
able robot, is a mechanical system worn by humans to highlighted a range of rigid exoskeleton limitations, and
augment, complement or substitute the function of the they also recognised their novelty and potential [18, 25,
wearer’s limbs [20]. Early developed exoskeletons were 31]. Common perceived limitations or concerns regard-
stationary devices used to train patients on a treadmill ing rigid exoskeletons across studies included: safety
with body-weight support, reducing loads on lower limbs issues such as joint misalignment; creation of only one
for rehabilitation, such as DGO [21], LOPES [22] and device to fit all patients; difficulty of use, including don-
ALEX [23]. Later, commercially available, portable assis- ning and doffing; weight and cost; and device appearance
tive exoskeletons were developed, including Ekso, Rewalk [18, 25, 31, 36]. User perspectives for traditional rigid
[24], Indego and Exo H2 with an increasing number in exoskeletons demonstrated a disconnect between those
Morris et al. Journal of NeuroEngineering and Rehabilitation (2023) 20:18 Page 3 of 15

with clinical knowledge who understand the require- Methods

ments of assistive devices, and the engineers with the Initially, the researchers individually scoped out the lit-
technical knowledge to create such devices [25]. erature, to highlight areas of potential interest for review
Soft-robotics is an emerging field with capabilities to and used this initial exploration to define the aim, and
address the limitations of bulky, rigid and heavy exo- subsequent scope, of the review. It was evident that there
skeletons through designing wearable, soft devices that was limited literature on patient and physiotherapist per-
are lightweight, compliant and flexible, resulting in safe spectives on hard and soft exoskeletons (See the "Intro-
human interaction, suitable for body assistance [37, 38]. duction" section). A decision was made to collectively
Soft exoskeletons are different from rigid exoskeletons as explore both patient and physiotherapist perspectives so
they have an interface with the wearer that is a non-rigid that there was sufficient literature to compile this review.
structure, for instance, textiles, velcro or straps [39]. A A greater amount of discussion exists into rigid exoskel-
device may also be a hybrid of both, and would therefore etons, and therefore, it was decided to focus the solutions
not technically be a fully soft exoskeleton (despite some- on more novel soft exoskeletons. It should be noted that
times being described as a soft exoskeleton). Examples soft exoskeletons are preferred for users who retain some
include an exoskeleton with compliant/soft actuators walking ability or only require partial assistance, whilst
but a rigid structure-based body attachment, or a system users needing significant body weight support require a
with rigid actuators mounted on the body using a soft rigid exoskeleton [43, 44]. Consequently, the findings of
structure. A review of 52 lower-limb exoskeletons found papers regarding rigid exoskeletons will contribute to the
that only 11% were fully soft exoskeletons [40]. A recent discussion of developing soft exoskeletons, but the reader
review on soft wearable robots reported an exponential should be mindful that the users may have different
growth of using pneumatic artificial muscles (PAMs), needs as we explore solutions for those who are further
electrically-driven actuators, and textiles/fabric-based along their rehabilitation pathway and typically require
actuators over the past 10 years [41]. less physical assistance.
If the advantages of soft robotics are to be realised and In order to gain a greater insight into users’ perspec-
implemented effectively and transitioned rapidly into tives, literature with qualitative and quantitative studies
clinical and community settings, the engineering and were included in the review. As exoskeletons have pro-
clinical gap must be reduced. Consequently, this state-of- gressed significantly within recent years, it was prefer-
the-art review aims to identify the limitations of existing able to have more recent papers. However, the Wollf et al.
exoskeletons as perceived by clinicians and patients, and (2014) [34] paper was highly relevant to our review, and it
discuss the potential soft-robotic solutions. The review was cited frequently in other literature regarding patient
informs FREEHAB, a project which aims to design perspectives of exoskeletons. Consequently, papers were
wearable, assistive soft-robotic devices for people with included if they were published after 2014. Following the
impaired mobility (project website - The Right Trousers guidance of Grant and Booth [45] regarding state-of-the-
[42]). This collaborative review was undertaken by Free- art-reviews, no formal quality appraisal was carried out.
hab researchers with both clinical (LM) and engineering However, studies were only included if data collection
(RSD, NR) expertise, reducing the clinical-engineering methods were transparent so that the researchers could
disconnect. identify relevant study contexts (for example, the sample
The "Methods" section will outline the methods of the population) and whether correct research conduct was
review. The "Patient and physiotherapist perceived limi- undertaken.
tations of exoskeletons" section will discuss the patient The review aimed to focus on finding solutions for exo-
and physiotherapist perceived limitations of existing skeleton issues that were user-led. Therefore, the review
rigid exoskeletons based upon a review of the existing was led by a health researcher (LM) without an engineer-
literature. The "Patient and physiotherapist perceived ing background and without (at this time) active involve-
limitations of exoskeletons" section will also introduce ment in the technologies of soft exoskeletons. It was
potential solutions to these limitations. The "Discussion" important that the engineers did not outline the perspec-
section will summarise the main findings in relation to tives of the users, as they would bring their own bias due
wider literature, and has a wider discussion on future to their knowledge of the technologies that they could
assistive suits and identifies how soft-robotic technolo- develop.
gies may provide solutions. LM independently searched and identified relevant
literature using the databases MEDLINE, AHMED and
CINHAL. Snowballing of papers was also carried out.
LM collated the literature into a summary table and
the selected literature was also discussed with MC and
Morris et al. Journal of NeuroEngineering and Rehabilitation (2023) 20:18 Page 4 of 15

AT researchers with a physiotherapy and occupational a physiotherapist in Vaughan et al.’s study [25] (who had
therapy background, respectively. Themes were identi- actually used the device for one year) expressed concerns
fied, which were recurring patterns regarding patient and for how the device would respond to atypical muscle
physiotherapist perspective of exoskeletons across the tone, providing an imagined example of a patient with
papers. which included the themes which would become hyper-reflexia and the device misinterpreting this as
the framework for presentation of findings (Additional sitting. Physiotherapists in Read et al.’s study [31] had
file 1: Table S1). undertaken training with the Ekso rigid exoskeleton and
The themes were presented to the research team and used it as part of their interventions. The physiotherapists
then research team members with engineering expertise highlighted that this device could cause a larger degree
carried out further literature searches for engineering of spasticity, due to patient anxiety for use of the equip-
solutions. The scope of these searches were defined by ment. Thus, it has been perceived by physiotherapists
the findings from LM’s reporting. This was to ensure that that the device could not only cause injury in its response
the solutions were based upon the user’s perspectives, to muscle tone, but it could exacerbate the problem. It
and not any agenda of the engineering researchers. A should be noted that although these concerns were not
narrative was then formed based upon the user’s needs, based on actual experiences, nonetheless, they remained
and how soft robotics may offer a solution. RSD and NR, present even after training and use of the devices for sev-
engineering researchers with mechanical and soft robotic eral months (training spring/summer 2017 and data col-
backgrounds, searched IEEE, SpringerLink, Scopus data- lection July 2017).
base for state-of-the-art technology that addressed assist- Primary concerns also included the device being inap-
ing patients and therapists. They concluded findings, propriate for particular patient groups. Physiotherapists
delivered engineering solutions to each theme and pro- were apprehensive that, for patients with limited core
vided a guideline in developing key elements of assisting strength, the device may impact their balance and cause
devices. Findings were shared with LM who compiled injury, with a physiotherapist referring to it as ‘throw-
them in order to create a narrative for the review. ing them through the motions’ [25] (p0.11). Concerns
regarding falls were shared by several users of wheel-
Patient and physiotherapist perceived limitations chairs [34]. Consequently, a physiotherapist (with no
of exoskeletons experience of using the device) stated that they would
The findings’ framework is based upon six themes: safety, only feel comfortable using the device if they maintained
one size fits all, ease of device use, weight and placement close proximity when mobilising patients [25]. There
of device, cost of device, and appearance. Themes did not were reservations for using the device with patients with
change from LM’s consultation of MC and AT, however, cognitive and communication deficits; however, discus-
the presentation of themes were ordered to reflect the sion was limited [18, 25].
weighting of the literature for the themes. Themes are A secondary safety concern, with expression limited to
presented below with their relevant findings. Five papers one physiotherapy student, but with particular relevance
were included that evaluated patient and/or physiothera- in light of the COVID-19 pandemic, was the ease of
pist perspectives of exoskeletons. cleaning the device [18]. Predominantly, secondary safety
concerns were in relation to creating one device to fit all.
Safety Compliance as a physical property is one of the most
Across the sources, safety concerns regarding use of important required features in developed exoskeletons,
rigid exoskeletons can be divided into: primary harm facilitating adaptability, comfort and safe interaction
incidents, secondary harm, and concerns of infection with human body [46]. Series Elastic Actuators (SEAs)
control. and Variable-stiffness Actuators (VSAs) are commonly
Several concerns were expressed regarding primary used in conventional rigid spring-based exoskeletons
harms that could be caused by a lack of device sen- because of their ability to change their stiffness [40].
sitivity and sophistication. In one qualitative study, Despite comprising rigid elements, SEAs and VSAs are
physiotherapy student views on the H2 rigid exoskel- considered compliant actuators with the capabilities of
eton were explored; they had not used the device but transmitting high forces and providing smooth assistance
had only seen a participant don/doff the device or had and avoiding restriction of natural body motions and
the process described to them (two out of three focus injury. However, they have certain disadvantages such
groups were online) and viewed videos of people walk- as mechanical friction and hysteresis (actuation delay).
ing with assistance from the device [18]. The students Often, the empirical behaviour such as the device’s prac-
felt that the device may force a patient to go past their tical stiffness does not match with prediction [40]; the
joint range of movement, causing injury [18]. Similarly, fitting of the rigid exoskeletons determines the expected
Morris et al. Journal of NeuroEngineering and Rehabilitation (2023) 20:18 Page 5 of 15

rotation axis of the joints and, therefore, it dictates the their weight between legs [25] (p0.7). Furthermore,
constraints and an undesired range of movement applied there were concerns that providing too much assistance
to the person. In addition, traditional rigid exoskeletons to an individual could cause passivity or increased
exploit self-adjustable body attachments to compensate dependence. A physiotherapy student voiced concerns
joint misalignment [47]. For example, a rigid full-DoF hip that patients may be unaware of the feedback they are
exoskeleton containing rotational hinges and perpendic- receiving from the rigid exoskeleton, which can lead
ular sliders has been shown to passively adapt to align the to device dependence [18]. This was the experience of
exoskeleton’s components with the user’s specific body a stroke survivor; they felt the rigid exoskeleton’s pre-
biometrics, reducing undesired interaction forces [48]. programmed gait pattern was walking for them, rather
Similarly, iT-Knee is a self-aligning rigid knee exoskel- than providing the assistance they required [25].
eton, delivering autonomous adaptability, while assisting Consequently, physiotherapists requested an exoskel-
lower limbs, and pure knee assistance decoupled from eton that they could tailor to the needs of each specific
other joint movements [49]. However, inclusion of these patient. For instance, they wanted to adjust joint angles,
joint-aligning mechanisms increases the complexity, length of the femur and the swing pattern [25]. Physio-
weight and rigidity of exoskeletons. therapists highlighted the issue of time consumed from
The decrease in rigid components can be observed altering an exoskeleton for each patient if it were in a
throughout the history of developments in exoskeletons rehabilitation facility clinic, and suggested that the device
using a variety of soft robotics technology to pursue have a function to retrieve patient specific settings [25].
totally soft exoskeletons, which is safer, more comfortable Rather than a one-size-fits-all device, both physiothera-
and friendly to users (Additional file 1: Fig. S1). Pneu- pists and several stroke survivors felt that a range of exo-
matic Artificial Muscles (PAMs) are common soft actua- skeletons may be required, to meet the differing needs of
tors that change shape and exert forces when pressurised early and later stages of rehabilitation, in both acute care
by air [50, 51]. PAMs have been used for rehabilitating and community rehabilitation [18, 25].
soft exoskeletons over several decades [52–66]. Cable- There were concerns that it might not be possible to
driven soft exoskeletons consist of minor rigid compo- have an exoskeleton that is suitable for all [31]. Prag-
nents (e.g. motors, gears and cables) which use textile matically, physiotherapists expressed issues in having
or soft attachments to deliver direct force transmission one device that can physically fit every patient, and they
and comfort to a user’s body during assistance. These felt skills may be required to fit the device so that it was
actuators are predominantly off-board (not attached to comfortable for the patient for an entire session [31]. In a
the suit, but tethered to the suit through cables), reduc- survey exploring how users of wheelchairs perceive exo-
ing the suit weight loaded on a user’s body and making skeletons, some were concerned that the device would
them suitable for use with a therapist who is able to assist not be suitable for their impairment, with examples pro-
carrying the actuator [43, 67–71]. Moreover, more recent vided include: hemiplegia, quadriplegia, low bone den-
PVC gel electroactive polymer actuators have been used sity, contractures, lack of arm/hand use, poor balance,
to build soft exoskeletons [72]. When assisting the human amputation, obesity, muscular dystrophy and asymmetri-
body, it can decrease the activity and energy spent by the cal lower extremities [34]. However, as this was an open-
targeted muscles [73]. However, there may be safety con- ended survey question, there was limited depth into why
cerns due to the high voltage supply required. patients perceived these impairments as preventing their
use of exoskeletons.
One size fits all
From the engineering perspective, the goal of soft assis-
Although rigid exoskeletons are designed with the tive devices is to generate predefined trajectories that
intention to facilitate motor learning of a typical gait train patients and recover their body motions, while
pattern, physiotherapists felt that the device may cause simultaneously adapting to each patient’s specific needs.
unnatural movement. A pre-fixed gait pattern in the Therefore, rehabilitative devices must determine the
sagittal plane was perceived as imposing a gait pattern assistive conditions, estimating the amount of required
on a patient that did not correlate with real life walk- assistance, and timing of activation and withdrawal of
ing [18]. Moreover, it was highlighted that a one-size- assistance [74]. However, these parameters vary sig-
fits-all device had unnatural hip/pelvic alignment and nificantly between patients, causing time-consuming
knee alignment, and subsequently impacted their base adjustment.
of support and caused new compensatory movements A sophisticated control algorithm, called human-in-
[25]. This was the experiences of several stroke survi- the-loop optimisation was developed for cable-driven
vors who used a rigid exoskeleton and stated that the exoskeletons to solve these issues. The algorithm is able
device ‘felt unnatural’ and made it harder to transfer to adapt its assistance strategy based on the individual’s
Morris et al. Journal of NeuroEngineering and Rehabilitation (2023) 20:18 Page 6 of 15

walking performance [69, 70]. Although starting with a given situation; accurately acquiring the measurements
standard walk-assisting force profile, this algorithm ena- required for proper fit; a need to check and recheck that
bles the exoskeletons to rapidly adjust the assisting force all is operating as intended; and an understanding of
and provide precise actuation to match the cyclic walk- patient needs [31]. The physiotherapists perceived the
ing motions, improving and maintaining optimal walking training sessions as ‘challenging’, and it was stated that
performance at all time [69, 70]. they felt the skills had to be maintained (p0.5). Physi-
Flexibility and adaptability, which may be offered by otherapists in Vaughan-Graham et al. [25] perceived it as
novel textiles, are the key solution to the problems of essential for ongoing support and training, while physi-
rigidity and low adaptability with existing exoskeletons otherapy students wanted a contactable technical expert
(See the “Safety” section). Flexible textile materials, such in case of exoskeleton issues [18]. Physiotherapy students
as soft braces, straps and garments, are currently the felt that training may be a deterrent for the exoskeleton’s
most effective solution for the compliant connection use, particularly for less experienced therapists who find
between an exoskeleton and the user’s body. They are time management more challenging [18].
used to transfer assisting forces and hold the suit in an There were also ease of use factors that were specific
appropriate configuration, providing compatibility with to certain patient groups. This included the ability to
natural motions and safety [40, 75]. Moreover, semi- use exoskeletons without crutches, which was ranked as
soft exoskeletons, containing rigid components and soft 3.71 out of 5 on the Likert scale in terms of importance
attachments, were designed to include adaptability by of design feature (ranked 14 out of 17) [34]. This was
changing the length of their rigid linkages to fit various expressed as important to participants with hemiplegia,
body sizes. However, this component-adjustment process Muscular Dystrophy and users of crutches who wanted
consumes considerable time for each patient. Alterna- to be able to have free use of their arms while carrying
tively, variable-stiffness materials may be integrated into out activities such as cooking [34]. Physiotherapists also
body attachments. For example, a 3D-printed variable- expressed concerns for ease of use for patients with cog-
stiffness structure stimulated by heat and electricity may nitive, perceptual, and communication impairments, and
be incorporated into adaptive body attachments [76]. the potential for harm while using the device [18, 25].
In terms of the design considerations for engineers, it
Ease of device use is essential that the device is easy to put on and take off.
The ease by which an exoskeleton can be used was a com- A soft trouser, which integrates soft robotic actuators,
mon theme across several studies [18, 25, 31, 34, 35]. (rather than a mechanical assembly that constrains and
Wollf et al. [34] highlighted that, out of 17 criteria for anchors certain areas in the body) is easier to wear and
importance of exoskeleton design features, ease of device reduces unproductive time during therapy. The challenge
use was number 4 for users of wheelchairs. Bortole et al. remains for the soft structure to effectively interface with
[35] highlighted that, for their sample of stroke patients, the body and to provide sufficient torque/force and ten-
ease of exoskeleton use was ranked as 7.2 on a Likert sion/compression to deliver mechanical assistance as
scale, with 10 being ‘extremely easy to use’; one patient required [46]. A lightweight, portable, active undressing
expressed that ‘wearing it is fast and simple’ (p0.11). Time trouser [77] is a good example of a compliant exoskeleton
was a common rationale for wanting the exoskeleton to integrating a soft pneumatic adaptive belt inside a regu-
be easy to use, which was frequently related to donning lar trouser. It can expand and loosen due to the pressure
and doffing the device [25, 31, 34]. One stroke survivor input supplied by a compressed gas cartridge, allowing
stated that it took 30-40 minutes to fit the device which ease of donning and doffing. As mentioned previously
they felt was ‘lengthy’ (p0.5), while another stroke survi- (See the “One size fits all” section), the autonomous con-
vor did not want half their therapy time being absorbed trol-optimising algorithm can also vitally decrease time
in this way [25] Read et al. [31] stated that sessions took and effort therapists spent to manually adjust the exo-
60 minutes using the Ekso rigid exoskeleton and 90-120 skeleton setting for each patient [70].
minutes for the initial assessment, and physiotherapists
highlighted the time-consuming nature of the device. Weight and placement of device
Time management was also discussed in relation to the Studies commonly referenced weight, size and placement
training required for physiotherapists to use the device. of exoskeletons. In the Vaughan-Graham et al. study
Physiotherapists felt this training had to be multi-faceted [25], both stroke surivors and physiotherapists were
to address the complexities of the device, which included: concerned about the weight of the rigid exoskeleton; in
device-specific technical know-how; maintaining patient particular, therapists felt the device’s pelvic placement
safety; the necessity of working within time constraints; could result in the patient’s centre of mass being shifted
deciding the appropriateness of the technology in a backwards, disturbing their gait pattern. Wollf et al. [34]
Morris et al. Journal of NeuroEngineering and Rehabilitation (2023) 20:18 Page 7 of 15

survey demonstrated that, for users of wheelchairs, port- and physiotherapy students perceived the difficulty in
ability of the device was 4.09 out of 5 in importance of funding this across a facility budget, and a private clinic,
exoskeleton features (ranked 10 out of 17 features). In the respectively [18, 25]. A physiotherapist felt that, if the
same study, battery life of the device was ranked num- device were to be shared across entire programs, there
ber 6 - a consideration that was shared by physiothera- could be added complications regarding bookings, and
pists - suggesting that a potential trade-off exists between another physiotherapist remarked that there had to be a
operating time and device weight/portability [25, 34]. A significant benefit in order to justify the cost [25]. It was
further design consideration highlighted was the poten- perceived that the cost of exoskeletons could hinder clini-
tial for skin breakdown due to pressure sores; however, cal uptake [18, 25].
this response was limited to one patient [34]. To the authors’ knowledge, there is no literature on
Reducing the weight of exoskeletons has been a key cost evaluation of exoskeletons or use of cost reducing
focus for engineers designing rehabilitative and assis- materials. However, the soft exoskeletons can generally
tive devices. Existing rigid portable exoskeletons aim to separate into two major parts: a suit with integrated soft
restore mobility of disabled patients, examples include actuators, and a power-supplying unit. Presently, there
Exo-H2, Indego, ReWalk and EksoNR, have masses is an increasing trend to use more fabrics to create soft
between 11 and 25 kg [78]. They can support and move exoskeletons [80]. These soft devices are low cost and
patients with mass over 100 kg. In contrast, compliant affordable, and they have the additional benefit of mini-
exoskeletons using off-board tethered cable-driven actua- mising the required power-supply unit, thus increasing
tors and light textile attachments to transmit assisting its portability.
force to a user’s body have significantly lower masses
of around 0.9 kg (weight of suit alone), dramatically Appearance
reducing parasitic or undesirable loads on the body [43, Appearance of exoskeletons was a patient consideration;
68–70]. Although extremely lightweight compliant assis- however, it was ranked as the least important device cri-
tance devices have been shown to improve walking, their teria for users of wheelchairs (3.23 mean importance out
operation has been limited to treadmill training because of 5) [25, 34]. There appeared to be variation in expec-
of difficulty in carrying off-board, heavy actuation units tations of the exoskeleton appearance; one participant
and energy source. Myosuit [71] and XoSoft [79] are remarked that they did not want to look like a robot and
examples of portable cable-driven exoskeletons including the device needed to be wearable under clothes, while
on-board actuators with entire masses of 4.1 and 4.6 kg, another participant expressed accepting the limitations
respectively, significantly lighter than a contrasting cable- of the device appearance in order to improve their mobil-
driven exosuit (12.15 kg) [67]. The mass of pneumatic- ity. The minimal level of importance of device appearance
driven exoskeletons can be even lower (less than 0.16 kg); in the Wolff et al. [34] survey only provides an average of
however, this excludes the weight of the heavy pumps mean importance and it may not reflect the strength and
and compressors required for the air supply [63, 66]. variety of opinions of patients.
Placement of body attachments is another critical part Existing soft exoskeletons have been designed with
of exoskeletons. Key anchors, such as the shoulder, the aesthetics and discretion as important considerations,
iliac crest of the hip and the plantar surface of the feet, while maintaining high body-assisting performance [46].
are defined as effective body locations onto which to Textile materials and garments have been used as the
attach assistive devices [57]. These specific areas have main components of the soft exoskeletons to safely inter-
the thinnest skin above the bone compared to other sur- act with a user’s body, delivering assistance in a discreet
rounding areas of the body, which can prevent misalign- manner. One excellent example is integrating soft actua-
ment, pressure sore, skin damages and muscle injuries tors inside a normal trouser for undressing assistance
while transmitting assisting forces to the skeleton. [77].

Cost of device Discussion

Cost of exoskeletons was a consideration shared by both This state-of-the-art review has highlighted a range of
physiotherapists and patients [18, 25, 34]. The survey of patient and physiotherapist perceived concerns and
wheelchair users highlighted that the exoskeleton cost design considerations regarding rigid and soft exoskel-
was second in importance only to design features (2/17), etons. Patient and physiotherapists had reservations
with the open-ended responses demonstrating sev- regarding rigid exoskeletons’ safety, such as falls, despite
eral patient concerns of affordability [34]. Physiothera- not having an experience that would warrant this or hav-
pists likewise discussed the concerns for the cost of any ing seen wider evidence that demonstrates that falls were
devices to patients [25]. Furthermore, physiotherapists only present in testing of early exoskeleton prototypes
Morris et al. Journal of NeuroEngineering and Rehabilitation (2023) 20:18 Page 8 of 15

[81]. The significance placed upon falling is unsurpris- However, rigid exoskeletons were not easy to use, with
ing; falls have widespread physical and psychological one study citing 30-40 minutes simply to fit the device
impact on individuals and a survey of wheelchair users [25]. As previously highlighted, typical therapy time for
demonstrated that minimising the risk of falling was their stroke survivors is already below the recommended 45
top priority when evaluating exoskeleton function [34]. minutes per day [10]. A systematic review exploring the
Other concerns shared by the users of rigid exoskeletons clinical applications of the HAL exoskeleton [28] found
were that the device may force patients into unnatural that, of the three papers that reported the breakdown of
movement patterns, or even erroneously detecting and the time using the devices, all the sessions took 90 min-
forcing movements, for instance, interpreting the patient utes, with one study reporting up to 60 minutes effective
as trying to sit when they are in fact walking. This paper time, while the other two reported only 20-30 minute
then explored the use of soft technologies with greater effective therapy time [85, 86]. Devices can be initially
sophistication, which are more sensitive to the users’ time-consuming; National Institute for Health and Care
movements and are thus able to more precisely apply Excellence (NICE) [87] states that training physiothera-
forces as required. pists to use an Ekso exoskeleton takes one week and the
From an engineering perspective, the first challenge is therapist must initially only use the device under supervi-
developing new soft actuators that are lightweight, com- sion of a physiotherapist who is familiar with the Ekso.
pliant and sufficiently powerful enough to deliver smooth It is evident that future devices must be more efficient in
and safe assistance for natural mobility [82, 83]. They relation to the required training and time taken to use the
must be capable of varying their stiffness and deforming device.
when exposed to external forces generated by patients, We perceive that the future exoskeletons will become
reducing unexpected harms. Furthermore, they must be totally soft and naturally integrate with normal clothing.
suitable to fit inside a garment-like suit that is wearable Their actuators and body attachments will be combined
and comfortable. The level of stiffness is directly related to create multifunctional assistive clothing with capabili-
to the amount of force that can be transmitted to the ties of stiffness variability and morphology deformation
human body; therefore, the balance between stiffness on every areas of the suit. For example, at no assistance,
and assistive effectiveness must be considered. For exam- the entire suit turns soft, improving ease of donning and
ple, compliant actuators can deliver safety and comfort doffing. Moreover, it is perceived to be able to harvest
together with portability due to their low weight, but may energy gained from passive shape deformation and heat
have decreased bandwidth or peak force when compared loss released from the body surface during daily activity.
to conventional heavier rigid actuation technologies Also, when activated, certain areas of the suit can be con-
such as motors and gears [46]. Additionally, actuation trolled to become stiffer to support loads on lower limbs
speed must be considered when delivering assistance that or to prevent undesired movements and joint misalign-
merges seamlessly with natural body movements, since ment. In contrast, other areas can actively vary their stiff-
asynchronous actuation can result in increasing muscle ness to deform, e.g. contract, elongate, bend and twist,
power consumption and fatigue of users and negative and enable actuators to effectively transmit forces to
changes in mobility patterns. assist required body movements and also prevent joint
Both physiotherapists and patients were concerned misalignment. In addition, active morphology deforma-
that if there were only one exoskeleton device that was tion can enable suit adaptability to specific users and self-
made to fit all patients, it may result in unnatural move- fitting for comfortable usage by controlling shrinking and
ments [18, 25], which was the experience of users in the loosening of the suit to fit the user’s body. A variety of
recent Vaughan et al. study, where there was unnatural developed textile actuators was classified depending on
hip/pelvic alignment [25]. A longitudinal study of healthy their purpose and reviewed in [75].
participants demonstrated the individual nature of gait Physiotherapists and patients all highlighted the impor-
characteristics, and concluded that assessment and tance of having a device that was lightweight, to prevent
therapy must therefore take into account the patient’s the user’s gait pattern being altered [25] and to allow it
unique differences [84]. This review highlighted that to be portable [34]. However, a long battery life was also
physiotherapists wanted a device that they could tailor desired, suggesting the need for a balance between a
to an individual [25]. However, they did note that alter- lightweight portable device that can operate for a short
ing a device between patients may be time-consuming period and a heavier device that has longevity of use [34,
[25], and they were concerned that it may not be pos- 88]. As therapy time is limited to 35 minutes for stroke
sible to have a device that can physically fit all patients survivors [10], this would be the minimal time accepted,
[31]. It was important for the device to be easy to use, however, if the device is to be used by multiple patients
both in terms of donning/doffing the device and training. in a day, greater device battery capacity or a short
Morris et al. Journal of NeuroEngineering and Rehabilitation (2023) 20:18 Page 9 of 15

recharge time may be required. The requirements for Soft robotics actuators
a lighter assistive device are soft and efficient actuators Similar to the key metric performance of human skel-
(high torque-power and torque-weight ratio) and power etal muscles, soft fluidic and electrically-driven actua-
sources that have short recharge time. However, both tors have high potential to become future smart artificial
these requirements urge development in the material sci- muscles due to their high stress, strain and bandwidth,
ence. Within the current technology, wireless charging addressing the requirements to create the future soft exo-
during users’ session can be adopted to optimise stan- skeletons [93].
dalone charging time. Soft fluidic actuators have backdrivability (behaving
The cost of the device was important to both patients like a spring), low cost and high specific force and power,
and physiotherapists, in both terms of cost for the patient despite low efficiency around 30% because of losses in
to buy for personal use, and also the purchasing by clin- the fluidic-to-mechanical energy conversion process [40,
ics [18, 25, 31]. Physiotherapists would only want to pur- 93]. They can be divided into hydraulic and pneumatic
chase a device if the device benefits clearly outweighed actuators. Soft pneumatic actuators have lower band-
the cost [25]. In the UK, there are several bodies involved width than hydraulic actuators due to gas compression,
in making budget decisions, passing from the Depart- but are significantly lighter, making them more suitable
ment of Health and Social Care, to National Health Ser- to create soft exoskeletons (see Additional file 1: Fig. S2
vice then to Integrated Care systems (previously Core for the vision for future assist devices). Many prototype
Clinical Commissioning Groups) [89, 90]. It can be soft lightweight exoskeletons were built using PAMs [53],
expected that approval from commissioners for high-cost for example, McKibben muscles [51, 94], straight-fibre
services or products, such as soft exoskeletons, will be muscles [95–98], Pouch Motor actuators [99] and pleated
challenging. An economic evaluation explored the cost- PAMs [100] including Bubble Artificial Muscles [64, 65].
effectiveness of rigid exoskeletons in improving quality of However, one drawback of pneumatic artificial muscles
life and preventing secondary hip fractures in an imag- is the requirement for large, heavy, noisy pumps or com-
ined population of people with dementia or cardiovas- pressors, which limits their portability for ambulatory
cular diseases [91]. The multiple scenarios demonstrated applications.
that a significant improvement in reducing hip fractures Soft electrically-driven actuators are another potential
was not essential, however it was essential to improve candidate for future soft exoskeletons due to their high
quality of life in order to justify the cost of the exoskele- actuation performance, fast and quiet operation, and
ton (with the cost under £17,500) [91]. In 2017, Ekso was high efficiency [46, 93]. For example, dielectric elastomer
provided to one NHS Trust in a package costing £98,000 actuators (DEA) and ionic polymer-metal composites
(excluding VAT), which included the Ekso GT robotic (IPMC) are active polymers which deform when electri-
exoskeleton with the SmartAssist software, training for cally charged. DEAs can deliver high strain, bandwidth
up to four physiotherapists, a two?year warranty, sup- and efficiency, and are widely used in robotic applications
porting equipment [92]. This cost is significantly greater [101–103]. However, the major disadvantage of DEAs are
than the value outlined in the cost-benefit analysis, and the requirement for high voltage actuation (typically in
it is therefore evident that future exoskeletons must have the order of thousands of volts). Alternatively, low voltage
greater affordability. actuation is achieved in IPMC (in the order of a few volts)
Although the appearance of rigid exoskeletons was but at the cost of lower stress and power density [93].
commonly discussed by patients, their views varied, Dielectric fluid electrostatic actuators have been devel-
with some feeling appearance was irrelevant if the device oped as a new soft robotics actuation technology. Exam-
allowed them to live their life, and others not wanting ples include dielectrophoretic liquid zipping actuator
to feel stigmatised by a visible device [34]. This demon- [104–106], hydraulically amplified self-healing electro-
strates the individuality of patient needs when designing static (HASEL) actuators [107–109], soft fluidic pumps,
future exoskeletons. such as a stretc.hable pump [110] and an electro-pneu-
To build the next generation rehabilitative device, we matic pump [111, 112]. The recent stretc.hable pump and
propose that developments are required in i) building electro-pneumatic pump demonstrated important capa-
efficient soft robotic actuators, ii) fabricating comfortable bility to integrate with soft fluidic actuators, e.g. hydraulic
body attachments, iii) improving sensor technology and McKibben muscles [113] and pneumatic Bubble Artificial
iv) developing robust adaptive control strategies. Muscles, respectively. Together with the development of
lightweight battery technologies and on-board control-
lers, these soft electrostatic actuators promise a new gen-
eration of entirely soft, lightweight, flexible and portable
exoskeletons. Although their stress-strain performances
Morris et al. Journal of NeuroEngineering and Rehabilitation (2023) 20:18 Page 10 of 15

are lower than human muscle requirement, they combine Sensing system and mobility simulation
the benefits and address the drawbacks of both fluidic Typically, exoskeletons require a sensing system to be
and electrically-driven actuators. highly accurate, fast, and robust to disturbances. The
Auxetic or transformable structures has been explored sensing system is accountable for three fundamental
to develop ankle and knee braces that are lightweight features: (1) measuring force generation, (2) monitoring
and comfortable, similar to a textile or garment [114]. body motions, and (3) evaluating assistance efficiency.
Exploiting the advancement of additive manufactur- First, the soft exoskeletons require sensors to measure
ing and 3D printing, the transformable structure can be their actuators’ outputs, which are then fed back to their
actuated using micro pneumatic actuators or by pulling controller to deliver accurate assisting force and strain.
threads. There are numerous auxetic structures avail- Sensors are also used to prevent undesired damage, for
able, and their potential has not been fully investigated example, stopping actuation when high forces and out-
in actuation. Many of the transformable structures can of-range motions are detected.
bend, twist and contract, and their characteristics can Second, IMU (inertial measurement unit) sensors are
be altered depending on the way they are placed, such commonly used to track and simulate body movements
as unit type (e.g. block size, number of edges, number of by their attachment across body joints. With the devel-
hinges/constraints or layers) and connection type (e.g. opment in a real-time data-analysing system, IMUs were
series or parallel). These structures can be easily incor- able to precisely predict walking and sit-to-stand activi-
porated within the garment and their ability to transform ties [116, 117]. Alternatively, soft flat sensors, such as
in shape can be used to move joints or alter the local DEA stretc.h sensors [118] and a multi-bend/shape sen-
stiffness of parts of a suit. A combination of different sor [119], which can contract, extend, bend and twist,
auxetic families in a garment could be helpful to obtain may be integrated as one layer of the soft exoskeleton.
desired strains in different activities such as sit-to-stand These soft sensors can be used to measure and simulate
or walking. These make active auxetic structures another the entire 3D configuration of the suit in order to predict
potential solution to develop future soft exoskeletons. mobility activities and to detect incorrect mobility symp-
Additional file 1: Fig. S1 demonstrates the perceptual toms or patterns. Soft force sensors can be intergrated in
concept of the future assist device, illustrating soft artifi- the the soft exoskeleton to estimate the pressure distribu-
cial muscles, sensors and a power supplying unit. tion on the user’s skin and thereby to prevent skin dam-
age, especially around the attachments, and adjusting the
Body attachments assisting strategy or altering the exoskeleon morphology
The conditions of body attachment, such as size, shape for more user comfort and safety.
and attachment point, play a crucial role in patient com- We envision that all of these functional sensors need
fort that form an essential focus of evaluation for the per- to be soft and aesthetically embedded within soft exo-
formance of soft wearable exoskeletons. As previously skeletons to comprehensively monitor the user’s body.
discussed, the safe placement for attachments of the soft The future of assistive soft robotic clothing may include
exoskeletons on the user’s body is a shoulder, hip and feet multiple layers that contain actuating, sensing and con-
[57]. In addition, a guideline for designing aesthetic and trol units, operating synchronously to facilitate a person’s
inconspicuous exoskeletons is provided in Veale et al. improved mobility.
[46]. That is, the loads from the suit mounted on trunk As a result of the body motion information acquired
and each foot are recommended to be less than 15% and from suit sensors, a virtual mobility simulation can be
1.25% compared to the user’s body weight, respectively. simultaneously created. Additionally, an open source
The thickness of the suit along lower limbs should be platform that can capture the motion from the suit with
less than 30 mm. The power source can be located on the plug-and-play capabilities may facilitate rapid analy-
user’s back with the total volume limited to 0.023 m3. sis of patient mobility patterns. The integration of the
Although not considered by the patients and physio- above technologies with an online data communication
therapists, we perceive that breathability is an important and service has the potential to track mobility improve-
feature of body attachment and can significantly enhance ments and enable remote patient consultations with
comfort while wearing the soft exoskelton. This can be physiotherapists.
achieved by temperature and humidity exchanges on the
skin surface. For example, the suit can possess self-defor- Control algorithm
mation, which is sensitive to skin surface temperature Exoskeletons must always generate the appropriate
and humidity and autonomously deforms its structure to amount of assisting forces at the right time for effective
inhale/exhale surrounding air for cooling/warming of the assistance without negatively impacting a user’s mobility.
suit [115]. As previously shown, human-in-the-loop optimisation
Morris et al. Journal of NeuroEngineering and Rehabilitation (2023) 20:18 Page 11 of 15

was developed as an advanced control algorithm which survivors in an inpatient rehabilitation setting. They
can automatically adapt the assisting strategy based highlighted that robotic devices can create very subtle
on the user’s mobility, consistently delivering effective, improvements or change in quality and degree of move-
harmless and optimal assistance [69, 70]. Although based ment, which may be missed by less sensitive commonly
on the same predetermined assisting profile, this algo- used outcome measures. They underlined the need for
rithm can rapidly adjust itself to suit the mobility needs an understanding of the clinical reasoning that under-
of a variety of different patients, conserving therapy time. pins the prescription of robotics for upper-limb therapy
In order to deliver such sophistication, future exoskel- by physiotherapists, as well as the most effective time
etons require a soft, high-speed, micro-scale, computing to incorporate it into rehabilitation. This study is based
controllers that can be unobtrusively distributed across upon upper-limb therapy, however, it is still relevant to
the suit and which communciate and integrate to deliver the development of lower-limb therapy. Evidence dem-
low-level mechanical assistance to deliver a high-level onstrates the need for greater guidelines for robotics in
mobility goal. rehabilitation in general, which may encourage a ‘cultural
shift’ for robotics acceptance [123].
Beyond soft‑robotic solutions: future research Fundamentally, there must be an understanding of how
Implementation will only be successful if devices are therapists use devices and why therapists use devices
themselves effective and that this can be proven in clini- in the way they do; this is essential to not only design
cal and usability trials. A recent Cochrane review [120] robotic assistive devices that meet therapists’ needs,
of 62 trials (totalling 2400 participants) was carried out but also to create guidelines that can facilitate success-
to determine whether electromechanical-and-robot- ful implementation of such devices. Notably, the need
assisted gait training versus normal care after stroke to understand the therapist’s clinical reasoning and the
improved walking. It concluded that stroke survivors devices outcomes are interconnected. As Vaughn et al.
who received electromechanical-and-robot-assisted [25] study exploring exoskeleton use in stroke rehabilita-
gait training alongside physiotherapy were more likely tion concluded, unless client selection criteria and goals
to achieve independent walking than those who carried of device (both clinically reasoned) are established, there
out gait training without these devices. However, the is a risk of exoskeletons lacking statistically significant
study concluded that questions remained regarding the effect. Future research should use interviews and focus
most effective frequency and duration of the training and groups with therapists not only to explore their clinical
which design characteristics were important for bringing reasoning when using devices, but also to understand
about the improvement. This was in part due to differ- how devices might be tested meaningfully for their pur-
ences in device design, for instance, some devices having pose, in a standardised way.
FES. Further, the review concluded that the variation in This review identified that physiotherapists felt that
time since stroke needs to be considered in future testing training professionals in exoskeleton use had to be multi-
as the training may not benefit those who were ambula- faceted, and that the training was often negatively per-
tory at the beginning of the intervention. Consequently, ceived to be draining. Stephenson and Stephens [123]
it is necessary to understand specifically what about explored physiotherapists’ experiences of robotic therapy
devices make them ‘effective’ and for who, and what out- in upper limb rehabilitation within a stroke rehabilita-
come measures class this ‘effectiveness’. tion centre. Although initial starting up times for robotic
However, measuring effectiveness is a problem that is devices may be greater than conventional methods, it
widespread across the robotics field. A systematic review was perceived that the devices could free up more expe-
[121] explored the effectiveness of platform-based robotic rienced therapists’ time. However, they acknowledged
rehabilitative devices (devices which solely improve ankle that, without a greater evidence base, it was challenging
performance) for use with people with musculoskeletal to set the parameters for training. This reinforces our
or neurological impairment. They could only conclude conclusion for the need to create clear clinical guidelines
on the effectiveness of two devices due to the availabil- for device usage (clear device functions, recommended
ity of evidence. However, they found both devices to be usage time and appropriate patient groups). Additionally,
effective in improving ankle range of movement and sta- they concluded that close partnerships between the tech-
bility. They proposed that, to reach further conclusions nical device manufacturers and the professionals using
for these devices, there must be future work into creating the devices were essential for successful training of staff,
universally accepted evaluation criteria which are able to problem-solving and maintenance of equipment [123].
standardise the devices’ outcome evaluations. But this This further highlights the requirement for inter-discipli-
is not without its challenges. Flynn et al. [122] explored nary collaboration for robotic device uptake.
the sustainability of upper limb robotic therapy for stroke
Morris et al. Journal of NeuroEngineering and Rehabilitation (2023) 20:18 Page 12 of 15

Conclusion Author contributions

LM structured the review around the clinical perspective, and contributed
We present state-of-the-art technologies and exam- the abstract, introduction, conclusion and the discussion sections. RSD and
ples of current rigid and soft exoskeletons which have NR contributed the sections regarding the engineering design and future
been designed to address the needs highlighted by solutions. LM, RSD, NR, AT, MC, and JR were all involved in conceptualising and
final editing. All authors read and approved the final manuscript.
physiotherapists and patient users. This review has
demonstrated a range of issues with current rigid exo- Authors’ information
skeletons, with limitations related to device safety, one- LM is a Research Fellow on the Freehab at The University of the West Eng-
land, Bristol, UK; RSD and NR are Research Associates on the Freehab in the
size-fits-all feature, ease of use, weight, placement, cost, department of Engineering Mathematics at University of Bristol, UK; MC is a
and appearance. We provide a concept of future exo- co-applicant on the Freehab project, Portfolio Lead Health and Social Well
skeletons and soft-robotics solutions classified into four Being Research and Professor of Long Term Conditions at The University of
the West of England Bristol; AT is the Principal Investigator on the Freehab
key factors: soft robotic actuators, body attachments, project and is a Senior Occupational Therapy lecturer at the University of the
sensing system and control algorithm. The solutions West of England, Bristol; JR is the Chief Investigator on the Freehab project and
proposed are extensive and the considerations when is a Professor of Robotics in the department of Engineering Mathematics at
University of Bristol, UK.
designing future soft exoskeleton devices are complex.
Soft pneumatic-driven and electrically-driven actuators Funding
are perceived as having the highest potential for future The FREEHAB project and all authors are funded by the Engineering and
Physical Sciences Research Council (EPSRC) grant EP/S026096/1. JR is also
soft technology exoskeletons thanks to their high flex- supported by EPSRC grants EP/L015293/1, EP/S021795/1, EP/R02961X/1,
ibility, speed of response and portability, and stress and EP/V026518/1, and EP/T020792/1, and the Royal Academy of Engineering
strain performance that matches or exceeds human mus- through the Chair in Emerging Technologies scheme.
cles. Applying compliance to all components of exoskel-
etons can increase users’ comfort and help prevent harm Declaration
if assistance is misaligned or unsafe movements occur. Ethics approval and consent to participate
Variable-stiffness capability can stiffen certain areas of Not applicable.
the soft exoskeletons to maintain and deliver sufficient
Consent for publication
force transmission through the device to effectively assist All authors consent for publication.
lower limbs. This property also provides the devices with
adaptability to deform themselves to fit to various spe- Competing interests
The authors declare that they have no competing interests.
cific users’ requirements, increasing ease in donning/
doffing. The assistive device will use advanced sensors to
detect user intention and an adaptive control algorithm Received: 4 October 2021 Accepted: 16 December 2022
will learn users’ patterns of movement over time to better
respond when needed. Future devices must have these
features in order to be fit for purpose in time-restricted
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